see attachment
question sheet, book, answer sheet
u need just chapter4 in book
Answer Sheet
Name: ____________________________________ ID: _______________
Page 1 of 1
First Question: Essay 1 Point for Each Level of Proficiency
Read the article entitled, ‘From Novice to Expert’ by Patricia Benner found in
https://www.medicalcenter.virginia.edu/therapy-services/3%20-%20Benner%20-%20Novice%20to%20Expert-1
Then summarize the theory.
Instructions:
1- Make a COMPREHENSIVE SUMMARY of this theory in YOUR OWN WORDS. Focus on the five levels of proficiency from novice to expert.
2- Your comprehensive summary should range between 500 to 1,000 words.
3- No copy and pasting of sentences from the article. Paraphrase the sentences you will include in your comprehensive summary.
__________________________________________________________________
Second Question: Making a Theory Evaluation -1 Point for Each item
Fawcett’s framework for conceptual models separates questions for analysis from those intended for evaluation. For the evaluation, she proposed evaluation (judgment based on criteria) of the origins of the model, the degree of comprehensiveness of content, the logical congruence of its internal structure, the ability of the model to generate and test theories, the degree to which it is credible as demonstrated in its social utility (use, implementation), social congruency, and significance to society.
Read Chapter 10 A Model for Evaluation of Theories: Description, Analysis, critique, testing and Support from the e-book Theoretical Nursing Development and Progress 5th Edition, By Afaf Meleis. Then, MAKE COMPREHENSIVE EVALUATION of THE SISTER CALLISTA ROY’S ADAPTATION MODEL Using the Fawcett’s Criteria of Nursing Models Evaluation, which includes:
· Origins
· Content
· Logical congruency
· Generation
· Credibility
Instructions: Make your evaluation of the Sister Callista Roy’s Adaptation Model using a Fawcett’s criteria of Nursing Models Evaluation.
Third Question: Making a Theory Critique
Read Chapter 4: Florence Nightingale’s Legacy of Caring and Its Applications from the e-book Nursing Theories and Nursing Practice, Fourth Edition by Marlaine Smith and Marilyn Parker. Then Make a COMPREHENSIVE CRITIQUE of FLORENCE NIGHTINGALE’s ENVIRONMENTAL THEORY.
Instructions: Make a COMPREHENSIVE CRITIQUE of FLORENCE NIGHTINGALE’s ENVIRONMENTAL THEORY by combining inputs from at least two (2) critique articles from the internet and your own viewpoint based on the following criteria and units of analysis:
CRITERIA |
UNITS OF ANALYSIS |
(1) Relationship between structure and function |
(1.1) Clarity |
(1.2) Consistency |
|
(1.3) Simplicity/Complexity |
|
(1.4) Tautology/Teleology |
|
(2) Diagram of the Theory |
(2.1) Visual and Graphic Presentation |
(2.2) Logical Representation |
|
(2.3) Clarity |
|
(3) Circle of Contagiousness |
(3.1) Graphical origin of theory and geographical spread |
(3.2) Influence of theorist versus theory |
|
(4) Usefulness |
(4.1) Practice |
(4.2) Research |
|
(4.3) Education |
|
(4.4) Administration |
|
(5) External Components of Theory |
(5.1) Personal Values |
(5.2) Congruence with other Professional Values |
|
(5.3) Congruence with Social Values |
|
(5.4) Social Significance |
Page 4 of 4
·-• •• Fourth Edition
Nursing Theories
and Nursing Practice
Nursing Theories & Nursing Practice
Fourth Edition
3312_FM_i-xx 26/12/14 5:51 PM Page i
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
1915 Arch Street
Philadelphia, PA 19103
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Copyright © 2015 by F. A. Davis Company
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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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Preface to the Fourth Edition
v
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 http://davisplus.fadavis.com.
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
3312_FM_i-xx 26/12/14 5:51 PM Page v
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://
davisplus.fadavis.com. 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
exemplars.
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
3312_FM_i-xx 26/12/14 5:51 PM Page vi
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
3312_FM_i-xx 26/12/14 5:51 PM Page vii
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
3312_FM_i-xx 26/12/14 5:51 PM Page viii
Nursing Theorists
ix
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,
HWNC-BC
Co-Director, International Nurse Coach
Association
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
Professor
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
3312_FM_i-xx 26/12/14 5:51 PM Page ix
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
Professor
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
Professor
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
Dean
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
Campus
Aurora, Colorado
Ernestine Wiedenbach†
x Nursing Theorists
*Retired
†Deceased
3312_FM_i-xx 26/12/14 5:51 PM Page x
Contributors
xi
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
Engagement
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
Programs
Christine E. Lynn College of Nursing
Florida Atlantic University
Boca Raton, Florida
*Retired.
3312_FM_i-xx 26/12/14 5:51 PM Page xi
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
Professor
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
Consultant
Evidence Based Practice Nurse Consultants,
LLC
Howell, Michigan
Ann R. Peden, RN, CNS, DSN
Professor and Chair
Capital University
Columbus, Ohio
3312_FM_i-xx 26/12/14 5:51 PM Page xii
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
3312_FM_i-xx 26/12/14 5:51 PM Page xiii
xiv Contributors
Terri Kaye Woodward, MSN, RN, CNS, AHN-BC, HTCP
Founder
Cocreative Wellness
Denver, Colorado
Kelly White, RN, PhD, FNP-BC
Assistant Professor
South University
West Palm Beach, Florida
3312_FM_i-xx 26/12/14 5:51 PM Page xiv
Reviewers
xv
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
Professor
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
3312_FM_i-xx 26/12/14 5:51 PM Page xv
3312_FM_i-xx 26/12/14 5:51 PM Page xvi
Contents
xvii
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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Section I
An Introduction to Nursing Theory
1
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2
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.
Section
I An Introduction to Nursing Theory
2
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Chapter 1Nursing Theory and the
Discipline of Nursing
MARLAINE C. SMITH AND
MARILYN E. PARKER
The Discipline of Nursing
Definitions of Nursing Theory
The Purpose of Theory in a Professional
Discipline
The Evolution of Nursing Science
The Structure of Knowledge in the
Discipline of Nursing
Nursing Theory and the Future
Summary
References
Marilyn E. ParkerMarlaine C. Smith
3
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.
Domain
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
practice.
• 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.
Tradition
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
nursing.
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
theories.
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
research.
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
launched.
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
perspectives.
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
research.
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
others.
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
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
strategies.
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
models.
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
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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
understanding the nature of nursing as a pro-
fessional discipline provide a frame of refer-
ence to clarify nursing theory.
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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
MARILYN E. PARKER AND
MARLAINE C. SMITH
Study of Theory for Nursing Practice
A Guide for Study of Nursing Theory for
Use in Practice
Summary
References
Marlaine C. SmithMarilyn E. Parker
19
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 http://davisplus.fadavis.com
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by the American Nurses Credentialing Cen-
ter (www.nursecredentialing.org/magnet) 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
Practice
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
theory?
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
practice?
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
described?
• 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
theory?
• 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
theory?
• What were the social, economic, and
political influences that informed the
theory?
• What images of nurses and nursing
influenced the development of the
theory?
• 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
authorities?
CHAPTER 2 • A Guide for the Study of Nursing Theories for Practice 21
3312_Ch02_019-022 26/12/14 10:04 AM Page 21
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
practice?
• How has the theory been used to guide
programs of nursing education?
• How has the theory been used to
guide nursing administration and
organizations?
• 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
practice?
• 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
future?
• 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
References
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
MARILYN E. PARKER AND
MARLAINE C. SMITH
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
Summary
References
Marlaine C. SmithMarilyn E. Parker
23
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
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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
perspective.
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
classroom?
• 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
work?
• 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
situations.
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
today?
• 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
situation?
• Who was I as a nurse in the situation?
• What was the relationship between
the person, family, or community and
myself?
• 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
situation?
• 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
situation?
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.
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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
practice.
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
practice?
• 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
theory.
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
nursing
• 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
Practice
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-
science.org.
3312_Ch03_023-034 26/12/14 10:08 AM Page 32
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
model.
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
were offered.
References
Boykin, A., Parker, M., & Schoenhofer, S. (1994). Aes-
thetic knowing grounded in an explicit conception of
nursing. Nursing Science Quarterly, 7(4), 158–161.
Boykin, A., Schoenhofer, S. & Valentine, K. (2013.
Transformation for Nursing and Healthcare Leaders:
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Springer.
Carper, B. A. (1978). Fundamental patterns of knowing
in nursing. Advances in Nursing Science, 1(1), 13–23.
Chinn, P., & Jacobs, M. (2007). Integrated theory and
knowledge development in nursing. (7th edition).
St. Louis, MO: Mosby.
Chinn, P., & Kramer, M. (2007). Integrated knowledge
development in nursing (7th ed.). St. Louis,
MO: Mosby.
Chinn, P., & Kramer, M. (2011). Integrated theory
and knowledge development in nursing (8th ed.).
St. Louirs, MO: Mosby.
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Fawcett, J. (2004). Analysis and evaluation of contempo-
rary nursing knowledge. Philadelphia: F.A. Davis.
Fawcett, J. & DeSanto-Madeya . (2012). Analysis
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Fitzpatrick, J., & Whall, A. (2004). Conceptual models
of nursing. Stamford, CT: Appleton & Lange.
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Leight, S. B. (2002). Starry night: Using story to inform
aesthetic knowing in women’s health nursing.
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Meleis, A. (2011). Theoretical nursing: Development and
progress (5th ed.). Philadelphia: Lippincott.
Meleis, A. (2004). Theoretical nursing: Development and
progress (3rd ed.). Philadelphia: Lippincott.
Munhall, P. (1993). Unknowing: Toward another
pattern of knowing in nursing. Nursing Outlook, 41,
125–128.
Parker, M. (1993). Patterns of nursing theories in practice.
New York: National League for Nursing.
Parker, M. E. (2002). Aesthetic ways in day-to-day
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Improving patient care through self-awareness and
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Parse, R. R. (1987). Nursing science: Major paradigms,
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Phenix, P. H. (1964). Realms of meaning. New York:
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Pierson, W. (1999). Considering the nature of intersub-
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Rogers, M. E. (1988). Nursing science and art: A
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Ruth-Sahd, L. A. (2003). Intuition: A critical way of
knowing in a multicultural nursing curriculum.
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Smith, M. C. (2013). Evaluation of middle range theo-
ries for the discipline of nursing. In M. J. Smith &
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(pp. 35–50). New York, NY: Springer.
Stevens, B. (1998). Nursing theory: Analysis, application,
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Thompson, C. (1999). A conceptual treadmill: The need
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Whall, A. (2004). The structure of nursing knowledge:
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34 SECTION I • An Introduction to Nursing Theory
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Section II
Conceptual Influences on
the Evolution of Nursing Theory
35
3312_Ch04_035-054 26/12/14 2:28 PM Page 35
36
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.
Section
II Conceptual Influences on the Evolution of Nursing Theory
36
3312_Ch04_035-054 26/12/14 2:28 PM Page 36
Chapter 4Florence Nightingale’s Legacy
of Caring and Its Applications
LYNNE M. HEKTOR DUNPHY
Introducing the Theorist
Early Life and Education
Spirituality
War
Introducing the Theory
The Medical Milieu
The Feminist Context of Nightingale’s
Caring
Ideas About Nursing
Nightingale’s Legacy for 21st Century
Nursing Practice
Summary
References
Florence Nightingale
37
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
3312_Ch04_035-054 26/12/14 2:28 PM Page 37
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.
—FLORENCE NIGHTINGALE, CITED IN COOK
(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.
3312_Ch04_035-054 26/12/14 2:28 PM Page 38
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.
Spirituality
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.
—FLORENCE NIGHTINGALE, PRIVATE NOTE,
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
documented.
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
CHAPTER 4 • Florence Nightingale’s Legacy of Caring and Its Applications 39
3312_Ch04_035-054 26/12/14 2:28 PM Page 39
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-
sibility.
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).
War
I stand at the altar of those murdered men and
while I live I fight their cause.
—NIGHTINGALE, CITED IN WOODHAM-SMITH
(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
40 SECTION II • Conceptual Influences on the Evolution of Nursing Theory
3312_Ch04_035-054 26/12/14 2:28 PM Page 40
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,
1988).
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).
42 SECTION II • Conceptual Influences on the Evolution of Nursing Theory
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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
1854
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
100
48 per
100 22
per
100
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.
—FLORENCE NIGHTINGALE, NOTES ON
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.
3312_Ch04_035-054 26/12/14 2:28 PM Page 44
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
CHAPTER 4 • Florence Nightingale’s Legacy of Caring and Its Applications 45
3312_Ch04_035-054 26/12/14 2:28 PM Page 45
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.
—FLORENCE NIGHTINGALE, PRIVATE NOTE,
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
radically.
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,
1860/1969)
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
CHAPTER 4 • Florence Nightingale’s Legacy of Caring and Its Applications 47
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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.
—FLORENCE NIGHTINGALE, NOTES ON
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
48 SECTION II • Conceptual Influences on the Evolution of Nursing Theory
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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,
prescient.
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
CHAPTER 4 • Florence Nightingale’s Legacy of Caring and Its Applications 49
3312_Ch04_035-054 26/12/14 2:28 PM Page 49
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
(1994).
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
nursing.
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
discipline.
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
environment.
10. Sickness and wellness are governed by the
same laws of health.
11. The nurse should be observant and
confidential.
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
Assumptions).
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
50 SECTION II • Conceptual Influences on the Evolution of Nursing Theory
3312_Ch04_035-054 26/12/14 2:28 PM Page 50
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
3312_Ch04_035-054 26/12/14 2:28 PM Page 51
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?
Noise
Chattering hopes
and advices
Variety
Observation
Personal cleanliness
Petty management
Light
Order
of
significance
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.
Observation
Management
Ventilation & warming
Health of houses (pure air, water & light)
“Nursing”
“Environment”
Cleanliness
of rooms &
walls
Taking food
What food ?
Personal
cleanliness
Bed &
bedding
Light,
noise &
variety
Chattering
hopes &
advices
Fig 4 • 6 Nightingale’s model of nursing and the environment. Illustration developed by V. Fondriest, RN, BSN,
and J. Osborne, RN, C BSN.
“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
3312_Ch04_035-054 26/12/14 2:28 PM Page 52
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
Commonwealth.
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
SHIRLEY C. GORDON
Introducing the Theorists
Overview of Wiedenbach, Henderson,
and Hall’s Conceptualizations of Nursing
Practice Applications
Practice Exemplars
Summary
References
Ernestine Wiedenbach
55
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 http://davisplus.fadavis.com.
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
56 SECTION II • Conceptual Influences on the Evolution of Nursing Theory
3312_Ch05_055-066 26/12/14 2:41 PM Page 56
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
Nursing
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
CHAPTER 5 • Early Conceptualizations About Nursing 57
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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
58 SECTION II • Conceptual Influences on the Evolution of Nursing Theory
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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
recreation.
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
sciences
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.)
3312_Ch05_055-066 26/12/14 2:41 PM Page 59
Care
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)
Cure
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)
Core
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)
Wiedenbach
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
Adm
inistra
tio
n
Validation
I
d
e
n
t i
f i
ca
t io
n
Exper iencing
indiv idua l
C
o
-o
rdination
C
on
st
ru
ct
io
n
Col
labora t ion
Nurs ing A
dm
in
is t r a
tio
n
N
u
rs
in
g
ed
uc
at
ion
Nursing Organiz
ati
on
s
A
d
va
n
ced study
Research
P
ub
lic
at
io
n
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
practice.
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.
Henderson
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,
1955).
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).
Hall
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.
PRACTICE EXEMPLARS
Wiedenbach
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
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
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.
64 SECTION II • Conceptual Influences on the Evolution of Nursing Theory
3312_Ch05_055-066 26/12/14 2:41 PM Page 64
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.
References
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(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.
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St. Louis, MO: C. V. Mosby.
Dickoff, J., James, P., & Wiedenbach, E. (1968). Theory
in a practice discipline. Nursing Research, 14(5),
415–437.
Englert, B. (1971). How a staff nurse perceives her role
at Loeb Center. Nursing Clinics of North America,
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bach, Henderson, and Orlando’s theories and their
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phia: F. A. Davis.
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Gordon, S. C. (2001). Virginia Avenel Henderson
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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
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3312_Ch05_055-066 26/12/14 2:41 PM Page 66
Chapter 6Nurse–Patient Relationship
Theories
Hildegard Peplau, Joyce Travelbee, and
Ida Jean Orlando
ANN R. PEDEN, JACQUELINE STAAL,
MAUDE RITTMAN, AND DIANE
LEE GULLETT
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
References
67
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
References
Part Three Ida Jean Orlando’s
Dynamic Nurse–Patient
Relationship
Introducing the Theorist
Overview of Orlando’s Theory of the
Dynamic Nurse–Patient Relationship
Practice Applications
Practice Exemplar
References
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
nothing.”
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
chapter.
Part One Peplau’s Nurse–Patient Relationship
ANN R. PEDEN1
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.
68 SECTION II • Conceptual Influences on the Evolution of Nursing Theory
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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
CHAPTER 6 • Nurse–Patient Relationship Theories 69
3312_Ch06_067-086 26/12/14 11:18 AM Page 69
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
Relationship
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
70 SECTION II • Conceptual Influences on the Evolution of Nursing Theory
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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
http://davisplus.fadavis.com.
3312_Ch06_067-086 26/12/14 11:18 AM Page 71
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
interventions.
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” (www.stmarys.org/relation-
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
72 SECTION II • Conceptual Influences on the Evolution of Nursing Theory
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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
Continued
3312_Ch06_067-086 26/12/14 11:18 AM Page 73
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.
3312_Ch06_067-086 26/12/14 11:18 AM Page 74
CHAPTER 6 • Nurse–Patient Relationship Theories 75
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Part Two Joyce Travelbee’s Human-to-Human
Relationship Model and Its Applications
JACQUELINE STAAL
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
Conceptualization
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
76 SECTION II • Conceptual Influences on the Evolution of Nursing Theory
3312_Ch06_067-086 26/12/14 11:18 AM Page 76
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
CHAPTER 6 • Nurse–Patient Relationship Theories 77
3312_Ch06_067-086 26/12/14 11:18 AM Page 77
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.
78 SECTION II • Conceptual Influences on the Evolution of Nursing Theory
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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
developed.
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
examination.
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).
References
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: www.iom.edu/Reports/2001/Crossing-
the-Quality-Chasm-A-New-Health-System-for-
the-21st-Century.aspx
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
Elsevier.
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.
3312_Ch06_067-086 26/12/14 11:18 AM Page 81
Part Three Ida Jean Orlando’s Dynamic Nurse–
Patient Relationship
MAUDE RITTMAN AND DIANE GULLETT
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,
2007.
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,
1991).
Overview of Orlando’s Theory
of the Dynamic Nurse–Patient
Relationship
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,
1972).
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
3312_Ch06_067-086 26/12/14 11:18 AM Page 82
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
3312_Ch06_067-086 26/12/14 11:18 AM Page 83
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
concerns.
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 (www.vawnet.org) and the Florida
Coalition Against Domestic Violence
(www.fcadv.org). 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
3312_Ch06_067-086 26/12/14 11:18 AM Page 85
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).
References
Abraham, S. (2011). Fall prevention conceptual frame-
work. The Health Care Manager, 30(2), 179–184. doi:
10.1097/HCM.0b013e31826fb74
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),
59–75.
Grove, C. (2008). Staff intervention to improve patient
satisfaction (master’s thesis). Retrieved from Pro-
Quest Dissertations and Theses database. (UMI
1454183)
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:
10.1177/1078390305277443
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:
10.111/j.1365-2648.2008.04795.x
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Section III
Conceptual Models/Grand
Theories in the Integrative-
Interactive Paradigm
87
3312_Ch07_087-104 26/12/14 2:43 PM Page 87
88
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.
Section
III
88
1 Person refers to individuals, families, groups or communities.
3312_Ch07_087-104 26/12/14 2:43 PM Page 88
Chapter 7Dorothy Johnson’s Behavioral
System Model and Its
Applications
BONNIE HOLADAY
Introducing the Theorist
Overview of Johnson’s Behavioral
System Model
Applications of the Model
Practice Exemplar by Kelly White
Summary
References
Dorothy Johnson
89
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
responsibility.
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
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.
Reorganization
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.
Person
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
Goal
Function
Affiliative Subsystem
Goal
Function
Aggressive/Protective Subsystem
Goal
Function
Dependency Subsystem
Goal
Function
Eliminative Subsystem
Goal
Function
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
environment
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
Continued
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94 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
Ingestive Subsystem
Goal
Function
Restorative Subsystem
Goal
Function
Sexual Subsystem
Goal
Function
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.”
Subsystems
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
3312_Ch07_087-104 26/12/14 2:43 PM Page 94
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.
Environment
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.
Health
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
CHAPTER 7 • Dorothy Johnson’s Behavioral System Model and Its Applications 97
3312_Ch07_087-104 26/12/14 2:43 PM Page 97
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,
98 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
3312_Ch07_087-104 26/12/14 2:43 PM Page 98
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.
Education
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 http://davisplus.fadavis.com
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
cancer.
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
hospitalized.
3312_Ch07_087-104 26/12/14 2:43 PM Page 100
CHAPTER 7 • Dorothy Johnson’s Behavioral System Model and Its Applications 101
Practice Exemplar cont.
Assessment
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:
Internal/external
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.
Continued
3312_Ch07_087-104 26/12/14 2:43 PM Page 101
102 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
Practice Exemplar cont.
Evaluation
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.
Epilogue
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.
3312_Ch07_087-104 26/12/14 2:43 PM Page 102
CHAPTER 7 • Dorothy Johnson’s Behavioral System Model and Its Applications 103
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the Johnson model. University of California, San
Francisco.
Wu, R. (1973). Behavior and illness. Englewood Cliffs,
NJ: Prentice-Hall.
104 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
3312_Ch07_087-104 26/12/14 2:43 PM Page 104
Chapter 8Dorothea Orem’s Self-Care
Deficit Nursing Theory
DONNA L. HARTWEG
Introducing the Theorist
Overview of the Theory
Applications of the Theory
Practice Applications
Practice Exemplar by Laureen Fleck
Summary
References
105
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”
(www.scdnt.com). 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 (www.scdnt.com/ja/jarchive.html). Twelve
biennial Orem congresses have been held
throughout the world (Berbiglia, Hohmann, &
Bekel, 2012; www.ioscongress2012.lu).
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 (www.medicalarchives.jhmi.edu/
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 http://davisplus.fadavis.com
3312_Ch08_105-132 26/12/14 5:50 PM Page 106
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
3312_Ch08_105-132 26/12/14 5:50 PM Page 107
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
108 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
3312_Ch08_105-132 26/12/14 5:50 PM Page 108
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,
2011).
Concepts
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
Self-care
Self-care
demands
Conditioning
factors
Conditioning
factors
Conditioning
factors
Self-care
agency
Deficit
Nursing
agency
RR
R
R
R
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
(2008).
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
110 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
3312_Ch08_105-132 26/12/14 5:50 PM Page 110
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
Operations
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
Capabilities
for self-care
operations
Power components
(enabling capabilities
for self-care)
Foundational capabilities
and disposition
Fig 8 • 2 Structure of self-care agency.
3312_Ch08_105-132 26/12/14 5:50 PM Page 111
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
resources.
Self-Care Requisites
To provide the framework for determining the
TSCD, Orem developed three types of self-care
112 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
3312_Ch08_105-132 26/12/14 5:50 PM Page 112
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
pesticides.
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
well-being.
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)
CHAPTER 8 • Dorothea Orem’s Self-Care Deficit Nursing Theory 113
3312_Ch08_105-132 26/12/14 5:50 PM Page 113
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
caregivers.
Self-Care Deficit (Dependent-Care
Deficit)
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
System)
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
professional-technological.
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
114 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
3312_Ch08_105-132 26/12/14 5:50 PM Page 114
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
self-care
Nurse
action
Patient
action
Patient
action
Nurse
action
Nurse
action
Supports and protects
patient
Performs some self-care
measures for patient
Compensates for self-care
limitations of patient
Assists patient as required
Performs some self-care
measures
Regulated self-care
agency
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,
2011).
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
“supportive”
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,
employment,
and health sta-
tus facilitated
SC practices;
smoking and
chronic condi-
tions were
barriers.
Before and
after beginning
caregiving:
GMs were sta-
tistically differ-
ent with fewer
days of eating
Armer, Brooks, &
Steward (2011),
USA
Arvidsson,
Bergman,
Arvidsson,
Fridlund, & Tops
(2011), Sweden
Burdette (2012),
USA
Carthron,
Johnson, Hubbart,
Strickland, &
Nance (2010),
USA
To examine
patient per-
ceptions of
SC limitations
to meet TSCD
to reduce
lymphedema
To describe
the meaning
of health-
promoting
SC in pa-
tients with
rheumatic
diseases
To examine
relationship
among SCA,
SC, and
obesity
To compare
diabetes self-
management
activities of
primary care-
giving grand-
mothers (GM)
Breast cancer
survivors,
postsurgery
(N = 14)
Rheumatic
disease
patients
(N = 12)
Rural midlife
women
(N = 224)
African
American
GMs with
type 2
diabetes
(N = 68, 34
per group)
SCA,
especially
estimative,
transi-
tional, and
productive
phases of
self-care
necessary
to de-
crease
risk of lym-
phedema;
supportive-
educative
nursing
system
Health-
promoting
SC
BCFs,
SCA, and
SC prac-
tices; com-
plemented
with rural
nursing
theory
BCF (fam-
ily system
factor of
grand-
mother
role;
patterns of
Secondary
analysis of
qualitative
data from
pilot study
(Armer
et al.,
2009)
Phenome-
nology
Predictive
correla-
tional
design
was used.
Nonexper-
imental,
compara-
tive design
Continued
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-
management
blood glucose
tests. Fewer self-
management
blood glucose
tests and fewer
eye examina-
tions were per-
formed by GMs
providing pri-
mary care to
grandchildren.
Significant dif-
ference was
found between
self-care
agency and
quality of life in
treatment
group vs con-
trol group at
8 weeks after
prostatectomy.
Four themes
emerged on self-
management:
daily life prac-
tices (dietary, ex-
ercise, medicine,
doctor follow-up,
blood sugar
self-monitoring,
use of herbal
remedies), af-
fect of illness,
family support
and need for
everyday life
as before
diagnosis (e.g.,
maintaining
religious prac-
tices during
Ramadan).
For patients
with RA, pa-
tients with
higher disabil-
ity and pain
had lower self-
care agency.
The potential for
development of
Kim (2011),
Korea
Lundberg &
Thrakul (2011),
Sweden &
Thailand
Ovayolu,
Ovayolu, &
Karadag (2011),
Turkey
before and
after begin-
ning caregiv-
ing activities;
to compare
these GMs’
self-manage-
ment activi-
ties with
those of GMs
not providing
primary care
To determine
effectiveness
of a program
to develop
SCA based
on SC needs
specific to
prostatectomy
To explore
Thai Muslim
women’s self-
management
of type 2
diabetes
To explore re-
lationship
among SCA,
disability lev-
els, and other
factors
Prostate can-
cer patients
(N = 69)
Thai Muslim
women living
in Bangkok
(N = 29)
Turkish pa-
tients with
rheumatoid
arthritis (RA)
(N = 467)
living);
TSCD;
SCA,
especially
power
compo-
nents
SCA;
quality
of life
Orem’s
SCDNT
was used
as frame-
work
SCA;
Factors re-
lated to
health-
care, such
as pain
and dis-
ability
level.
Quasi-
experimen-
tal; non-
equivalent
control
group using
pre–post
test design
Ethno-
graphic
study using
participant
observation
Cross-
sectional;
descriptive–
correla-
tional
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
knowledge,
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,
self-monitoring.
Both systolic
and diastolic
readings of
treatment group
were lower
than control
group.
Demonstrated
improvement in
health indica-
tors after design
of a nursing sys-
tem directed at
deficits in SCA
related to
HDSCR.
51% of patients
had the re-
quired hepatitis
B SC knowl-
edge, espe-
cially need for
exercise, rest,
and methods of
prevention of
transmission
through sexual
activity. There
was a knowl-
edge deficit re-
lated to diet and
management/
monitoring of
disease.
Level of educa-
tion, type of
occupation,
previous health
education, and
Rujiwatthanakorn,
Panpakdee,
Malathum, &
Tanomsup (2011),
Thailand
Surucu & Kizilci
(2012), Turkey
Thi (2012), South
Vietnam
To examine
effectiveness
of a SC man-
agement
program
To explore
the use of
SCDNT in di-
abetes self-
management
education
To describe
levels of SC
knowledge in
patients
Thais with
essential
hypertension
(N = 96)
Type 2 dia-
betes patients
Hepatitis B in-
patients and
outpatients
(N = 230)
SC de-
mands,
self-care
ability
and
blood
pressure
control
TSCD,
HDSCR,
SCA
SCA (SC
knowl-
edge),
SCR,
BCFs
Quasi-
experimen-
tal
Descriptive
case study
Descriptive/
compara-
tive
Table 8 • 1 Examples of Research Applications—cont’d
Author (Year), Population/ SCDNT
Country Purpose Settings Concept(s) Methods Results
Continued
3312_Ch08_105-132 26/12/14 5:50 PM Page 121
122 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
health-care set-
ting affected
levels of SC
knowledge.
Knowledge
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
reasoning.
Wilson,
Mood,
Nordstrom
(2012), USA
To determine
whether
reading low
literacy pam-
phlets on
radiation
side effects
affect patient
knowledge
Urban radia-
tion oncology
clinic pa-
tients,
(N = 47)
SCA: SC
knowledge
of radia-
tion side
effects
Nonexperi-
mental,
exploratory
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
living.
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
Editorial
demonstrating
use of theoreti-
cal framework
to design a
brief checklist
An exemplar
for the six HD-
SCRs specific
health situation
and model for
developing
other condi-
tions using
multifaceted
technological
care
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-
teriovenous
fistula SC
Alspach
(2011), USA
Casida,
Peters, Peters,
& Magnan
(2009), USA
Green
(2012), USA
Hohdorf
(2010),
Germany
Hudson &
Macdonald
(2010),
Canada
Hypertension/
heart failure
in elderly
Left-ventricular
assist devices
(LVAD)
Children with
special needs
Hospitalized
patients
Adults with
hemodialysis
arteriovenous
fistula self-
cannulation
Critical care
unit
Acute care
School setting
Acute care
settings
Community
dialysis unit
SC
HDSCR, in-
cluding SC
systems
SCR; SCD;
BCF; SCA;
DCA; SCS
SCDNT
SCDNT as
framework;
all concepts
including NA
Development
of checklist
tool to meas-
ure SC at
home after
critical care
discharge
Reformulation
of HDSCR
common to
patients with
LVAD using
five guidelines
described by
Orem (2001)
to validate
form and
adequacy
Demonstration
of utility of
SCDNT
through two
case studies:
wholly com-
pensatory sys-
tem for child
with cerebral
palsy; partly
compensatory
for child with
asthma; and
supportive-
educative sys-
tem for diabetic.
Exemplified
change of
focus to
theory-based
nursing
practice
Demonstration
of SCDNT as
guide to de-
velop and
update patient-
teaching re-
sources in
preparation for
home care; as-
sisted nurses
with role
clarification
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
Continued
3312_Ch08_105-132 26/12/14 5:50 PM Page 123
124 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
Theoretical
paper incorpo-
rating elements
of other theo-
ries to expand
supportive-
developmental
technologies in
patients with
serious mental
illness
Demonstrates
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
SCDNT as
component of
health system
practice model
Pickens
(2012), USA
Seed &
Torkelson
(2012), USA
Surucu &
Kizilci,
(2012),
Turkey
Swanson &
Tidwell
(2011), USA
Wanchai,
Armer, &
Stewart
(2010), USA,
Canada,
Germany
Adults with
schizophrenia
Acute psychi-
atric care
Use of
SCDNT in
type 2 dia-
betes self-
management
education
Integration
model of
shared gover-
nance using
magnet com-
ponents to
promote pa-
tient safety
Breast cancer
survivors
Psychiatric
nursing care
Recovery
principles
University set-
ting; diabetes
education
center
Orem’s self-
care deficit
theory as
general prac-
tice frame-
work
Multiple
settings
based on
review of 11
studies from
1990
through
2009
SCA:
motivation
component
SCDNT con-
cepts in align-
ment with
recovery can
be used to
structure inter-
ventions and
research in
acute psychi-
atric settings
BCFs; SCA;
SCD; TSCD,
with empha-
sis on HDSCR
SCA; SCD;
helping
methods
SCA
Explored vari-
ous theories
of motivation
to develop
SCDNT’s
foundational
capability
and power
component of
motivation
SCDNT pro-
vided a com-
prehensive
framework
for delivering
interventions
that empower
individuals to
make choices
in care and
treatment
through part-
nerships and
education
Implemented
steps of gen-
eral nursing
process using
Orem-specific
concepts
Demonstrates
incorporation
of SCDNT as
the theoreti-
cal guide to
professional
practice at
one institution
and its com-
bination
shared gover-
nance to en-
hance patient
safety
SC agency
enhancement
through use
of comple-
mentary or
alternative
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
maintain
physical and
emotional
well-being
and to man-
age side ef-
fects of
treatment
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,
2011).
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,
FNP-BC, CDE
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],
2013)
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).
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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
http://davisplus.fadavis.com. 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
http://davisplus.fadavis.com.
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
http://davisplus.fadavis.com.
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
http://davisplus.fadavis.com.
5See Table 9-8 in the bonus chapter content available at
http://davisplus.fadavis.com.
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 http://davisplus.fadavis.com.
7See Table 9-11 in the bonus chapter content available
at http://davisplus.fadavis.com.
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 http://davisplus.fadavis.com.
9See Table 9-3 in the bonus chapter content available at
http://davisplus.fadavis.com.
10 See Table 9-7 in the bonus chapter content available
at http://davisplus.fadavis.com.
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
http://davisplus.fadavis.com.
12See Table 9-10 in the bonus chapter content available
at http://davisplus.fadavis.com.
13See Table 9-11 in the bonus chapter content available
at http://davisplus.fadavis.com.
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 http://davisplus.fadavis.com.
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. As researchers con-
tinue to integrate King’s theory and framework
with the dynamic health-care environment, fu-
ture applications involving evidence-based
practice will continue to demonstrate the ade-
quacy of King’s work in nursing practice.
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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 http://davisplus.fadavis.com
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
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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.
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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).
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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
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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.
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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.
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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).
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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
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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
.neumansystemsmodel.org.
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
(gfarr@nursing.upenn.edu).
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
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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
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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. The
Trustees are dedicated to the improvement of
health for people worldwide through develop-
ment and use of the NSM to guide practice,
education, research, and administration (www
.neumansystemsmodel.org/trustees).
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182 SECTION III • Conceptual Models/Grand Theories in the Integrative-Interactive Paradigm
References
Amaya, M. A. (2002). The Neuman systems model and
clinical practice: An integrative review 1974–2000.
In B. Neuman & J. Fawcett (Eds.), The Neuman
systems model (4th ed., pp. 216–243). Upper Saddle
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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 http://davisplus.fadavis.com.
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
.mrmnursingtheory.org), 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
.mrmnursingtheory.org).
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.
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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
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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
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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
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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.
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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
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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-
galedeclaration.net. 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
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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.
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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. http://www.kenwilber.com. 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. http://www.kenwilber.com. 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. http://www.kenwilber.com.
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. http://www.kenwilber.com. 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
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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,
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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,
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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
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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.
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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
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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
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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 http://davisplus.fadavis.com
See Barbara Dossey’s website at www.dosseydossey.com to download the theory of integral nursing PowerPoint and one-page
handout.
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CHAPTER 13 • Barbara Dossey’s Theory of Integral Nursing 231
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Wilber, K. (2005b). Integral life practice. Denver, CO:
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Wilber, K. (2006). Integral spirituality. Boston:
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healing: A theory. Alternative Therapies in Health and
Medicine, 10(6), 40–49.
Zahourek, R. (2013). Holistic nursing research:
Challenges and opportunities. In B. M. Dossey &
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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
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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
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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
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• 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
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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,
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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, and practicing. Rogers’s
nursing science postulates a pandimensional
universe of human–environmental energy fields
manifesting as continuously innovative, increas-
ingly diverse, creative, and unpredictable unitary
field patterns. The principles of homeodynamics
provide a way to understand the process of
human–environmental change, paving the way
for Rogerian theory–based practice. Rogers
often reminded us that unitary means whole.
Therefore, people are always whole, regardless
of what they are experiencing in the moment,
and therefore do not need nurses to facilitate
their wholeness. Rogers identified noninvasive
modalities as the basis for nursing practice now
and in the future. She stated that nurses must
use “nursing knowledge in non-invasive ways in
a direct effort to promote well-being” (Rogers,
1994a, p. 34). This focus gives nurses a central
role in health care rather than medical care. She
also noted that health services should be com-
munity based, not hospital based. Hospitals are
properly used to provide satellite services in spe-
cific instances of illness and trauma; they do not
provide health services. Rogers urged nurses to
develop autonomous, community-based nurs-
ing centers. See Boxes 14-1 and 14-2.
242 SECTION IV • Conceptual Models and Grand Theories in the Unitary–Transformative Paradigm
1 For additional information please go to bonus chapter
content available at FA Davis http://davisplus.fadavis.com
3312_Ch14_235-262 26/12/14 4:55 PM Page 242
For example, Todaro-Franceschi (2006) iden-
tified the existence of synchronicity experi-
ences, meaningful coincidences, in many who
were grieving the loss of a spouse, a pioneering
effort in delineating a unitary view of death and
dying. From the results of her qualitative study,
she described how such experiences help the
bereaved to relate to their deceased loved ones
in a new, meaningful way, one that is poten-
tially healing, rather than in the traditional view
of learning to let go and move on. Malinski
(2012) conceptualized the unitary rhythm of
dying–grieving, highlighting the shared nature
of this process, for the one grieving is also dying
a little just as the one dying is simultaneously
grieving. She synthesized this unitary rhythm
as “a process of kaleidoscopic patterning flow-
ing now swiftly now gently, spiraling creatively
through shifting rhythms of now-elsewhen-
elsewhere, becoming in solitude and silence
alone-all one, timeless-boundaryless” (p. 242).
Pandimensional awareness and experience of
this rhythm means recognition that there is no
space or time, no boundary or separation. The
reality is one of unity amid changing configu-
rations of patterning, with endless potentials.
Unfortunately, a number of ideas relevant
to nursing practice that Rogers discussed ver-
bally never made it into print, for example,
healing, intentionality, and expanded views on
Therapeutic Touch. In three audiotaped and
transcribed dialogues among Rogers, Malinski,
and Meehan on January 26, 1988, for example,
she described healing as a process, everything
that happens as persons actualize potentials
they identify as enhancing health and wellness
for themselves. Todaro-Franceschi (1999)
described healing in a similar way, with nurses
knowingly participating in the healing process
by helping people actualize “their unique
potentials—whatever those potentials may be”
(p. 104). Cowling (2001) described healing as
appreciating wholeness, offering unitary pattern
appreciation as the praxis for exploring whole-
ness within the unitary human–environmental
mutual process.
Rogers also reminded us that change is a
neutral process, neither good nor bad, one that
we cannot direct but in which we participate.
In this vein, in the transcribed dialogue among
CHAPTER 14 • Martha E. Rogers’s Science of Unitary Human Beings 243
Box 14-1 Nursing Practice Evolves (Update 1/2013)
The relevance of Rogerian nursing science
to both human well-being and nursing is
precisely the transformative vision of people
and the world that it offers. Recognizing this,
the nursing department at Bronx Lebanon
Hospital Center, Bronx, New York, has made
the decision to use Rogerian nursing science as
the framework for practice throughout the
hospital. People are complex, society is chang-
ing, and nursing’s image is changing and so is
our practice, which is driven by the science of
nursing, according to Dr. Jeanine M. Frumenti,
Vice President, Patient Care Services/Chief
Nursing Officer. Rogerian nursing science was
chosen because it is inclusive and reflective of
people’s ever-changing relationship to their
environment, whereas many other nursing
theories are reflective of the art of nursing.
According to Frumenti, nurses need to be
open to unfolding pattern and pandimensional
experiences; everything is integrated and
changing. The Rogerian nursing science
assists Bronx Lebanon nurses in actualizing
transformative practice for themselves and
their clients.
Box 14-2 Rogerian Nursing Science Wiki (http://rogeriannursingscience.wikispaces.com)
In 2008, Howard Butcher launched a wiki
site on Rogerian science with the purpose of
providing a website to gather Rogerian schol-
ars so they can mutually cocreate a compre-
hensive and easily accessible and in-depth
explication of the science of unitary human
beings. The wiki can be viewed by anyone and
is organized like a textbook with chapters on
the following: Rogers’ life, the aim of nursing
science, Rogerian cosmology and philosophy,
Rogers’ postulates, Rogerian science, Rogerian
theories, practice methods, and research
methods. There are links of all the issues of
Visions: The Journal of Rogerian Nursing Science
as well as photos. The wiki is not complete;
it is ever evolving. However, it is a valuable
resource to all interested in learning more
about the science of unitary human beings.
Rogers (1986) identified the living–dying
process as one characterized by rhythmical
patterning, opening the door to new ways of
studying and working with the dying process.
3312_Ch14_235-262 26/12/14 4:55 PM Page 243
Rogers, Malinski, and Meehan on Therapeutic
Touch, Rogers described this modality as a
neutral process, one that facilitates the pattern-
ing most commensurate with well-being for
the person, whatever that is. There is no ex-
change of energy, no identification of desired
outcomes in Therapeutic Touch. Rather than
intentionality, Rogers suggested knowing par-
ticipation as most congruent with her think-
ing, seeing intentionality as too closely tied to
will and intent. However, she did suggest that
a unitary view of intentionality was worthy
of study.
Rogers also questioned the concept of spir-
ituality, which she saw as too often confused
with religiosity. Smith (1994) and Malinski
(1991, 1994) have both explored a Rogerian
view of spirituality. Barrett (2010) suggested
that the interrelationships of pandimensional-
ity, consciousness, and spirituality will become
clearer and increasingly important. She defined
consciousness “as the Spirit in all that is, was,
and will be” and spirituality “as experiencing the
Spirit in all that is, was, and will be” (italics in
the original; p. 53).
Phillips (2010b) created the terms ener-
gyspirit and Homo pandimensionalis to highlight
expanding “pandimensional relative present
awareness” (p. 8). In a discussion about the big
bang, he suggested that if energy is indeed uni-
tary, discussions of physical energy are not only
incomplete but inaccurate. Phillips speculated,
“What if the big bang was a cataclysm of spirit
integral with energy that was not separated into
physical and spirit, but made their presence as
a unitary whole. Then, we have a new phenom-
enon known as energyspirit, one word. This en-
ergyspirit was the origin of the universe and
human beings and all their changes” (p. 9). En-
ergyspirit thus replaces any discussion of mind-
bodyspirit. Already of no relevance to Rogerian
nursing science, perhaps mindbodyspirit can be
replaced now with energyspirit throughout the
unitary perspective. As pandimensional relative
present awareness is continuously changing, it
is possible that we will see the emergence of
new, unanticipated pattern manifestations
characterizing the human–environmental mu-
tual field process. Phillips suggests that this
emerging life form is Homo pandimensionalis.
Evolution of Rogerian Practice
Methods
A hallmark of a maturing scientific practice
discipline is the development of specific prac-
tice and research methods evolving from the
discipline’s extant conceptual systems. Rogers
(1992) asserted that practice and research
methods must be consistent with the science
of unitary human beings to study irreducible
human beings in mutual process with a pandi-
mensional universe. Therefore, Rogerian prac-
tice and research methods must be congruent
with Rogers’ postulates and principles if they
are to be consistent with Rogerian science.
The goal of nursing practice is the promotion
of well-being and human betterment. Nursing
is a service to people wherever they may reside.
Nursing practice—the art of nursing—is the
creative application of substantive scientific
knowledge developed through logical analysis,
synthesis, and research. Since the 1960s, the
nursing process has been the dominant nursing
practice method. The nursing process is an
appropriate practice methodology for many
nursing theories. However, there has been some
confusion in the nursing literature concerning
the use of the traditional nursing process within
Rogers’s nursing science.
In early writings, Rogers (1970) did make
reference to nursing process and nursing diag-
nosis. But in later years she asserted that nurs-
ing diagnoses were not consistent with her
scientific system. Rogers (quoted in Smith,
1988, p. 83) stated:
Nursing diagnosis is a static term that is quite inap-
propriate for a dynamic system. . . . it [nursing diag-
nosis] is an outdated part of an old worldview, and
I think by the turn of the century, there are going to
be new ways of organizing knowledge.
Furthermore, nursing diagnoses are particu-
laristic and reductionist labels describing cause
and effect (i.e., “related to”) relationships incon-
sistent with a “nonlinear domain without spatial
or temporal attributes” (Rogers, 1992, p. 29).
The nursing process is a stepwise sequential
process inconsistent with a nonlinear or pandi-
mensional view of reality. In addition, the term
244 SECTION IV • Conceptual Models and Grand Theories in the Unitary–Transformative Paradigm
3312_Ch14_235-262 26/12/14 4:55 PM Page 244
intervention is not consistent with Rogerian
science. Intervention means to “come, appear,
or lie between two things” (American Heritage
Dictionary, 2000, p. 916). The principle of in-
tegrality describes the human and environ-
mental field as integral and in mutual process.
Energy fields are open, infinite, dynamic, and
constantly changing. The human and environ-
mental fields are inseparable, so one cannot
“come between.” The nurse and the client are
already inseparable and interconnected. Out-
comes are also inconsistent with Rogers’ prin-
ciple of helicy: expected outcomes infer
predictability. The principle of helicy describes
the nature of change as being unpredictable.
Within an energy-field perspective, nurses in
mutual process assist clients in actualizing their
field potentials by enhancing their ability to
participate knowingly in change. Given the in-
consistency of the traditional nursing process
with Rogers’ postulates and principles, the sci-
ence of unitary human beings requires the de-
velopment of new and innovative practice
methods derived from and consistent with the
conceptual system. A number of practice
methods have been derived from Rogers’s pos-
tulates and principles.
Barrett’s Rogerian Practice Method
Barrett’s Rogerian practice methodology for
health patterning was the first accepted alter-
native to the nursing process for Rogerian
practice (see Chapter 29). It was followed by
Cowling’s conceptualization.
Cowling’s Rogerian Practice
Cowling (1990) proposed a template compris-
ing 10 constituents for the development of
Rogerian practice models. Cowling (1993b,
1997) refined the template and proposed that
“pattern appreciation” was a method for uni-
tary knowing in both Rogerian nursing re-
search and practice. Cowling preferred the
term appreciation rather than assessment or ap-
praisal because appraisal is associated with
evaluation. Appreciation has broader meaning,
which includes “being fully aware or sensitive
to or realizing; being thankful or grateful for;
and enjoying or understanding critically or
emotionally” (Cowling, 1997, p. 130). Pattern
appreciation has a potential for deeper under-
standing. For a description of the constituents,
see Bonus content for the chapter.2
Unitary Pattern-Based Praxis Method
Butcher (1997a, 1999a, 2001) synthesized
Cowling’s Rogerian practice constituents with
Barrett’s practice method to develop a more
inclusive and comprehensive practice model.
In 2006, Butcher expanded the “praxis” model
by illustrating how the Rogerian cosmology,
ontology, epistemology, esthetics, ethics, pos-
tulates, principles, and theories all form an
“interconnected nexus” informing both Roger-
ian-based practice and research models
(Butcher, 2006a, p. 9). The unitary pattern–
based practice (Fig. 14-1) consists of two non-
linear and simultaneous processes: pattern
manifestation appreciation and knowing, and
voluntary mutual patterning. The focus of
nursing care guided by Rogers’s nursing
science is on pattern transformation by facili-
tating pattern recognition during pattern man-
ifestation knowing and appreciation and by
facilitating the client’s ability to participate
knowingly in change, harmonizing person–
environment integrality, and promoting heal-
ing potentialities and well-being through
voluntary mutual patterning
Pattern Manifestation Knowing and
Appreciation
Pattern manifestation knowing and apprecia-
tion is the process of identifying manifestations
of patterning emerging from the human–
environmental field mutual process and in-
volves focusing on the client’s experiences, per-
ceptions, and expressions. “Knowing” refers to
apprehending pattern manifestations (Barrett,
1988), whereas “appreciation” seeks a percep-
tion of the “full force of pattern” (Cowling,
1997). Pattern is the distinguishing feature of
the human–environmental field. Everything
experienced, perceived, and expressed is a
manifestation of patterning. During the
process of pattern manifestation knowing and
appreciation, the nurse and client are coequal
CHAPTER 14 • Martha E. Rogers’s Science of Unitary Human Beings 245
2 For additional information please go to bonus chapter
content available at FA Davis http://davisplus.fadavis.com
3312_Ch14_235-262 26/12/14 4:55 PM Page 245
participants. In Rogerian practice, nursing sit-
uations are approached and guided by a set of
Rogerian-ethical values, a scientific base for
practice, and a commitment to enhance the
client’s desired potentialities for well-being.
Unitary pattern–based practice begins by
creating an atmosphere of openness and free-
dom so that clients can freely participate in the
process of knowing participation in change.
Approaching the nursing situation with an ap-
preciation of the uniqueness of each person
and with unconditional love, compassion, and
empathy can help create an atmosphere of
openness and healing patterning (Butcher,
2002; Malinski, 2004). Rogers (1966/1994)
defined nursing as a humanistic science dedi-
cated to compassionate concern for humans.
Compassion includes energetic acts of uncon-
ditional love and means (1) recognizing the
interconnectedness of the nurse and client by
being able to fully understand and know the
suffering of another, (2) creating actions de-
signed to transform injustices, and (3) not only
grieving in another’s sorrow and pain but also
rejoicing in another’s joy (Butcher, 2002).
Pattern manifestation knowing and appre-
ciation involves focusing on the experiences,
perceptions, and expressions of a health situa-
tion, revealed through a rhythmic flow of
communion and dialogue. In most situations,
the nurse can initially ask the client to describe
his or her health situation and concern. The di-
alogue is guided toward focusing on uncover-
ing the client’s experiences, perceptions, and
expressions related to the health situation as a
means to reaching a deeper understanding of
unitary field pattern. Humans are constantly
all-at-once experiencing, perceiving, and ex-
pressing (Cowling, 1993a). Experience in-
volves the rawness of living through sensing
and being aware as a source of knowledge and
includes any item or ingredient the client
246 SECTION IV • Conceptual Models and Grand Theories in the Unitary–Transformative Paradigm
Unitary pattern-based praxis
Rogerian cosmology Rogerian philosophy
Rogerian science
Rogerian theories Pattern-based researchPattern-based practice
Pattern manifestation
Knowing and appreciation
Voluntary mutual
patterning
Unitary field pattern
portrait research
method
Knowing participation in change
Pattern transformation
Potentialities for human betterment and well-being
Fig 14 • 1 The unitary pattern-based praxis model. (Model from Butcher, H. K.
[2006a]. Unitary pattern-based praxis: A nexus of Rogerian cosmology, philosophy, and
science. Visions: The Journal of Rogerian Nursing Science, 14[2], 8–33.)
3312_Ch14_235-262 26/12/14 4:55 PM Page 246
senses (Cowling, 1997). The client’s own ob-
servations and description of his or her health
situation includes his or her experiences. “Per-
ceiving is the apprehending of experience or
the ability to reflect while experiencing”
(Cowling, 1993a, p. 202). Perception is mak-
ing sense of the experience through awareness,
apprehension, observation, and interpreting.
Asking clients about their concerns, fears, and
observations is a way of apprehending their
perceptions. Expressions are manifestations of
experiences and perceptions that reflect human
field patterning. In addition, expressions are
any form of information that comes forward in
the encounter with the client. All expressions
are energetic manifestations of field patterns.
Body language, communication patterns, gait,
behaviors, laboratory values, and vital signs are
examples of energetic manifestations of human–
environmental field patterning.
Because all information about the client–
environment–health situation is relevant, var-
ious health assessment tools, such as the
comprehensive holistic assessment tool devel-
oped by B. M. Dossey, Keegan, and Guzzetta
(2004), may also be useful in pattern knowing
and appreciation. However, all information
must be interpreted within a unitary context.
A unitary context refers to conceptualizing all
information as energetic/dynamic manifesta-
tions of pattern emerging from a pandimen-
sional human–environmental mutual process.
All information is interconnected, is insepa-
rable from environmental context, unfolds
rhythmically and acausally, and reflects the
whole. Data are not divided or understood by
dividing information into physical, psycholog-
ical, social, spiritual, or cultural categories.
Rather, a focus on experiences, perceptions,
and expressions is a synthesis more than and
different from the sum of parts. From a uni-
tary perspective, what may be labeled as ab-
normal processes, nursing diagnoses, or illness
or disease are conceptualized as episodes of
discordant rhythms or nonharmonic reso-
nancy (Bultemeier, 2002).
A unitary perspective in nursing practice
leads to an appreciation of new kinds of infor-
mation that may not be considered within other
conceptual approaches to nursing practice. The
nurse is open to using multiple forms of know-
ing, including pandimensional modes of
awareness (intuition, meditative insights, tacit
knowing) throughout the pattern manifesta-
tion knowing and appreciation process. Intu-
ition and tacit knowing are artful ways to
enable seeing the whole, revealing subtle pat-
terns, and deepening understanding. Pattern
information concerning time perception, sense
of rhythm or movement, sense of connected-
ness with the environment, ideas of one’s own
personal myth, and sense of integrity are rele-
vant indicators of human–environment–health
potentialities (Madrid & Winstead-Fry, 1986).
A person’s hopes and dreams, communication
patterns, sleep–rest rhythms, comfort–discomfort,
waking–beyond waking experiences, and de-
gree of knowing participation in change pro-
vide important information regarding each
client’s thoughts and feelings concerning a
health situation.
The nurse can also use a number of pattern
appraisal scales derived from Rogers’s postulates
and principles to enhance the collecting and un-
derstanding of relevant information specific to
Rogerian science. For example, nurses can use
Barrett’s (1989) power as knowing participation
in change tool as a way of knowing clients’ en-
ergy field patterns in relation to their capacity
to knowingly participate in the continuous pat-
terning of human and environmental fields as
manifest in frequencies of awareness, choice
making ability, sense of freedom to act inten-
tionally, and degree of involvement in creating
change. Watson’s (1993) assessment of dream
experience scale can be used to know and
appreciate the clients’ dream experiences, and
Ference’s (1979, 1986) human field motion tool
is an indicator of the wave frequency pattern of
the energy field.
Hastings-Tolsma’s (1992) diversity of human
field pattern scale may be used as a means for
knowing and appreciating a clients’ perception
of the diversity of their energy field pattern,
Johnston’s (1994) human image metaphor scale
can be used as a way of knowing and appreciat-
ing the clients’ perception of the wholeness of
their energy field, and the well-being picture
scale for adults (Gueldner et al., 2005; Johnson,
Guadron, Verchot, & Gueldner, 2011) and for
CHAPTER 14 • Martha E. Rogers’s Science of Unitary Human Beings 247
3312_Ch14_235-262 26/12/14 4:55 PM Page 247
children (Terwillinger, Gueldner, & Bronstein,
2012) afford a way to measure a person’s sense
of unitary well-being. Paletta (1990) developed
a tool consistent with Rogerian science that
measures the subjective awareness of temporal
experience.
The pattern manifestation knowing and ap-
preciation is enhanced through the nurse’s
ability to grasp meaning, create a meaningful
connection, and participate knowingly in the
client’s change process (Butcher, 1999a).
“Grasping meaning entails using sensitivity,
active listening, conveying unconditional ac-
ceptance, while remaining fully open to the
rhythm, movement, intensity, and configura-
tion of pattern manifestations” (Butcher,
1999a, p. 51). Through integrality, nurse and
client are always connected in mutual process.
However, a meaningful connection with the
client is facilitated by creating a rhythm and
flow through the intentional expression of un-
conditional love, compassion, and empathy.
Together, in mutual process, the nurse and
client explore the meanings, images, symbols,
metaphors, thoughts, insights, intuitions,
memories, hopes, apprehensions, feelings, and
dreams associated with the health situation.
Rogerian ethics are integral to all unitary
pattern–based practice situations. Rogerian
ethics are pattern manifestations emerging
from the human–environmental field mutual
process that reflect those ideals concordant
with Rogers’ most cherished values and are
indicators of the quality of knowing partici-
pation in change (Butcher, 1999b). Thus,
unitary pattern–based practice includes mak-
ing the Rogerian values of reverence, human
betterment, generosity, commitment, diver-
sity, responsibility, compassion, wisdom, jus-
tice-creating, openness, courage, optimism,
humor, unity, transformation, and celebration
intentional in the human–environmental field
mutual process (Butcher, 1999b, 2000).
When initial pattern manifestation know-
ing and appreciation is complete, the nurse
synthesizes all the pattern information into a
meaningful pattern profile. The pattern profile
is an expression of the person–environment–
health situation’s essence. The nurse weaves
together the expressions, perceptions, and
experiences in a way that tells the client’s story.
The pattern profile reveals the hidden meaning
embedded in the client’s human–environmental
mutual field process. Usually the pattern pro-
file is in a narrative form that describes the
essence of the properties, features, and quali-
ties of the human–environment–health situa-
tion. In addition to a narrative form, the
pattern profile may also include diagrams,
poems, listings, phrases, metaphors, or a com-
bination of these. Interpretations of any meas-
urement tools may also be incorporated into
the pattern profile.
Voluntary Mutual Patterning
Voluntary mutual patterning is a process of
transforming human–environmental field
patterning. The goal of voluntary mutual pat-
terning is to facilitate each client’s ability to
participate knowingly in change, harmonize
person–environment integrality, and promote
healing potentialities, lifestyle changes, and
well-being in the client’s desired direction of
change without attachment to predetermined
outcomes. The process is mutual in that both
the nurse and the client are changed with
each encounter, each patterning one another
and coevolving together. “Voluntary” signifies
freedom of choice or action without external
compulsion (Barrett, 1998). The nurse has
no investment in changing the client in a
particular way.
Whereas patterning is continuous, voluntary
mutual patterning may begin by sharing the
pattern profile with the client. Sharing the pat-
tern profile with the client is a means of vali-
dating the interpretation of pattern information
and may spark further dialogue, revealing new
and more in-depth information. Sharing the
pattern profile with the client facilitates pattern
recognition and also may enhance the client’s
knowing participation in his or her own change
process. An increased awareness of one’s own
pattern may offer new insight and increase
one’s desire to participate in the change process.
In addition, the nurse and client can continue
to explore goals, options, choices, and voluntary
mutual patterning strategies as a means to
facilitate the client’s actualization of his or her
human–environmental field potentials.
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3312_Ch14_235-262 26/12/14 4:55 PM Page 248
A wide variety of mutual patterning strate-
gies may be used in Rogerian practice, includ-
ing many “interventions” identified in the
Nursing Intervention Classification (Bulechek,
Butcher, & Dochterman, 2013). However, “in-
terventions,” within a unitary context, are not
linked to nursing diagnoses and are reconcep-
tualized as voluntary mutual patterning strate-
gies, and the activities are reconceptualizied as
patterning activities. Rather than linking vol-
untary mutual patterning strategies to nursing
diagnoses, the strategies emerge in dialogue
whenever possible out of the patterns and
themes described in the pattern profile. Fur-
thermore, Rogers (1988, 1992, 1994a) placed
great emphasis on modalities that are tradition-
ally viewed as holistic and noninvasive. In
particular, the use of sound, dialogue, affirma-
tions, humor, massage, journaling, exercise,
nutrition, reminiscence, aroma, light, color,
artwork, meditation, storytelling, literature,
poetry, movement, and dance are just a few of
the voluntary mutually patterning strategies
consistent with a unitary perspective. In addi-
tion, patterning modalities have been devel-
oped that are conceptualized within the science
of unitary human beings such as Butcher’s
metaphoric unitary landscape narratives (2006b)
and written emotional expression (2004a), Ther-
apeutic Touch (Malinski, 1993), guided imagery
(Butcher & Parker, 1988; Levin, 2006), magnet
therapy (Kim, 2001), and music (Horvath, 1994;
Johnston, 2001). Sharing of knowledge through
health education and providing health education
literature and teaching also have the potential
to enhance knowing participation in change.
These and other noninvasive modalities are
well described and documented in both
the Rogerian (Barrett, 1990; Madrid, 1997;
Madrid & Barrett, 1994) and the holistic nurs-
ing practice literature (B. M. Dossey, 1997; B.
M. Dossey, Keegan, & Guzzetta, 2004).
The nurse continuously apprehends changes
in patterning emerging from the human–
environmental field mutual process throughout
the simultaneous pattern manifestation know-
ing and appreciation and voluntary mutual
patterning processes. Although the concept
of “outcomes” is incompatible with Rogers’
notions of unpredictability, outcomes in the
Nursing Outcomes Classification (Moorhead,
Johnson, Maas, & Swanson, 2013) can be
reconceptualized as potentialities of change or
“client potentials” (Butcher, 1997a, p. 29), and
the indicators can be used as a means to eval-
uate the client’s desired direction of pattern
change. At various points in the client’s care,
the nurse can also use the scales derived from
Rogers’s science (previously discussed) to co-
examine changes in pattern. Regardless of
which combination of voluntary patterning
strategies and evaluation methods is used, the
intention is for clients to actualize their poten-
tials related to their desire for well-being and
betterment.
The unitary pattern–based practice method
identifies the aspect that is unique to nursing
and expands nursing practice beyond the tra-
ditional biomedical model dominating much
of nursing. Rogerian nursing practice does not
necessarily need to replace hospital-based and
medically driven nursing interventions and
actions for which nurses hold responsibility.
Rather, unitary pattern–based practice com-
plements medical practices and places treat-
ments and procedures within an acausal,
pandimensional, rhythmical, irreducible, and
unitary context. Unitary pattern–based practice
provides a new way of thinking and being in
nursing that distinguishes nurses from other
health care professionals and offers new and
innovative ways for clients to reach their
desired health potentials.
Applications of Theory and Research
Research is the bedrock of nursing practice.
The science of unitary human beings has a long
history of theory-testing research. As new
practice theories and health patterning modal-
ities evolve from the science of unitary human
beings, there remains a need to test the viabil-
ity and usefulness of Rogerian theories and
voluntary health patterning strategies. The
mass of Rogerian research has been reviewed
in a number of publications (Butcher, 2008;
Caroselli & Barrett, 1998; Dykeman &
Loukissa, 1993; Fawcett, 2013; Fawcett &
Alligood, 2003; Kim, 2008; Malinski, 1986a;
Phillips, 1989; Watson, Barrett, Hastings-
Tolsma, Johnston, & Gueldner, 1997). Rather
CHAPTER 14 • Martha E. Rogers’s Science of Unitary Human Beings 249
3312_Ch14_235-262 26/12/14 4:55 PM Page 249
than repeat the reviews of Rogerian research,
the following section describes current method-
ological trends within the science of unitary
human beings to assist researchers interested
in Rogerian science in making methodological
decisions.
Rogers (1994b) maintained that both
quantitative and qualitative methods may be
useful for advancing Rogerian science. Simi-
larly, Barrett (1996), Barrett and Caroselli
(1998), Barrett, Cowling, Carboni, and
Butcher (1997), Cowling (1986), Rawnsley
(1994), and Smith and Reeder (1996) have
all advocated for the appropriateness of mul-
tiple methods in Rogerian research. Con-
versely, Butcher (cited in Barrett et al., 1997),
Butcher (1994), and Carboni (1995b) have
argued that the ontological and epistemolog-
ical assumptions of causality, reductionism,
particularism, control, prediction, and linear-
ity of quantitative methodologies are incon-
sistent with Rogers’s unitary ontology and
participatory epistemology. Later, Fawcett
(1996) also questioned the congruency be-
tween the ontology and epistemology of
Rogerian science and the assumptions embed-
ded in quantitative research designs; like
Carboni (1995b) and Butcher (1994), she
concluded that interpretive/qualitative meth-
ods may be more congruent with Rogers’s
ontology and epistemology. This chapter pres-
ents an inclusive view of methodologies.
Approaches to Rogerian Research
Cowling (1986) was among the first to suggest
a number of research designs that may be ap-
propriate for Rogerian research, including
philosophical, historical, and phenomenolog-
ical ones. There is strong support for the ap-
propriateness of phenomenological methods in
Rogerian science. Reeder (1986) provided a
convincing argument demonstrating the con-
gruence between Husserlian phenomenology
and the Rogerian science of unitary human be-
ings. Experimental and quasi-experimental de-
signs are problematic because of assumptions
concerning causality; however, these designs
may be appropriate for testing propositions
concerning differences in the change process
in relation to “introduced environmental
change” (Cowling, 1986, p. 73). The researcher
must be careful to interpret the findings in a
way that is consistent with Rogers’s notions of
unpredictability, integrality, and nonlinearity.
Emerging interpretive evaluation methods,
such as Guba and Lincoln’s (1989) Fourth
Generation Evaluation, offer an alternative
means for testing for differences in the change
process within or between groups (or both)
more consistent with the science of unitary
human beings.
Cowling (1986) contended that in the
early stages of theory development, designs
that generate descriptive and explanatory
knowledge are relevant to the science of uni-
tary human beings. For example, correlational
designs may provide evidence of patterned
changes among indices of the human field.
Advanced and complex designs with multiple
indicators of change that may be tested using
linear structural relations (LISREL) statisti-
cal analysis may also be a means to uncover
knowledge about the pattern of change
(Phillips, 1990). Barrett (1996) suggested
that canonical correlation may be useful in ex-
amining relationships and patterns across do-
mains and may also be useful for testing
theories pertaining to the nature and direc-
tion of change. Another potentially promis-
ing area yet to be explored is participatory
action and cooperative inquiry (Reason,
1994), because of their congruence with
Rogers’s notions of knowing participation in
change, continuous mutual process, and inte-
grality. Cowling (1998) proposed that a case-
oriented approach is useful in Rogerian
research because case inquiry allows the re-
searcher to attend to the whole and strives to
comprehend his or her essence.
Selecting a Focus of Rogerian Inquiry
In selecting a focus of inquiry, concepts that
are congruent with the science of unitary
human beings are most relevant. The focus of
inquiry flows from the postulates, principles,
and concepts relevant to the conceptual sys-
tem. Noninvasive voluntary patterning modal-
ities, such as guided imagery, Therapeutic
Touch, humor, sound, dialogue, affirmations,
music, massage, journaling, written emotional
250 SECTION IV • Conceptual Models and Grand Theories in the Unitary–Transformative Paradigm
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expression, exercise, nutrition, reminiscence,
aroma, light, color, artwork, meditation,
storytelling, literature, poetry, movement,
and dance, provide a rich source for Rogerian
science-based research. Creativity, mystical
experiences, transcendence, sleeping-beyond-
waking experiences, time experience, and para-
normal experiences as they relate to human
health and well-being are also of interest in
this science. Feelings and experiences are a
manifestation of human–environmental field
patterning and are a manifestation of the
whole (Rogers, 1970); thus, feelings and expe-
riences relevant to health and well-being are
an unlimited source for potential Rogerian
research. Discrete particularistic biophysical
phenomena are usually not an appropriate
focus for inquiry because Rogerian science
focuses on irreducible wholes. An exception
could be the use of such phenomena, for ex-
ample blood pressure, as part of diverse data
collected to obtain different views of pattern
manifestations and pattern change.
For example, see Madrid, Barrett, and
Winstead-Fry’s (2010) study of Therapeutic
Touch and blood pressure, pulse, and respira-
tions in the operative setting with patients un-
dergoing cerebral angiography, and Malinski
and Todaro-Franceschi’s (2011) study of
comeditation and anxiety and relaxation in a
nursing school setting.
Rogers clearly identified that everything is
a manifestation of the whole, of field pattern-
ing. However, one cannot use just the numer-
ical data, mere “facts,” so interpretation would
differ accordingly (Rogers, 1989). Researchers
need to ensure that concepts and measurement
tools used in the inquiry are defined and con-
ceptualized within a unitary perspective and
congruent with Rogers’s principles and postu-
lates. Diseases or medical diagnoses are not the
focus of Rogerian inquiry. Disease conditions
are conceptualized as labels and as manifesta-
tions of patterning emerging acausally from
the human–environmental mutual process.
Measurement of Rogerian Concepts
The Human Field Motion Test (HFMT) is an
indicator of the continuously moving position
and flow of the human energy field. Two major
concepts—“my motor is running” and “my field
expansion”—are rated using a semantic differ-
ential technique (Ference, 1979, 1986). Exam-
ples of indicators of higher human field motion
include feeling imaginative, visionary, transcen-
dent, strong, sharp, bright, and active. Indica-
tors of relative low human field motion include
feeling dull, weak, dragging, dark, pragmatic,
and passive. The tool has been widely used in
numerous Rogerian studies.
The Power as Knowing Participation in
Change Tool (PKPCT) has been used in more
than 26 major research studies (Caroselli &
Barrett, 1998) and is a measure of one’s capac-
ity to participate knowingly in change as man-
ifested by awareness, choices, freedom to act
intentionally, and involvement in creating
changes using semantic differential scales. Sta-
tistically significant correlations have been
found between power as measured by the
PKPCT and the following: human field mo-
tion, life satisfaction, spirituality, purpose in
life, empathy, transformational leadership
style, feminism, imagination, and socioeco-
nomic status. Inverse relations with power
have been found with anxiety, chronic pain,
personal distress, and hopelessness (Caroselli
& Barrett, 1998).
Diversity is inherent in the evolution of the
human–environmental mutual field process.
The evolution of the human energy field is
characterized by the creation of more diverse
patterns reflecting the nature of change. The
Diversity of Human Field Pattern Scale meas-
ures the process of diversifying human field
pattern and may also be a useful tool to test
theoretical propositions derived from the pos-
tulates and principles of Rogerian science to
examine the extent of selected patterning
modalities designed to foster harmony and
well-being (Hastings-Tolsma, 1992; Watson
et al., 1997). Other measurement tools devel-
oped within a unitary science perspective may
be used in a wide variety of research studies and
in combination with other Rogerian measure-
ments. For example, there are the Assessment
of Dream Experience Scale, which measures
the diversity of dream experience as a beyond-
waking manifestation using a 20-item Likert
scale (Watson, 1993; Watson et al., 1997);
CHAPTER 14 • Martha E. Rogers’s Science of Unitary Human Beings 251
3312_Ch14_235-262 26/12/14 4:55 PM Page 251
Temporal Experience Scale, which measures
the subjective experience of temporal aware-
ness (Paletta, 1990); and Mutual Exploration
of the Healing Human Field–Environmental
Field Relationship Creative Measurement
Instrument developed by Carboni (1992),
which is a creative qualitative measure de-
signed to capture the changing configurations
of energy field pattern of the healing human–
environmental field relationship.
A number of new tools have been developed
that are rich sources of measures of concepts
congruent with unitary science. The Human
Field Image Metaphor Scale used 25 metaphors
that capture feelings of potentiality and inte-
grality rated on a Likert-type scale. For exam-
ple, the metaphor “I feel at one with the
universe” reflects a high degree of awareness of
integrality; “I feel like a worn-out shoe” reflects
a more restricted perception of one’s potential
(Johnston, 1994; Watson et al., 1997). Future
research may focus on developing an under-
standing of how human field image changes in
a variety of health-related situations or how
human field image changes in mutual process
with selected patterning strategies.
Research Methods Specific to Science
of Unitary Human Beings
The criteria for developing Rogerian research
methods are presented in the supplementary
material (for a description of the constituents
see Bonus content for the chapter.)3 They are a
synthesis and modification of the Criteria
of Rogerian Inquiry developed by Butcher
(1994) and the Characteristics of Operational
Rogerian Inquiry developed by Carboni
(1995b). The criteria are a useful guide in de-
signing research methods that are consistent
with Rogers’s principles and postulates. Two
Rogerian research methods were developed
using the criteria and the Unitary Field Pattern
Portrait research method and Rogerian Process
Inquiry. A third method developed by Cowling
(2001), Unitary Appreciative Inquiry is also de-
scribed in the bonus content for the chapter.3
Rogerian Process of Inquiry
Carboni (1995b) developed the Rogerian
process of inquiry from her characteristics of
Rogerian inquiry. The method’s purpose is
to investigate the dynamic enfolding-unfolding
of the human field–environmental field en-
ergy patterns and the evolutionary change of
configurations in field patterning of the
nurse and participant. Rogerian process of
inquiry transcends both matter-centered
methodologies espoused by empiricists and
thought-bound methodologies espoused by phe-
nomenologists and critical theorists (Carboni,
1995b). Rather, this process of inquiry is
evolution-centered and focuses on changing
configurations of human and environmental
field patterning.
The flow of the inquiry starts with a sum-
mation of the researcher’s purpose, aims, and
visionary insights. Visionary insights emerge
from the study’s purpose and researcher’s un-
derstanding of Rogerian science. Next, the
researcher focuses on becoming familiar with
the participants and the setting of the inquiry.
Shared descriptions of energy field perspec-
tives are identified through observations and
discussions with participants and processed
through mutual exploration and discovery. The
researcher uses the Mutual Exploration of the
Healing Human Field–Environmental Field
Relationship Creative Measurement Instru-
ment (Carboni, 1992) as a way to identify, un-
derstand, and creatively measure human and
environmental energy field patterns. Together,
the researcher and the participants develop a
shared understanding and awareness of the
human–environmental field patterns mani-
fested in diverse multiple configurations of
patterning. All the data are synthesized using
inductive and deductive data synthesis.
Through the mutual sharing and synthesis of
data, unitary constructs are identified. The
constructs are interpreted within the perspec-
tive of unitary science, and a new unitary the-
ory may emerge from the synthesis of unitary
constructs. Carboni (1995b) also developed
special criteria of trustworthiness to ensure the
scientific rigor of the findings conveyed in the
form of a Pandimensional Unitary Process
252 SECTION IV • Conceptual Models and Grand Theories in the Unitary–Transformative Paradigm
3 For additional information please go to bonus chapter
content available at FA Davis http://davisplus.fadavis.com
3312_Ch14_235-262 26/12/14 4:55 PM Page 252
Report. Carboni’s research method affords a
way of creatively measuring manifestations of
field patterning emerging during coparticipa-
tion of the researcher and participant’s process
of change.
The Unitary Field Pattern Portrait
Research Method
The unitary field pattern portrait (UFPP) re-
search method (Butcher, 1994, 1996, 1998,
2005) was developed at the same time Car-
boni was developing the unitary process of
inquiry and was derived directly from the cri-
teria of Rogerian inquiry. The purpose of
the UFPP research method is to create a uni-
tary understanding of the dynamic kaleido-
scopic and symphonic pattern manifestations
emerging from the pandimensional human–
environmental field mutual process as a means
to enhance the understanding of a significant
phenomenon associated with human better-
ment and well-being. The UFPP research
method is part of the unitary pattern–based
praxis model (see Fig. 14-1) illustrating the
inherent unity of Rogerian philosophy, sci-
ence, theory, practice, and research (Butcher,
2006a). There are eight essential aspects and
three essential processes in the method. The
aspects include initial engagement, a priori
nursing science, immersion, manifestation
knowing and appreciation, the unitary field
pattern profile, mutually constructed unitary
field pattern profile, the unitary field pattern
portrait, and theoretical unitary field pattern
portrait. The UFPP (see Fig. 14-2) and the
three essential processes are creative pattern
synthesis, immersion and crystallization, and
evolutionary interpretation.
1. Initial Engagement: Inquiry within the
UFPP begins with initial engagement,
which is a passionate search for a research
question of central interest to understand-
ing unitary phenomena associated with
human betterment and well-being. For
example, experiences, perceptions, and
expressions related to noninvasive volun-
tary patterning modalities such as guided
imagery, Therapeutic Touch, humor, sound,
dialogue, affirmations, music, massage,
journaling, written emotional expression,
exercise, nutrition, reminiscence, aroma,
light, color, artwork, meditation, story-
telling, literature, poetry, movement, and
dance provide a rich source for UFPP
research. Creativity, mystical experiences,
transcendence, sleeping-beyond-waking
experiences, time experience, and paranor-
mal experiences as they relate to human
health and well-being are also experiences
that can be researched using the UFPP.
The UFPP research method can also be
used to create a unitary conceptualization
and understanding of an unlimited number
of human experiences relevant to under-
standing health and well-being within a
unitary perspective. New concepts that
describe unitary phenomena may also be
developed through research using this
method.
2. A priori nursing science identifies the
science of unitary human beings as the
researcher’s perspective. As in all research,
the perspective of the researcher guides
all aspects and processes of the research
method, including the interpretation
of findings.
3. Immersion involves becoming steeped in
the research topic. The researcher may
immerse in poetry, art, literature, music,
dialogue with self and/or others, research
literature, or any activity that enhances
the integrality of the researcher and the
research topic.
4. Pattern manifestation knowing and appre-
ciation includes participant selection, in-
depth dialoguing, and recording pattern
manifestations. Participant selection is
made using intensive purposive sampling.
Patterning manifestation knowing and
appreciation occurs in a natural setting and
involves using pandimensional modes of
awareness during in-depth dialoguing.
The activities described earlier in the pat-
tern manifestation knowing and apprecia-
tion process in the practice method are
used in this research method. However,
in the UFPP research method the focus
of pattern appreciation and knowing is on
experiences, perceptions, and expressions
CHAPTER 14 • Martha E. Rogers’s Science of Unitary Human Beings 253
3312_Ch14_235-262 26/12/14 4:55 PM Page 253
associated with the phenomenon of con-
cern. The researcher also maintains an in-
formal conversational style while focusing
on revealing the rhythm, flow, and config-
urations of the pattern manifestations
emerging from the human–environmental
mutual field process associated with the
research topic. The dialogue is taped and
transcribed. The researcher maintains ob-
servational, methodological, and theoretical
field notes, and a reflexive journal. Any
artifacts the participant wishes to share
that illuminate the meaning of the phe-
nomenon may also be included. Artifacts
may include pictures, drawings, poetry,
music, logs, diaries, letters, notes, and
journals.
5. Unitary field pattern profile is a rich de-
scription of each participant’s experiences,
perception, and expressions created
254 SECTION IV • Conceptual Models and Grand Theories in the Unitary–Transformative Paradigm
Unitary Field Pattern Portrait Research Method
Creative Pattern
Synthesis
Immersion and
Crystallization
Initial engagement A priori nursing science
Pattern manifestation knowing and appreciation
Mutually shaped unitary field pattern profile
Resonating unitary themes of
human/environmental pattern manifestations
Unitary field pattern profile
Unitary field pattern portrait
Evolutionary
Interpretation
Theoretical unitary field pattern portrait
Emerging unitary themes
of human-environmental
pattern manifestations
Mutual processing
Immersion
Fig 14 • 2 The unitary
field pattern portrait re-
search method. (Model from
Butcher, H. K. (2005). The
unitary field pattern portrait re-
search method: Facets, processes
and findings. Nursing Science
Quarterly, 18, 293–297.)
3312_Ch14_235-262 26/12/14 4:55 PM Page 254
through a process of creative pattern syn-
thesis. All the information collected for
each participant is synthesized into a nar-
rative statement (profile) revealing the
essence of the participant’s description of
the phenomenon of concern. The field pat-
tern profile is in the language of the partic-
ipant and is then shared with the
participant for revision and validation.
6. Mutual processing involves constructing
the mutual unitary field pattern profile by
mutually sharing an emerging joint or
shared profile with each successive partici-
pant at the end of each participant’s pat-
tern manifestation knowing and
appreciation process. For example, at the
end of the interview of the fourth partici-
pant, a joint construction of the phenome-
non is shared with the participant for
comment. The joint construction (mutual
unitary field pattern profile) at this phase
would consist of a synthesis of the profiles
of the first three participants. After verifi-
cation of the fourth participant’s pattern
profile, the profile is folded into the
emerging mutual unitary field pattern pro-
file. Pattern manifestation knowing and
appreciation continues until there are no
new pattern manifestations to add to the
mutual unitary field pattern profile. If it is
not possible to either share the pattern
profile with each participant or create a
mutually constructed unitary field pattern
profile, the research may choose to bypass
the mutual processing phase.
7. The UFPP is created by identifying emerg-
ing unitary themes from each participant’s
field pattern profile, sorting the unitary
themes into common categories, creating
the resonating unitary themes of human–
environmental pattern manifestations
through immersion and crystallization,
which involves synthesizing the resonating
themes into a descriptive portrait of the
phenomenon. The UFPP is expressed in
the form of a vivid, rich, thick, and accu-
rate aesthetic rendition of the universal
patterns, qualities, features, and themes
exemplifying the essence of the dynamic
kaleidoscopic and symphonic nature of the
phenomenon of concern.
8. The UFPP is interpreted from the perspec-
tive of the science of unitary human beings
using the process of evolutionary interpre-
tation to create a theoretical UFPP of the
phenomenon. The purpose of theoretical
UFPP is to explicate the theoretical struc-
ture of the phenomenon from the perspec-
tive of nursing science using the Rogers’s
postulates and principles. The theoretical
UFPP is expressed in the language of
Rogerian science, thereby lifting the UFPP
from the level of description to the level of
unitary science. Scientific rigor is main-
tained throughout processes by using the
criteria of trustworthiness and authenticity
(Butcher, 1998, 2005).
Butcher’s (1997b) study on the experience
of dispiritedness in later life was the first pub-
lished study using the UFPP. Ring (2009)
used the method to investigate and describe
changes in pattern manifestations in individu-
als receiving Reiki, and Fuller (2011) used the
UFPP method to create a vivid portrait of
adult substance users and family pattern in
rehabilitation.
CHAPTER 14 • Martha E. Rogers’s Science of Unitary Human Beings 255
Practice Exemplar
The focus of nursing care guided by Rogers’s
nursing science is on pattern transformation
by facilitating pattern recognition during pat-
tern manifestation knowing and appreciation
and by facilitating the client’s ability to partic-
ipate knowingly in change, harmonizing per-
son–environment integrality, and promoting
healing potentialities and well-being through
voluntary mutual patterning. The unitary pat-
tern–based practice model consists of two
nonlinear and simultaneous processes: pattern
manifestation appreciation and knowing, and
voluntary mutual patterning. To illustrate
practice guided by Rogerian science, consider
Continued
3312_Ch14_235-262 26/12/14 4:55 PM Page 255
256 SECTION IV • Conceptual Models and Grand Theories in the Unitary–Transformative Paradigm
Practice Exemplar cont.
Amanda, who is a 20-year-old college student
at a local university. She entered a nurse
owned and managed wellness center with her
mother. Pattern manifestation appreciation
and knowing as well as voluntary mutual pat-
terning begin simultaneously upon meeting as
the nurse practitioner apprehends that
Amanda’s eyes are downcast, she manifests
low energy, and she did not say a word when
first greeted. Amanda’s initial visit was 2 years
ago during her freshman year when she was
experiencing depressive symptoms. Amanda
had major life changes at the time: she broke
up with her boyfriend, her parents were going
through a divorce, and her grades were falling;
she was spending less time with her friends
and more time in her room; and she had ob-
viously lost weight. Today was similar as
Amanda and her mother entered the center to
see the nurse. After spending a few moments
in silence, the nurse ask Amanda to describe
her current situation, paying close attention to
her body language, words, and meanings as
she described her fears of failing school. En-
gaged in dialogue, Amanda revealed that for
the past 3 months, she has been increasingly
missing classes, having difficulty concentrating
and falling asleep, eating less, and spending
more time in her apartment. Her mother ex-
plained that Amanda had not come home for
the weekend in several weeks and doesn’t call
anymore.
Once her mother stepped out of the room,
Amanda began crying. She stated that she was
very stressed with school and misses her
friends. “Really, I just find myself staying in
bed and I don’t want to get out from under the
covers. I can’t seem to shut my brain off any-
more either. I don’t sleep. Yeah, that’s it if I
could just get some sleep, I know I would be
better.” Amanda was asked how she felt her
mood was. “I know I am depressed. I can feel
it.” Amanda continued to cry as she speaks
with her eyes down cast. When asked about
sleep, she stated that she was in bed a lot but
couldn’t seem to shut off her mind. “I can’t
even concentrate on one topic, and my brain
is off on another. I don’t even get hungry
anymore. The reason I haven’t come in is be-
cause I didn’t want you to see me like this
again. I was trying to get better.” Amanda was
having a difficult time focusing on one topic
and stated, “that big cloud is back again.” She
denied napping but does admit to feeling tired
“all the time.” The nurse invited Amanda to
participate in a brief deep-breathing and fo-
cusing exercise to help her become more re-
laxed and to enable her to reflect and describe
more deeply what she was experiencing in her
life situation. She revealed that her real fear
was failure and disappointing her mother. The
nurse then asked if Amanda would complete a
standard depression scale and the PKPCT
(Power as Knowing Participation in Change
Tool), and both were scored immediately.
Within Rogerian science, all information is rel-
evant, and even though the depression scale
was not specific to Rogerian science, the tool
can be interpreted within a unitary context.
Her score on the depression scale indicated
that Amanda was moderately depressed, which
is an indication her human–environmental
field mutual process. Rather than labeling
or diagnosing Amanda having “minor depres-
sion,” the nurse understood Amanda’s field
pattering as lower frequency energy pattering
and discordant with her environmental field.
Amanda’s scores on the 48-item PKPCT are
helpful in revealing her ability to participate in
change in a knowingly matter. In all four
dimensions of the tool (awareness, choices,
freedom to act intentionally, and involvement
in creating changes), Amanda’s scores were
low, indicating she manifested low power in
her change process. As the nurse shared and
dialogues with her about the scores on the
scales, she confirmed that she was feeling
helpless and unable to develop a plan to help
change her situation.
The nurse and Amanda worked together in
mutual process to develop a plan that would
help her experience her power to deal more ef-
fectively with her feelings and her academic
work. The nurse documented the encounter
by writing a health pattern profile that in-
cluded descriptions of Amanda’s experiences,
3312_Ch14_235-262 26/12/14 4:55 PM Page 256
CHAPTER 14 • Martha E. Rogers’s Science of Unitary Human Beings 257
Practice Exemplar cont.
expressions, and perceptions of her health sit-
uation using her words as much as possible,
and they mutually agreed on a plan that was
designed to enhance her energy, help her bet-
ter manage her school work and diet, and fa-
cilitate rest at night. During voluntary mutual
patterning, the nurse first asked Amanda’s
mother to come back into the room. Together
they explored her mother’s feelings about the
importance of Amanda’s academic perform-
ance. Her mother revealed that she was more
concerned about her daughter’s health than
her grades, which actually helped relieve much
of the pressure she was feeling about her aca-
demic performance. A plan was developed
that included Amanda meeting with the fac-
ulty instructors in two of the courses in which
she was performing poorly to see what she can
do to make up for any missed assignments. In
one other course, both she and her mother
agreed it might be best to withdraw from the
course and retake it the following semester.
The nurse developed a “Power Prescription
Plan” that included Amanda developing a
daily activity schedule so that her time would
be more structured with a balance of study
time, exercise at the recreational center, in-
creased nutrition, and rest. Amanda enjoyed
swimming, so the schedule included her
swimming 4 of 7 days for 1 hour each time ini-
tially. Amanda also was interested in but had
never tried yoga, which she admitted was pop-
ular with a number of her friends. She agreed
to reengage with several of her close friends
and join one of the local yoga clubs on campus.
Together the nurse and Amanda developed an
imagery exercise that was meaningful to her,
and Amanda agreed to practice it daily.
Amanda also agreed to weekly sessions with
the nurse practitioner so that they can together
monitor Amanda’s progress and her involve-
ment in her change process. In the weekly ses-
sions, the nurse and Amanda would also
continue to explore the deeper meanings of
“depressed” feelings, mutually explore the
choices she was making, and identify new op-
tions that would allow her to achieve her
hopes and dreams. The session concluded with
Therapeutic Touch with both Amanda and
her mother.
■ Summary
If nursing’s content and contribution to the
betterment of the health and well-being of a
society is not distinguishable from other disci-
plines and has nothing unique or valuable to
offer, then nursing’s continued existence may
be questioned. Thus, nursing’s survival rests on
its ability to make a difference in promoting
the health and well-being of people. The sci-
ence of unitary human beings offers nursing a
new way of conceptualizing health events con-
cerning human well-being that is congruent
with the most contemporary scientific theories.
As with all major theories embedded in a new
worldview, new terminology is needed to cre-
ate clarity and precision of understanding and
meaning. There is an ever-growing body of
literature demonstrating the application of
Rogerian science to practice and research.
Rogers’s nursing science is applicable in all
nursing situations. Rather than focusing on
disease and cellular biological processes, the
science of unitary human beings focuses on
human beings as irreducible wholes insepara-
ble from their environment.
For 30 years, Rogers advocated that nurses
should become the experts and providers of
noninvasive modalities that promote health.
Now, the growth of “complementary/integra-
tive,” noninvasive practices is outpacing the
growth of allopathic medicine. If nursing con-
tinues to be dominated by biomedical frame-
works that are indistinguishable from medical
care, nursing will lose an opportunity to be-
come expert in unitary health-care modalities.
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258 SECTION IV • Conceptual Models and Grand Theories in the Unitary–Transformative Paradigm
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Chapter 15Rosemarie Rizzo Parse’s
Humanbecoming Paradigm
ROSEMARIE RIZZO PARSE
Introducing the Theorist
Overview of Parse’s Humanbecoming
Paradigm
Application of Theory
Summary
References
Rosemarie Rizzo Parse
263
Introducing the Theorist
Rosemarie Rizzo Parse is a Distinguished Pro-
fessor Emerita at Loyola University Chicago
as well as a Fellow in the American Academy
of Nursing, where she initiated and is imme-
diate past chair of the Nursing Theory–Guided
Practice Expert Panel. She is founder and
editor of Nursing Science Quarterly; president
of Discovery International, which sponsors in-
ternational nursing theory conferences; and
founder of the Institute of Humanbecoming,
where each summer in Pittsburgh she teaches
new material on the ontological, epistemolog-
ical, and methodological aspects of the human-
becoming paradigm. There are also sessions
on the Humanbecoming Community Change
Model (Parse, 2003a, 2012a, 2013a, 2014), the
Humanbecoming Teaching–Learning Model
(Parse, 2004, 2014), the Humanbecoming
Mentoring Model (Parse, 2008c, 2014), the
Humanbecoming Leading–Following Model
(Parse, 2008b, 2011a, 2014), and the Human-
becoming Family Model (Parse, 2008a, 2009a,
2014). The goal of all sessions is the under-
standing of the meaning of humanuniverse
from a humanbecoming perspective.
Dr. Parse has published more than 300 ar-
ticles and 10 books. Her books include Nursing
Fundamentals (Parse, 1974); Man-Living-
Health: A Theory of Nursing (Parse, 1981);
Nursing Research: Qualitative Methods (Parse,
Coyne, & Smith, 1985); Nursing Science: Major
Paradigms, Theories, and Critiques (Parse, 1987);
Illuminations: The Human Becoming Theory in
Practice and Research (Parse, 1995); The Human
Becoming School of Thought (Parse, 1998a); Hope:
An International Human Becoming Perspective
(Parse, 1999a); Qualitative Inquiry: The Path
3312_Ch15_263-278 26/12/14 5:54 PM Page 263
of Sciencing (Parse, 2001); Community: A
Human Becoming Perspective (Parse, 2003a);
and The Humanbecoming Paradigm: A Trans-
formational Worldview (Parse, 2014). Her
books and other publications have been trans-
lated into many languages, as her theory is a
guide for practice in health-care settings, and
her research methodologies are used by nurse
scholars in Australia, Canada, Denmark, Fin-
land, Greece, Italy, Japan, South Korea, Sweden,
Switzerland, Taiwan, the United Kingdom, the
United States, and many other countries on five
continents.
Dr. Parse has received two lifetime achieve-
ment awards, one from the Midwest Nursing
Research Society and one from the Asian
Nurses’ Association. The Rosemarie Rizzo
Parse Scholarship was endowed in her name
at the Henderson State University School of
Nursing. She is a sought-after speaker and
consultant for local, national, and international
venues. She also received the Medal of Honor
from the University of Lisbon.
Dr. Parse is a graduate of Duquesne Uni-
versity in Pittsburgh and received her master’s
and doctorate from the University of Pitts-
burgh. She was a member of the faculty of the
University of Pittsburgh, dean of the School of
Nursing at Duquesne University, professor and
coordinator of the Center for Nursing Re-
search at Hunter College of the City Univer-
sity of New York (1983–1993), and professor
and Niehoff Chair in Nursing Research at
Loyola University Chicago (1993–2006).
Since January 2007, she has been a consultant,
visiting scholar, and adjunct professor at the
New York University College of Nursing.
Overview of Parse’s
Humanbecoming
Paradigm
Prologue: Reflections on the Discipline
and Profession of Nursing
At present, nurse leaders in research, admin-
istration, education, and practice are focusing
attention on expanding the knowledge base of
nursing through enhancement of the disci-
pline’s frameworks and theories. Nursing is
both a discipline and a profession (Parse,
1999b). The goal of the discipline is to expand
knowledge about human experiences through
creative conceptualization and research (Parse,
2005, 2009c). The knowledge base of the dis-
cipline is the scientific guide to living the art
of nursing. The discipline-specific knowledge
is born and fostered in academic settings where
research and education advance knowledge to
new realms of understanding (Parse, 2008d,
2009b). The goal of the profession is to provide
service to humankind through living the art of
the science. Members of the nursing profes-
sion are responsible for regulating the stan-
dards of practice and education based on
disciplinary knowledge that reflects safe health
service to society in all settings (Parse, 1999b,
2012b, 2013b).
The Profession of Nursing
The profession of nursing consists of people ed-
ucated according to nationally regulated, de-
fined, and monitored standards that are
intended to preserve the integrity of health care
for members of society. The standards are spec-
ified predominantly in medical terms, accord-
ing to a tradition largely related to nursing’s
early subservience to medicine. Recently, nurse
leaders in health-care systems and in regulating
organizations have been developing standards
(Mitchell, 1998) and regulations (Damgaard,
2012; Damgaard & Bunkers, 1998, 2012) con-
sistent with discipline-specific knowledge as ar-
ticulated in the theories and frameworks of
nursing. This is a significant development that
has fortified the identity of nursing as a disci-
pline with its own body of knowledge—one
that specifies the service that society can expect
from members of the profession (Parse, 2011c).
With the rapidly changing health policies and
the general dissatisfaction of consumers with
health-care delivery, clearly stated expectations
for services from each of nursing’s paradigms
are a welcome change (Parse, 1999b, 2013a).
The Discipline of Nursing
The discipline of nursing encompasses at least
three paradigmatic perspectives about huma-
nuniverse (Parse, 2012a, 2013a). The totality
paradigm posits the human as body–mind–spirit
264 SECTION IV • Conceptual Models and Grand Theories in the Unitary–Transformative Paradigm
3312_Ch15_263-278 26/12/14 5:54 PM Page 264
whose health is considered a state of biological,
psychological, social, and spiritual well-being.
The body–mind–spirit perspective is particu-
late—focusing on the bio–psycho–social–
spiritual parts of the whole human as the
human interacts with and adapts to the envi-
ronment. The ontology leads to research and
practice on phenomena related to preventing
disease and maintaining and promoting health
according to societal norms. The totality para-
digm frameworks and theories are more closely
aligned with the medical model tradition.
Nurses practicing according to this paradigm
are concerned with participation of persons in
health-care decisions but have specific regi-
mens and goals to bring about change for the
people they serve (Parse, 1999b).
In contrast, the simultaneity paradigm
views the human as unitary—indivisible,
unpredictable, and everchanging (Parse,
1987, 1998a, 2007b), wherein health is con-
sidered a value and a process. The ontology
leads research and practice scholars to focus
on, for example, energy and environmental
field patterns (Rogers, 1992). Nurses focus
on power in knowing participation (Barrett,
2010; Rogers, 1992).
In 2012, Parse identified a third paradigm,
the humanbecoming paradigm (Parse, 2012a,
2013a). (Fig. 15-1) This was created inasmuch
as the ontology, epistemology, and methodolo-
gies of the humanbecoming school of thought
have moved on from the traditional metapara-
digm conceptualization and beyond the totality
and simultaneity paradigms (Parse, 2013a,
2014). With the humanbecoming paradigm in
the ontology, humanuniverse is an indivisible,
unpredictable everchanging cocreation, and liv-
ing quality is the becoming visible-invisible be-
coming of the emerging now. The ethos of
humanbecoming is also described and this is
unlike any other paradigm. With the epistemol-
ogy, the focus of study is on universal living
experiences. With the methodologies, sciencing
(the research process) is qualitative (Parse
research method and the humanbecoming
hermeneutic method), and living the art of hu-
manbecoming is in true presence with illumi-
nating meaning, shifting rhythms, and inspiring
transcending (Parse, 1981, 1992, 1997a, 1998a,
CHAPTER 15 • Rosemarie Rizzo Parse’s Humanbecoming Paradigm 265
Totality Paradigm Simultaneity Paradigm Humanbecoming Paradigm
Ontology
Human
Biopsychosocialspiritual being
Universe
Internal and external
environment
Health
A state and process of well-being
Epistemology
Human attributes
Methodologies
(research and practice)
Quantitative, qualitative, mixed
Steps of the nursing process
Copyright, Rosemarie Rizzo Parse, 2014
Ontology
Human
Unitary pattern
Universe
Unitary pattern in mutual
process with the human
Health
A value and a process
Epistemology
Human patterns
Methodologies
(research and practice)
Quantitative, qualitative, praxis
Pattern recognition
Ontology
Humanuniverse
Indivisible, unpredictable,
everchanging cocreation
Ethos of Humanbecoming-
Dignity
Presence, existence, trust, worth
Living quality
Becoming visible-invisible
Becoming of the emerging now
Epistemology
Universal living experiences
Methodologies
(sciencing and living the art)
Qualitative
True presence illuminating
meaning, shifting rhythms,
inspiring transcending
Paradigms of the Discipline of Nursing
Fig 15 • 1 Paradigms of the discipline of nursing. (Copyright ©2014, Rosemarie Rizzo Parse.)
3312_Ch15_263-278 26/12/14 5:54 PM Page 265
2010, 2014). Nurses living the humanbecom-
ing paradigm beliefs hold that their primary
concern is people’s perspectives of living quality
with human dignity (Parse, 1981, 1992, 1997a,
1998a; 2010, 2012a, 2013a, 2014). The new
conceptualization living quality is described in
detail in Parse (2013a). (See Parse, 2012a and
2013a, for details about the humanbecoming
paradigm.)
Because the ontologies of these three para-
digmatic perspectives are different, they lead
to different research and practice modalities,
different ethical considerations, and different
professional services to humankind. (See Parse,
2010, for the humanbecoming ethical tenets of
human dignity, which are reverence, awe, be-
trayal, and shame.) Humanbecoming is a basic
human science that has cocreated universal hu-
manuniverse living experiences as a central
focus. It is called a paradigm and a school of
thought because it encompasses a unique on-
tology, epistemology, and methodologies
(Parse, 1997b, 2010, 2012a, 2013a, 2014).
Parse’s (1981) original work was titled
Man-Living-Health: A Theory of Nursing.
When the term mankind was replaced with
male gender in the dictionary definition of man,
the name of the theory was changed to human
becoming (Parse, 1992). No aspect of the prin-
ciples changed at that time. With the publica-
tion of The Human Becoming School of Thought
(1998a), Parse expanded the original work to
include descriptions of three research method-
ologies and additional specifics related to the
practice methodology (Parse, 1987), thus clas-
sifying the science of humanbecoming as a
school of thought (Parse, 1997b). The funda-
mental idea of humanbecoming—that humans
are indivisible, unpredictable, everchanging, as
specified in the ontology—precludes any use
of terms such as physiological, biological, psycho-
logical, or spiritual to describe the human.
These terms are particulate, thus inconsistent
with the ontology. Other terms inconsistent
with humanbecoming include words often
used to describe people, such as noncompliant,
dysfunctional, and manipulative.
In 2007, Parse set forth a clarification of
the ontology of the school of thought. She
specified humanbecoming as one word and
humanuniverse as one word (Parse, 2007b).
Joining the words creates one concept and fur-
ther confirms the idea of indivisibility. She also
described postulates to clarify the ontology fur-
ther (Parse, 2007b). The ontology—that is, the
assumptions, postulates, and principles—sets
forth beliefs that are clearly different from
other nursing frameworks and theories. Disci-
pline-specific knowledge is articulated in
unique language specifying a position on the
phenomenon of concern for each discipline.
The humanbecoming language is unique to
nursing. For example, the three humanbecom-
ing principles contain nine concepts written in
verbal form with -ing endings to make clear
the importance of the ongoing process of
change as basic to humanuniverse emergence.
In addition, each concept is explicated with
paradoxes, not opposites, but rhythms, further
specifying the uniqueness of the humanbe-
coming language.
The humanbecoming encompasses the on-
tology, the epistemology, and the research and
practice methodologies as described here. In
2012, the school of thought was expanded and
new conceptualizations created the humanbe-
coming paradigm (Parse 2012a, 2013a, 2014).
The Ontology
The assumptions, postulates, and principles
of the humanbecoming paradigm comprise
the ontology (Parse, 2007b, 2012a, 2013a;
Fig. 15-2).
Philosophical Assumptions
The assumptions of the humanbecoming
paradigm are written at the philosophical level
of discourse (Parse, 1998a, 2010, 2012a,
2013a, 2014). There are nine fundamental
assumptions about humanuniverse, ethos of
humanbecoming, and living quality (Parse,
2013a, 2014). The assumptions arose begin-
ning with the first book in 1981, from a syn-
thesis of ideas from the science of unitary
human beings (Rogers, 1992) and from exis-
tential phenomenological thought, particularly
Heidegger, Merleau-Ponty, and Sartre; see
Parse, 1981, 1992, 1994a, 1995, 1997a, 1998a,
266 SECTION IV • Conceptual Models and Grand Theories in the Unitary–Transformative Paradigm
3312_Ch15_263-278 26/12/14 5:54 PM Page 266
2013a, 2014). In the assumptions, Parse posits
humanuniverse as indivisible, unpredictable,
and everchanging, cocreating unique becom-
ing. She also posits additional descriptions of
humanuniverse, ethos of humanbecoming, and
living quality. Living quality is the chosen way
of being in the becoming visible-invisible be-
coming of the emerging now (2012a, 2013a,
2014). Humans live an all-at-onceness, which
is the becoming visible-invisible of the emerg-
ing now, in freely choosing meanings that arise
with the illimitable (2007b, 2012a, 2013a,
2014). The chosen meanings are the value
priorities cocreated in transcending with the
possibles (Parse, 1998a).
Postulates and Principles
In 2007, Parse elaborated certain truths em-
bedded in the conceptualizations of the ontol-
ogy (2007b). In so doing she expanded the
idea of cocreating reality as a seamless sym-
phony of becoming (Parse, 1996), a central
thought foundational to the ontology, as fore-
grounded with four postulates of illimitability,
paradox, freedom, and mystery [See Parse
(2007b) for detailed descriptions of the postu-
lates]. The meanings of the postulates perme-
ate all three of the principles; the words of
the postulates are not used in the statements of
the principles. Thus, the wording has been clar-
ified to provide semantic consistency without
CHAPTER 15 • Rosemarie Rizzo Parse’s Humanbecoming Paradigm 267
Assumptions
Humanuniverse is
indivisible, unpredictable,
everchanging.
Humanuniverse is
cocreating reality
as a seamless symphony
of becoming.
Humanuniverse is
an illimitable mystery with
contextually construed
pattern preferences.
Ethos of humanbecoming
is dignity.
Ethos of humanbecoming
is august presence, a
noble bearing of
immanent distinctness.
Ethos of humanbecoming
is abiding truths of
presence, existence,
trust,
and worth.
Living quality is the
becoming visible-invisible
becoming
of the emerging now.
Living quality is the
everchanging whatness
of becoming.
Living quality is the
personal expression of
uniqueness.
Postulates
Illimitability is the
indivisible unbounded
knowing extended to
infinity, the all-at-once
remembering-prospecting
with the emerging now.
Paradox is an intricate
rhythm expressed as a
pattern preference.
Freedom is contextually
construed liberation.
Mystery is the unexplain-
able, that which cannot
be completely known
unequivocally.
Principles
Structuring meaning is
the imaging and valuing
of languaging.
Configuring rhythmical
patterns is the revealing-
concealing and
enabling-limiting of
connecting-separating.
Cotranscending with
possibles is the powering
and originating of
transforming.
Concepts and
Paradoxes
Imaging:
explicit-tacit; reflective-
prereflective
Valuing:
confirming–not
confirming
Languaging:
speaking–being silent;
moving–being still
Revealing-concealing:
disclosing–not disclosing
Enabling-limiting:
potentiating-restricting
Connecting-separating:
attending-distancing
Powering:
pushing-resisting;
affirming–not affirming;
being-nonbeing
Originating:
certainty-uncertainty;
conforming–not
conforming
Transforming:
familiar-unfamiliar
Copyright, Rosemarie Rizzo Parse, 2014
The Humanbecoming Ontology
Fig 15 • 2 The humanbecoming ontology. (Copyright ©2014, Rosemarie Rizzo Parse.)
3312_Ch15_263-278 26/12/14 5:54 PM Page 267
changing the original meaning of the princi-
ples. The principles of humanbecoming, often
referred to as the theory, describe the central
phenomenon of nursing (humanuniverse), and
arise from the three major themes of the as-
sumptions: meaning, rhythmicity, and tran-
scendence. Each principle describes a theme
with three concepts. Each of the concepts ex-
plicates fundamental paradoxes of humanbe-
coming (Parse, 1998a, 2007b). The paradoxes
are rhythms lived all-at-once as pattern pref-
erences (Parse, 2007b). Paradoxes are not op-
posites or problems to be solved but rather are
ways humans live their chosen meanings. This
way of viewing paradox is unique to the hu-
manbecoming school of thought (Mitchell,
1993a; Parse, 1981, 1994b, 2007b).
Statements of Principles
The statements of principles are presented in
detail in Parse (2007b, 2010, 2012a, 2013a,
2014). With the first principle (see Parse 1981,
1998a, 2007b, 2013a, 2014), Parse explicates
the idea that humans construct personal realities
with unique choosings arising with illimitable
humanuniverse options. Reality, the meaning
given to a situation, is the individual human’s
everchanging seamless symphony of becoming
(Parse, 1996). The seamless symphony is the
unique story of the human as mystery emerging
with the explicit-tacit knowings of imaging. The
human lives the confirming–not confirming of
valuing as cherished beliefs, while languaging
with speaking–being silent and moving–being
still in the becoming visible-invisible of the
emerging now (for details, see Parse 2007b,
2012a, 2013a, 2014).
The second principle (Parse, 1981, 1998a,
2007b, 2010) describes rhythmical humanuniverse
patterns. The paradoxical rhythm “revealing–
concealing is disclosing–not disclosing all-
at-once” (Parse, 1998a, p. 43). Not all is explic-
itly known or can be told in the unfolding
mystery of humanbecoming. “Enabling–limiting
is living the opportunities–restrictions present
in all choosings all-at-once” (Parse, 1998a, p. 44).
There are opportunities and restrictions what-
ever the choice; all choosings are potentiating–
restricting (see Parse, 2007b and 2014 for
details). “Connecting–separating is being with and
apart from others, ideas, objects and situations
all-at-once” (Parse, 1998a, p. 45). It is a coming
together and moving apart; there is closeness in
the separation and distance in the closeness—a
rhythmical attending–distancing (for details, see
Parse 2007b, 2012a, 2013a).
With the third principle, Parse (1981,
1998a, 2007b, 2010, 2012a, 2013a) explicated
the idea that humans are everchanging, that is,
moving on with the possibilities of their in-
tended hopes and dreams. A changing diversity
unfolds as humans affirm and do not affirm in
the pushing–resisting of powering, as creating
new ways of living the conformity–nonconfor-
mity and certainty–uncertainty of originating
sheds new light on the familiar–unfamiliar of
transforming. Powering is the pushing–resisting
of affirming–not affirming being in light of
nonbeing (Parse, 1998a, 2007b, 2012a, 2013a,
2014). The being–nonbeing rhythm is all-at-
once living the everchanging becoming visible-
invisible becoming of the emerging now.
Humans, in originating, seek to conform–not
conform, that is, to be like others and unique
all-at-once, while living the ambiguity of the
certainty–uncertainty embedded in all change.
The changing diversity arises with transforming
the familiar–unfamiliar, as illimitable possibles
are viewed in a different light.
The three principles, together with the
postulates and assumptions, comprise the
ontology of the humanbecoming school of
thought. The principles are referred to as
the humanbecoming theory. The concepts,
with the paradoxes, describe humanuniverse.
This ontological base gives rise to the episte-
mology and methodologies of humanbecom-
ing. Epistemology refers to the focus of
inquiry. Consistent with the humanbecoming
school of thought, the focus of inquiry is
universal living experiences (Parse, 2005,
2012a, 2013a).
Applications of Theory
Humanbecoming Research
Methodologies
Sciencing humanbecoming is coming to
know; it is an ongoing inquiry to discover and
understand the meaning of living experiences.
268 SECTION IV • Conceptual Models and Grand Theories in the Unitary–Transformative Paradigm
3312_Ch15_263-278 26/12/14 5:54 PM Page 268
of which have been published (for example,
Baumann, 2000, 2003, 2009, 2013; Bunkers,
2010, 2012; Condon, 2010; Doucet, 2012a,
2012b; Doucet & Bournes, 2007; MacDonald
& Jonas-Simpson, 2009; Maillard-Struby,
2012; Morrow, 2010; Naef & Bournes, 2009;
S. M. Smith, 2012, and many others). Parse
(1999a) was the principal investigator for a
nine-country research study on the living ex-
perience of hope using the Parse method, with
participants from Australia, Canada, Finland,
Italy, Japan, Sweden, Taiwan, the United
Kingdom, and the United States. The findings
from these studies and the stories of the par-
ticipants are published in Hope: An Interna-
tional Human Becoming Perspective (Parse,
1999a). Collaborative research projects using
the Parse research method have also been
published on feeling very tired (Baumann,
2003; Huch & Bournes, 2003; Parse, 2003b).
Six studies have been published in which au-
thors used the humanbecoming hermeneutic
method (Baumann, 2008; Baumann, Carroll,
Damgaard, Millar, & Welch, 2001; Cody,
1995, 2001; Ortiz, 2003; Parse, 2007a)
Living-the-art projects are initiated when a
researcher wishes to describe the changes, sat-
isfactions, and effectiveness when humanbe-
coming guides practice (Parse, 1998a, 2001,
2006). The major purpose of the project is to
understand what happens when humanbe-
coming is living nurse with person, family, and
community. A number of researchers have
conducted such living-the-art projects, all of
which demonstrated enhanced satisfaction
among persons, families, and communities
(Bournes & Ferguson-Paré, 2007, 2008;
Bournes et al., 2007; Jonas, 1995a; Legault &
Ferguson-Paré, 1999; Maillard-Strüby, 2007;
Mitchell, 1995; Northrup & Cody, 1998;
Santopinto & Smith, 1995), and a synthesis of
the findings of these and other such studies
was written and published (Bournes, 2002;
Doucet & Bournes, 2007).
Humanbecoming: Living the Art
The goal of the nurse living the humanbecom-
ing beliefs is true presence in bearing witness
and being with others in their changing pat-
terns of living quality. True presence is lived
CHAPTER 15 • Rosemarie Rizzo Parse’s Humanbecoming Paradigm 269
The humanbecoming research tradition has
two basic research methods (Parse, 1998a,
2005, 2011b). These two methods flow from
the ontology of the school of thought. The
basic research methods are the Parse method
(Parse, 1987, 1990, 1992, 1995, 1997a, 1998a,
2001, 2005, 2011b, 2012a, 2013a, 2014) and
the humanbecoming hermeneutic method (Cody,
1995; Parse, 1995, 1998a, 2001, 2005, 2011b,
2012a, 2013a, 2014). The humanbecoming
hermeneutic method was created in congru-
ence with the assumptions and principles of
Parse’s theory, drawing from works by Bern-
stein (1983), Gadamer (1976, 1960/1998),
Heidegger (1962), Langer (1976), and Ricoeur
(1976, 1981).
The purpose of these two basic research
methods is to advance the science of humanbe-
coming by studying universal living experiences
from participants’ descriptions (Parse method)
and from written texts and art forms (human-
becoming hermeneutic method). The phenom-
ena for study with the Parse method are
universal living experiences such as joy, sorrow,
hope, grieving, and courage, among others.
Written texts from any literary source or art
form may be the subject of sciencing with the
humanbecoming hermeneutic method. The
processes of both methods call for a unique
dialogue, researcher with participant, or re-
searcher with text or art form. The researcher in
the Parse Method is in true presence as the par-
ticipant moves with an unstructured dialogue
about the living experience under study. The re-
searcher in the humanbecoming hermeneutic
method is in true presence with the emerging
possibilities in the horizon of meaning arising
in dialogue with texts or art forms. True pres-
ence is an intense attentiveness to unfolding
essences and emergent meanings. The re-
searcher’s intent with these research methods is
to discover structures (Parse method) and emer-
gent meanings (humanbecoming hermeneutic
method; see Parse, 2001, 2005, 2011b, 2012a,
2013a, 2014). The contributions of the findings
from studies using these two methods include
“new knowledge and understanding of humanly
lived experiences” (Parse, 1998a, p. 62).
Many nurse scholars worldwide have con-
ducted studies using the Parse method, many
3312_Ch15_263-278 26/12/14 5:54 PM Page 269
nurse with person, family, and community in
illuminating meaning, synchronizing rhythms,
and mobilizing transcendence (Parse, 1987,
1992, 1994a, 1995, 1997a, 1998a, 2010, 2012a,
2013a, 2014). The nurse with individuals or
groups is in true presence with the unfolding
meanings as persons explicate, dwell with, and
move on with changing patterns of diversity.
Living true presence is unique to the art of
humanbecoming. True presence is not to be
confused with terms now prevalent in the lit-
erature such as authentic presence, transforming
presence, presencing, and others. It is sometimes
misinterpreted as simply asking persons what
they want. Often nurses say it is what they al-
ways do (Mitchell, 1993b); this is not true
presence. “True presence is an intentional re-
flective love, an interpersonal art grounded in
a strong knowledge base” (Parse, 1998a, p. 71).
The knowledge base underpinning true pres-
ence is specified in the assumptions, postulates,
and principles of humanbecoming (Parse,
1981, 1992, 1995, 1997a, 1998a, 2007b, 2010,
2012a, 2013a, 2014). True presence is a free-
flowing attentiveness in the emerging now that
arises from the belief that the humanuniverse is
indivisible, unpredictable, everchanging. Hu-
mans freely choose with situations, structure
personal meaning, live paradoxical rhythms,
and move beyond with changing diversity
(Parse, 1998a, 2007b, 2012a, 2013a, 2014).
Parse (1987, 1998b) states that to know, un-
derstand, and live the beliefs of humanbecom-
ing requires concentrated study of the ontology,
epistemology, and methodologies and a com-
mitment to a different way of being with
people. The different way that arises from the
humanbecoming beliefs is true presence.
True presence is a powerful humanuniverse
connection. It is lived in face-to-face discus-
sions, silent immersions, and lingering pres-
ence (Parse, 1987, 1998a). Nurses may be with
persons, families, and communities in discus-
sions, imaginings, or remembrances through
stories, films, drawings, photographs, movies,
metaphors, poetry, rhythmical movements,
and other expressions (Parse, 1998a).
Many publications explicate the art of true
presence with a variety of persons and groups.
(See, for example, Arndt, 1995; Banonis,
1995; Bournes, 2000, 2003, 2006; Bournes,
Bunkers, & Welch, 2004; Bournes & Flint,
2003; Bournes & Naef, 2006; Butler, 1988;
Butler & Snodgrass, 1991; Chapman,
Mitchell, & Forchuk, 1994; Cody, Mitchell,
Jonas-Simpson, & Maillard-Strüby, 2004;
Hansen-Ketchum, 2004; Hutchings, 2002; Jonas,
1994, 1995b; Jonas-Simpson & McMahon,
2005; Karnick, 2005, 2007; Lee & Pilkington,
1999; Mattice & Mitchell, 1990; Mitchell,
1988, 1990; Mitchell & Bournes, 2000;
Mitchell, Bournes, & Hollett, 2006; Mitchell
& Bunkers, 2003; Mitchell & Cody, 1999;
Mitchell & Copplestone, 1990; Mitchell &
Pilkington, 1990; Naef, 2006; Norris, 2002;
Paille & Pilkington, 2002; Quiquero, Knights,
& Meo, 1991; Rasmusson, 1995; Rasmusson,
Jonas, & Mitchell, 1991; M. K. Smith, 2002;
Stanley & Meghani, 2001; and others).
Living the Art of Humanbecoming
With Persons and Groups
It is important here to clarify some terminology.
Nursing practice is a generic term that refers to the
genre of activities of the profession in general.
The term practice is not appropriate to use when
referring to humanbecoming, because according
to various dictionary definitions it means a habit,
or to drill, exercise, try repeatedly, or do over and
over again. The word practice is antithetical to the
ontology, as a major focus of humanbecoming is
reverence, awe, human freedom, and dignity
(Parse, 2010). Humanbecoming nurses live the
art of the science of humanbecoming. The art of
humanbecoming refers to living true presence,
which arises directly from a sound understanding
of the ontology of the school of thought. True
presence flows only from nurses and health pro-
fessionals who have studied, understand, believe
in, and live the humanbecoming assumptions,
postulates, and principles. Living is the proper
term to describe what nurses experience when
with recipients of health care. Nurses and others
who live humanbecoming believe that persons,
families, and communities are the experts on
their own health-care situations, and all are
treated with dignity (Parse, 2010).
In nurse-with-person health-care situations,
nurses in true presence come to persons with
an availability to be with and bear witness, as
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3312_Ch15_263-278 26/12/14 5:54 PM Page 270
persons illuminate the meaning of the situations,
shift rhythms, and inspire transcending in focus-
ing on the becoming visible-invisible becoming
of the emerging now (Parse, 1981, 1987, 1998a,
2007b, 2010, 2012a, 2013a, 2014). Illuminating
meaning, shifting rhythms, and inspiring trans-
forming occur in the true presence of the human-
becoming nurse, as persons explicate their
situations, dwell with the becoming visible-in-
visible becoming of the emerging now. In expli-
cating, dwelling with, and moving on, persons
experience new insights and even surprises, as sit-
uations are seen in the new light that arises with
the true presence of nurses who bear witness and
do not label. Labeling or diagnosing is objectify-
ing, ignoring the importance of persons’ dignity
and freedom (Parse, 2010). Humanbecoming
nurses believe that persons know their way and
live quality according to their unique value pri-
orities (Parse, 2012a, 2013a). Humanbecoming
nurses do not have a preset agenda or teaching
plan about what persons should or ought do but
rather listen carefully to the intents and desires
stated by persons because these intents are value
priorities that are the living choices of persons.
With recipients of health care, humanbecoming
nurses ask what is most important for the mo-
ment and explore meanings, wishes, intents, and
desires related to what is emerging now from the
perspective of the recipients and these guide
nurses’ participation (Parse, 2008e, 2012a, 2013a,
2014). What may seem important to the nurse
may not be what is important to the person. For
example, when a nurse (not living humanbecom-
ing) thought that fear about the new diagnosis of
lung cancer was the most important issue for a
person, she began to design a teaching plan to
inform the person about the disease; however,
when a humanbecoming nurse asked the person,
“What is the most important issue for you right
now?” the gentleman answered, “Telling my
family and continuing to work to care for them.”
The humanbecoming nurse continued to discuss
these concerns with the gentleman with no
agenda except the one set by the gentleman. Hu-
manbecoming nurses are with persons in ways
that honor their wishes and desires. Persons are
seamless symphonies of becoming, and nurses are
only one note in the symphony (Parse, 1996).
Living the Art of Humanbecoming
With Community
The humanbecoming school of thought is
a guide for research, practice, education, and
administration in settings throughout the
world. Scholars from five continents have
embraced the belief system and live humanbe-
coming in a variety of venues, including
health-care centers and university nursing pro-
grams. The Humanbecoming Community
Model (Parse, 2003a, 2014), the Humanbe-
coming Teaching–Learning Model (Parse,
2004, 2014), The Humanbecoming Mentoring
Model (Parse, 2008c, 2014), the Humanbe-
coming Leading–Following Model (Parse,
2008b, 2011a, 2014) , and the Humanbecom-
ing family model (Parse 2008a, 2009a, 2014)
are disseminated and used in practice settings
worldwide. Many health centers throughout
the world have humanbecoming as a guide to
health care (Bournes et al., 2004; Cody et al.,
2014). In several university-affiliated practice
settings in Canada, humanbecoming practice
has been evaluated, and the theory has provided
underpinnings for standards of care (Bournes,
2002; Legault & Ferguson-Paré, 1999;
Mitchell, 1998; Mitchell, Closson, Coulis,
Flint, & Gray, 2000; Northrup & Cody, 1998)
and nursing best practice guidelines (Nelligan
et al., 2002). For example, in Toronto, Sunny-
brook Health Science Centre and University
Health Network had created multidisciplinary
standards of care that arise from the beliefs and
values of the humanbecoming school of
thought.
In settings worldwide where humanbecom-
ing has guided nursing practice on a large scale,
researchers examined the effects on the nurses
and persons who were involved (Bournes &
Ferguson-Paré, 2007, 2008; Bournes et al.,
2007; Jonas, 1995a; Legault & Ferguson-Paré,
1999; Maillard-Strüby, 2007; Mitchell, 1995;
Northrup & Cody, 1998; Santopinto & Smith,
1995). The findings of the studies describe what
happened when humanbecoming was used as a
guide for nursing practice on an orthopedic
surgery and rheumatology unit (Bournes &
Ferguson-Paré, 2007), on a cardiac surgery unit
(Bournes et al., 2007), on a medical oncology
CHAPTER 15 • Rosemarie Rizzo Parse’s Humanbecoming Paradigm 271
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unit and a general surgery unit (Bournes &
Ferguson-Paré, 2008), in a family practice unit
affiliated with a large teaching hospital (Jonas,
1995a), on a 41-bed vascular and general sur-
gery unit (Legault & Ferguson-Paré, 1999), on
an acute care medical unit (Mitchell, 1995), on
three acute care psychiatry units (Northrup
& Cody, 1998), on three units in a 400-bed
community teaching hospital (Santopinto &
Smith, 1995), and on a medical oncology unit
(Maillard-Strüby, 2007). The findings from
five of the studies are summarized in Bournes
(2002) and are consistent with those of more
recent evaluations (Bournes & Ferguson-Paré,
2007, 2008; Bournes et al., 2007; Maillard-
Strüby, 2007).
Bournes and Ferguson-Paré (2007, 2008)
and Bournes, Plummer, Hollett, and Ferguson-
Paré (2008) examined the impact of an inno-
vative academic employment model (the
humanbecoming 80/20 model—in which nurses
spent 80 percent of their paid work time in direct
patient care guided by humanbecoming and
20 percent of their paid work time learning
about humanbecoming and engaging in re-
lated professional development activities). The
humanbecoming 80/20 model has been imple-
mented on four units—three in Toronto, On-
tario (Bournes & Ferguson-Paré, 2007, 2008)
and one in Regina, Saskatchewan (Bournes
et al., 2007). The Regina project was imple-
mented in collaboration with Regina Qu’Ap-
pelle Health Region and the Saskatchewan
Union of Nurses.
Findings from the research (Bournes &
Ferguson-Paré, 2007, 2008; Bournes et al.,
2007) to evaluate implementation of the hu-
manbecoming 80/20 model have been ex-
tremely positive. For example, interviews with
nurses, patients, families, and other health pro-
fessionals in the Bournes and Ferguson-Paré
(2007) study “supported the humanbecoming
theory as an effective basis for learning and im-
plementing patient-entered care that benefits
both nurses and patients” (p. 251). Patients
and families in that study “reported that they
appreciated the reverent consideration given
to them by nurses who had learned about
humanbecoming-guided patient-centered care”
(p. 251). They also described “being confident
engaging in discussions with nurses who
understood and attentive experts interested
in who they were and what was important
to them” (p. 251). Similarly, the nurse par-
ticipants in Bournes and Ferguson-Paré’s
(2007) and Bournes and colleagues’ (2008)
studies reported that after learning about
humanbecoming-guided nursing practice, they
were more concerned with listening to patients
and families, being with them, getting to know
what is important to them, and respecting
them as the experts about their quality of life.
They also reported being more satisfied with
their work—a theme noted by nurse leaders
and allied health participants who shared that
nurses listened more and focused on patients’
perspectives. (Bournes & Ferguson-Paré,
2007, p. 251)
Participants in both studies described the
benefits of the program—not only in relation
to how it changed their relationships with pa-
tients but also in relation to how it changed
their view of how to be with their colleagues
in more meaningful ways (see Bournes &
Ferguson-Paré, 2007; Bournes et al., 2007).
In addition, study findings show that the cost
of providing education about humanbecom-
ing-guided practice and staffing the 80/20 as-
pect of the model is offset by higher nurse
and patient satisfaction scores and a reduction
in sick time and overtime (Bournes & Fergu-
son-Paré, 2007; Bournes et al., 2007). At a
large academic teaching hospital, the human-
becoming 80/20 model has been tested as the
basis for a mentoring program among expe-
rienced critical care nurses and new nurses
who want to work in critical care (Bournes et
al., 2008). The mentoring program is based
on the Humanbecoming Mentoring Model
(Parse, 2008c).
In South Dakota, a parish nursing model
was built on the Eight Beatitudes and the
principles of humanbecoming to guide nurs-
ing practice in the health model at the First
Presbyterian Church in Sioux Falls (Bunkers,
1998a, 1998b; Bunkers, Michaels, & Ethridge,
1997; Bunkers & Putnam, 1995). Bunkers
and Putnam (1995) stated, “The nurse, in
272 SECTION IV • Conceptual Models and Grand Theories in the Unitary–Transformative Paradigm
3312_Ch15_263-278 26/12/14 5:54 PM Page 272
practicing from the human becoming perspec-
tive and emphasizing the teachings of the
Beatitudes, believes in the endless possibilities
present for persons when there is openness,
caring, and honoring of justice and human
freedom” (p. 210). Also, the Board of Nursing
of South Dakota has adopted a decisioning
model based on the humanbecoming school
of thought (Damgaard & Bunkers, 1998,
2012). Augustana College (in Sioux Falls)
has humanbecoming as one theoretical focus
of the curricula for the baccalaureate and
master’s programs. The humanbecoming
theory was the basis of Augustana’s Health
Action Model for Partnership in Commu-
nity (Bunkers, Nelson, Leuning, Crane, &
Josephson, 1999). “The purpose of the model
is to respond in a new way to nursing’s social
mandate to care for the health of society by
gaining an understanding of what is wanted
from those living these health experiences”
(Bunkers et al., 1999, p. 94). The creation of
the model was “for persons homeless and low
income who are challenged with the lack of
economic, social and interpersonal resources”
(Bunkers et al., 1999, p. 92).
The humanbecoming school of thought is
the theoretical foundation of the baccalaure-
ate and master’s curricula at the California
Baptist University College of Nursing in
Riverside, California. Faculty and students
learn and live the art of humanbecoming in
the various venues where they practice. The
Nursing Center for Health Promotion with
the Charlotte Rainbow PRISM Model was
established in Charlotte, North Carolina, as
a venue for nurses to offer health-care deliv-
ery to homeless women and children with
diverse backgrounds. The PRISM Model,
based on humanbecoming, was the guide to
practice (Cody, 2003). At the Espace Medi-
ane community nursing center in Geneva,
Switzerland (for persons who have concerns
about cancer and palliative care), practice and
teaching–learning are guided by humanbe-
coming, meaning that nurses in the center
live true presence with visitors. They also link
with academic partners to provide an academic
service for postgraduate nursing students
specializing in oncology and palliative care
(Cody et al., 2004). The purpose of another
project was to evaluate what happens when
the art of humanbecoming was initiated in a
palliative care inpatient setting in Fribourg,
Switzerland (F. Maillard-Strüby, personal
communication, August, 7, 2008).
Shifting practice from the traditional
medical model mode to living the art of
humanbecoming is a challenge for health-care
institutions and requires high-level adminis-
trative commitment for resources, including
educational opportunities for nurses. The com-
mitment to humanbecoming practice requires
a change in value priorities systemwide
(Bournes, 2002; Bournes & DasGupta, 1997;
Linscott, Spee, Flint, & Fisher, 1999; Mitchell
et al., 2000).
Approximately 300 participants worldwide
who are interested in living the art of humanbe-
coming subscribe to Parse-L, an e-mail listserv
where Parse scholars share ideas. There is a Parse
home page on the Internet that is updated
regularly (see www.humanbecoming.org). Every
other year, most of the 100 or more members
of the International Consortium of Parse Schol-
ars meet in Canada or the United States for a
weekend immersion in humanbecoming theory,
research, and practice. The DVD The Human
Becoming School of Thought: Living the Art
of Human Becoming (International Consortium
of Parse Scholars, 2007; available from the Con-
sortium at www.humanbecoming.org) shows
Parse nurses in true presence with persons in dif-
ferent settings and features Rosemarie Rizzo
Parse talking about humanbecoming in prac-
tice. Parse is also featured on the video in the
Portraits of Excellence Series called Rosemarie
Rizzo Parse: Human Becoming (Fitne, 1997),
available from Fitne (www.fitne.net). Another
video showing nurse with persons is The Grief
of Miscarriage (Gerretsen & Pilkington, 1990).
There is also a video called I’m Still Here, which
is a humanbecoming research-based drama on
living with dementia (Ivonoffski, Mitchell,
Krakauer, & Jonas-Simpson, 2006). It is avail-
able from the Murray Alzheimer Research
and Education Program at the University of
Waterloo.
CHAPTER 15 • Rosemarie Rizzo Parse’s Humanbecoming Paradigm 273
3312_Ch15_263-278 26/12/14 5:54 PM Page 273
274 SECTION IV • Conceptual Models and Grand Theories in the Unitary–Transformative Paradigm
1 For additional information please go to bonus chapter
content available at FA Davis http://davisplus.
fadavis.com
■ Summary
Through the efforts of Parse scholars, the hu-
manbecoming paradigm continues to emerge
as a major force in the 21st-century evolution
of nursing knowledge. Knowledge gained
from basic research studies continue to be
synthesized to explicate further the meaning of
living experiences. The findings from living the
art research projects related to fostering under-
standing of humanbecoming with persons,
families, and communities also continue to be
synthesized. These syntheses guide decisions for
continually creating the vision for sciencing and
living the art of the humanbecoming paradigm
for the betterment of humankind.
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Chapter 16Margaret Newman’s Theory
of Health as Expanding
Consciousness
MARGARET DEXHEIMER PHARRIS
Introducing the Theorist
Overview of the Theory
Applications of the Theory
Practice Exemplar
Summary
References
279
Introducing the Theorist
Nurses who base their practice on Margaret
Newman’s theory of health as expanding con-
sciousness (HEC) focus on being fully present
to meaning and patterns in the lives of their
patients. Newman (2005) stated, “[O]ne does
not practice nursing using the theory, but
rather the theory becomes a way of being with
the client—a way of offering clients an oppor-
tunity to know and be known and to find their
way” (p. xiv). Through their relationship with
a nurse who understands the theory of HEC
and attends to the evolving pattern of what is
meaningful in their lives, patients are able to
realize a previously undiscovered path for ac-
tion. Just as patients’ health predicaments are
situated within the evolving pattern of complex
relationships and events in their lives, so too,
Newman’s theory has evolved within the con-
text of the meaningful relationships and events
of her life.
After graduating from Baylor University,
Newman returned to Memphis to work and to
care for her mother, who had been diagnosed
a few years earlier with amyotrophic lateral
sclerosis (ALS), a degenerative neurological
disease that progressively diminishes the
movement of all muscles except those of the
eyes. The process of caring for her mother over
a 5-year period was transformative. Not know-
ing the trajectory of the disease, Newman
learned to live day by day, fully immersed
in the present (Newman, 2008b). Newman
(2008a) stated she learned that “each day is
precious and that the time of one’s life is con-
tained in the present” (p. 225).
Caring for her mother provided Newman
with two additional significant realizations.
Margaret A. Newman
I don’t like controlling,
manipulating other people.
I don’t like deceiving, withholding,
or treating people as subjects or objects.
I don’t like acting as an objective non-person.
I do like interacting authentically, listening,
understanding, communicating freely.
I do like knowing and expressing myself in
mutual relationships.
—MARGARET NEWMAN (1985)
3312_Ch16_279-300 26/12/14 4:46 PM Page 279
The first was that simply having a disease
does not make a person unhealthy. Although
Newman’s mother’s life was confined by the
disease, her life was not defined by it. In other
words, she could experience health and whole-
ness in the midst of having a chronic and
progressive disease. The second important re-
alization was that time, movement, and space
are in some way interrelated with health,
which can be manifested by increased connect-
edness and quality of relationships.
These early seeds of the HEC theory found
fertile ground in 1959 when Newman entered
nursing school at the University of Tennessee
(UT) in Memphis. Her mother died 2 weeks
before the beginning of the fall semester.
Newman knew she could not go back to her
previous life; the experience with her mother
had deeply changed her.
After graduating from UT’s baccalaureate
nursing program, Newman stayed on at UT as
a clinical instructor. The next year she went to
the University of California, San Francisco
(UCSF), to obtain her master’s degree in med-
ical–surgical nursing. When she graduated
from UCSF in 1964, Newman was recruited
back to Memphis to become the director of the
Clinical Research Center. After directing
the Clinical Research Center for 21/2 years,
Newman decided to pursue doctoral studies
in nursing at New York University (NYU),
where she would be able to study with Martha
Rogers. In her doctoral work at NYU,
Newman began studying movement, time, and
space as parameters of health; however, she did
so out of a logical positivist scientific paradigm.
She designed an experimental study that ma-
nipulated participants’ movements and then
measured their perception of time (Newman,
1971, 1982). Her results showed a changing
perception of time across the life span, with
people’s subjective sense of time increasing
with age in such a way that time expanded for
them (Newman, 1987). Although her work
seemed to support what she later would term
health as expanding consciousness, at the time
Newman felt the method precluded direct ap-
plication to shape nursing practice, which was
what most interested her (Newman, 1997a).
After receiving her PhD in 1971, Newman
joined the NYU faculty. While there, Newman
published a seminal article in Nursing Outlook
on nursing’s theoretical evolution (Newman,
1972) and with colleague Florence Downs
coauthored two editions of a book on re-
search in nursing (Downs & Newman, 1977).
Newman’s early career in academia was cen-
tered on articulating the knowledge of the dis-
cipline and how it was developed.
In 1977, Newman joined the faculty at Penn
State University as the professor-in-charge of
graduate studies. At that time, she was invited
to speak at a theory conference to be held in
New York in 1978. It was in that address that
she first clearly articulated her theory of health.
The transcript of her talk was published as a
chapter in a book she wrote about theory de-
velopment in nursing (Newman, 1979), which
was one of the first books published on the sub-
ject. Newman also organized a Nursing Theory
Think Tank. She was also a member of a group
of nurse theorists facilitated by Sister Callista
Roy to discern how to organize nursing diag-
noses so that they would be rooted in the
knowledge of the discipline of nursing. This
group presented papers in 1978 and 1980 to the
North American Nursing Diagnosis Associa-
tion. In 1982, they presented an organizing
framework they had developed for nursing
diagnoses called patterns of unitary man
(humans).
In 1984, Newman took a position as nurse
theorist at the University of Minnesota. As
part of her theory development work, she con-
ducted a pilot study of pattern identification.
She invited Richard Cowling from Case
Western and Jim Vail from the Army Nurse
Corps to collaborate with her. Newman was at
that time also a consultant to the Army Nurse
Corps.
While at the University of Minnesota,
Newman published two editions of her book,
Health as Expanding Consciousness (Newman,
1986, 1994a), which attracted international at-
tention. She conducted a series of lectures and
dialogues in New Zealand in 1985 and in
Finland in 1987 on health as expanding con-
sciousness and nursing knowledge development.
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Shortly after retiring from her position at
the University of Minnesota, Margaret New-
man returned to Memphis, Tennessee, where
she continues to work on nursing knowledge
development through her writing and by dia-
loguing with students and scholars from
around the world.
Honors awarded to Dr. Newman include
being named a Fellow of the American Acad-
emy of Nursing and a New York University
Distinguished Scholar in Nursing. She has
received Sigma Theta Tau International’s
Founders Award for Excellence in Nursing
Research and the E. Louise Grant Award for
Nursing Excellence from the University of
Minnesota. She has been honored as an out-
standing alumna by both the University of
Tennessee and New York University. In 2008,
Dr. Newman was named a Living Legend by
the American Academy of Nursing.1
Overview of the Theory
As previously described, the seeds for the theory
of HEC were planted in Margaret Newman’s
childhood and experience of caring for her
mother as a young adult. Newman’s undergrad-
uate studies at the UT, master’s studies at the
UCSF, and doctoral studies at NYU also greatly
influenced her quest for exploring and articulat-
ing the knowledge of the discipline of nursing.
Reading and reflecting on the philosophical
work of scholars from various disciplines—
mainly Bentov (1978), Bohm (1980), Johnson
(1961), Prigogene (1976), Rogers (1970), and
Young (1976)—stretched Newman’s view of
the possibilities of nursing, and thus enriched
the theory of HEC. Work and dialogue with
colleagues and students further explicated the
theory.
Academic and Philosophical
Influences on the Theory
During her time at the University of California,
San Francisco, Newman explored how nurses
could respond to patients in a meaningful way
during short time spans. Newman’s interest in
attending to what is meaningful to the patient
was influenced by Ida Jean Orlando’s deliber-
ative nursing approach. Inspired by Orlando’s
theoretical work, Newman began making
deliberative observations about patients and
reflecting what she observed back to the pa-
tient. The specific attention stimulated patients
to respond by talking about what was mean-
ingful in their unique circumstances.
In a publication of the results of her explo-
ration of this approach to nursing during short
time spans, Newman (1966) recounted walk-
ing into the room of a patient who had been
in the hospital for some time. The patient was
reading the newspaper, and Newman noticed
that the woman was reading the want ads.
Newman simply stated, “Reading the want
ads, huh?” and waited for a response. The
woman, who had been diagnosed with a
chronic lung problem, worked in a factory that
exuded toxic fumes, and she would no longer
be able to work there. She was deeply con-
cerned about her future. What ensued through
their dialogue was a breakthrough for the
patient, whose health-care predicament was
couched in the larger context of her potential
loss of income. Newman asked the woman if
she had discussed this with her physician, and
the woman responded that she had not dis-
cussed it with anyone. When Newman asked
why not, the woman replied that no one had
asked her about it. Once the meaning of her
illness was understood within the context of
her entire life, not just her physical state, a path
toward health became apparent for the patient.
This process of focusing on meaning in pa-
tients’ lives to understand where the current
health predicament fits in the whole of peo-
ple’s lives has endured as central to HEC.
Newman’s theoretical insights evolved as
she delved into the works of Martha Rogers
and Itzhak Bentov, while at the same time re-
flecting back on her own experience (Newman,
1997b). Several of Martha Rogers’s assump-
tions became central in enriching Margaret
Newman’s theoretical perspective (Newman,
1997b). First and foremost, Rogers saw health
and illness not as two separate realities, but
CHAPTER 16 • Margaret Newman’s Theory of Health as Expanding Consciousness 281
1For additional information please go to bonus chapter
content available at FA Davis http://davisplus.fadavis.com
3312_Ch16_279-300 26/12/14 4:46 PM Page 281
rather as a unitary process. This was congruent
with Margaret Newman’s earlier experience
with her mother and with her patients. On a
very deep level, Newman knew that people
can experience health even when they are
physically or mentally ill. Health is not the op-
posite of illness, but rather health and illness
are both manifestations of a greater whole.
One can be very healthy in the midst of a ter-
minal illness.
Second, Rogers argued that all of reality is
a unitary whole and that each human being
exhibits a unique pattern. Rogers (1970) saw
energy fields to be the fundamental unit of all
that is living and nonliving, and she posited
that there is interpenetration between the
fields of person, family, and environment. Per-
son, family, and environment are not separate
entities but rather are an interconnected, uni-
tary whole (Rogers, 1990). Finally, Rogers saw
the life process as showing increasing complex-
ity. These assumptions from Rogers’s theory,
along with the work of Itzhak Bentov (1978),
helped to enrich Margaret Newman’s (1997b)
conceptualization of health and eventually the
articulation of her theory. Bentov viewed life
as a process of expanding consciousness, which
he defined as the informational capacity of the
system and the quality of interactions with the
environment.
Basic Assumptions of the Theory of
Health as Expanding Consciousness
Reflecting on these theoretical works helped
Newman prepare for her Toward a Theory of
Health presentation at the 1978 nursing theory
conference in New York City. It was at that
conference that the theory of health as expand-
ing consciousness was first formally explicated.
In her address (Newman, 1978) and in a writ-
ten overview of the address (Newman, 1979),
Newman outlined the basic assumptions that
were integral to her theory at that time. Draw-
ing on the work of Martha Rogers and Itzhak
Bentov and on her own experience and insight,
she proposed that:
• Health encompasses conditions known as
disease or pathology, as well as states where
disease is not present.
• Disease/pathology can be considered a
manifestation of the underlying pattern of
the person.
• The pattern of the person manifesting itself
as disease was present before the structural
and functional changes of disease.
• Removal of the disease/pathology will not
change the pattern of the individual.
• If becoming “ill” is the only way a person’s
pattern can be manifested, then that is
health for the person.
• Health is the expansion of consciousness
(Newman, 1979).
Newman’s presentation drew thunderous
applause as she ended with, “[t]he responsibil-
ity of the nurse is not to make people well, or
to prevent their getting sick, but to assist peo-
ple to recognize the power that is within them
to move to higher levels of consciousness”
(Newman, 1978).
Although Margaret Newman never set out
to become a nursing theorist, in that 1978
presentation in New York City, she articulated
a theory that resonated with what was mean-
ingful in the practice of nurses in many coun-
tries throughout the world. Nurses wanted to
go beyond combating diseases; they wanted to
accompany their patients in the process of dis-
covering meaning and wholeness in their lives.
Margaret Newman’s proposed theory served as
a guide for them to do so; it offered a new way
of looking at the essence of nursing practice.
Developing the Theory of HEC
After identifying the basic assumptions of the
theory of HEC, the next step was to focus on
how to test the theory with nursing research and
how the theory could inform nursing practice.
Newman began to concentrate on the following:
• The mutuality of the nurse–client interac-
tion in the process of pattern recognition
• The uniqueness and wholeness of the pattern
in each client situation
• The sequential configurations of pattern
evolving over time
• Insights occurring as choice points of action
potential
• The movement of the life process toward
expanded consciousness (Newman, 1997a)
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To test the theory of HEC, which em-
braces reality as an undivided whole, Newman
found that Western scientific research method-
ologies, which isolate particulate variables and
analyze the relationships between them, were
insufficient.
Newman saw a need to articulate that her
work fell within a new paradigm of nursing.
Like Martha Rogers (1970, 1990), Newman
sees human beings as unitary and inseparable
from the larger unitary field that combines
person, family, and community all at once.
Seeing change as unpredictable and transfor-
mative, she named the paradigm within
which her work and the work of Martha
Rogers are situated the unitary-transformative
paradigm (Newman, Sime, & Corcoran-Perry,
1991). A nurse practicing within the unitary–
transformative paradigm does not think of
mind, body, spirit, and emotion as separate
entities but rather sees them as manifestations
of an undivided whole.
Newman’s theory (1979, 1990, 1994a,
1997a, 1997b, 2008b) proposes that we cannot
isolate, manipulate, and control variables to
understand the whole of a phenomenon. The
nurse and client form a mutual partnership
to attend to the pattern of meaningful rela-
tionships and life experiences. In this way, a
patient who has had a heart attack can under-
stand the experience of the heart attack in the
context of all that is meaningful in his or her
life and, through the insight gained with pat-
tern recognition, experience expanding con-
sciousness. Newman’s (1994a, 1997a, 1997b)
methodology does not divide people’s lives into
fragmented variables but rather attends to the
nature and meaning of the whole, which be-
comes apparent in the nurse–patient dialogue.
A nurse practicing within the HEC theo-
retical perspective possesses multifaceted levels
of awareness and is able to sense how physical
signs, emotional conveyances, spiritual insights,
physical appearances, and mental insights are
all meaningful manifestations of a person’s
underlying pattern. These manifestations also
provide insight into the nature of the person’s
interactions with his or her environment. It
takes disciplined study and reflection on prac-
tical experience applying the theory for nurses
to be able to see pattern as insight into the
whole. Newman (2008b) states that practicing
within a unitary paradigm requires a com-
pletely new way of seeing reality—it is like
moving from seeing the Sun as revolving
around Earth to realizing that it is actually
Earth that revolves around the Sun.
Newman (1997a) asserted that knowledge
emanating from the unitary–transformative
paradigm is the knowledge of the discipline
and that the focus, philosophy, and theory of
the discipline must be consistent with each
other and therefore cannot flow out of differ-
ent paradigms. Newman (1997a) stated:
The paradigm of the discipline is becoming clear.
We are moving from attention on the other as object
to attention to the we in relationship, from fixing
things to attending to the meaning of the whole, from
hierarchical one-way intervention to mutual process
partnering. It is time to break with a paradigm of
health that focuses on power, manipulation, and
control and move to one of reflective, compassionate
consciousness. The paradigm of nursing embraces
wholeness and pattern. It reveals a world that is mov-
ing, evolving, transforming—a process. (p. 37)
Newman points the way for nurses to
practice and conduct research within a uni-
tary–transformative paradigm. In the unitary–
transformative paradigm, the process of the
nurse–patient partnership as integral to the
evolving definition of health for the patient
(Litchfield, 1993, 1999; Newman, 1997a) and
is synchronous with participatory philosophi-
cal thought (Skolimowski, 1994) and research
methodology (Heron & Reason, 1997).
When nurses view the world from a unitary
perspective, they begin to see the nature of re-
lationships and their meaning in an entirely
new light. The work of Frank Lamendola and
Margaret Newman (1994) with people with
HIV/AIDS illustrates this. In a study they
conducted, they found that the experience of
HIV/AIDS opened participants to suffering
and physical deterioration and at the same
time introduced greater sensitivity and open-
ness to themselves and others. Drawing on the
work of cultural historian William Irwin
Thompson, systems theorist Will McWhinney,
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and musician David Dunn, Lamendola and
Newman, stated:
They [Thompson, McWhinney, and Dunn] see the
loss of membranal integrity as a signal of the loss of
autopoetic unity analogous to the breaking down of
boundaries at a global level between countries, ide-
ologies, and disparate groups. Thompson views
HIV/AIDS not simply as a chance infection but part
of a larger cultural phenomenon and sees the
pathogen not as an object but as heralding the need
for living together characterized by a symbiotic rela-
tionship. (Lamendola & Newman, 1994, p. 14)
These authors pointed out that the AIDS
epidemic has necessitated greater intercon-
nectedness on the interpersonal, community,
and global level. It has also called for a recon-
ceptualization of the nature of the self and
of treatment—inviting a new sense of har-
monic integration within the immune system.
Lamendola and Newman quoted Thompson
(1989), who stated that we need to “learn to
tolerate aliens by seeing the self as a cloud in
a clouded sky and not as a lord in a walled-in
fortress.” This change in perspective helps
nurses and patients move away from military
metaphors in relationship to patients’ bodies
(i.e., combating disease, waging battles against
invading cells, etc.) to focus instead on har-
mony and balance. Nursing care within a uni-
tary perspective unveils meaning and opens
the possibility for a new way of living for
people with chronic conditions.
Applications of the Theory
Essential Aspects of Nursing Practice
Within the HEC Perspective
Newman (2008b) synthesizes the basic as-
sumptions of HEC in the following way:
• Health is an evolving unitary pattern of the
whole, including patterns of disease.
• Consciousness is the informational capacity
of the whole and is revealed in the evolving
pattern.
• Pattern identifies the human–environmental
process and is characterized by meaning. (p. 6)
Concepts important to nursing practice
grounded in the theory of HEC include expand-
ing consciousness, time, presence, resonance
with the whole, pattern, meaning, insights as
choice points, and the mutuality of the nurse–
patient relationship.
Expanding Consciousness
Ultimate consciousness has been equated with
love, which embraces all experience equally and
unconditionally: pain as well as pleasure, failure
as well as success, ugliness as well as beauty,
disease as well as nondisease.
—M. A. NEWMAN (2003, P. 241)
Consciousness within the theory of HEC
is not limited to cognitive thought. Newman
(1994a) defined consciousness as the infor-
mation of the system: the capacity of the sys-
tem to interact with the environment. In the
human system, the informational capacity
includes not only all the things we normally
associate with consciousness, such as think-
ing and feeling, but also all the information
embedded in the nervous system, the im-
mune system, the genetic code, and so on.
The information of these and other systems
reveals the complexity of the human system
and how the information of the system inter-
acts with the information of the environmen-
tal system (p. 33).
To illustrate consciousness as the interac-
tional capacity of the person–environment,
Newman (1994a) drew on the work of Bentov
(1978), who presented consciousness on a
continuum ranging from rocks on one end of
the spectrum (which have little known inter-
action with their environment), to plants
(which provide nutrients, give off oxygen, and
draw carbon dioxide from the atmosphere) to
animals (which can move about and interact
freely), to humans (who can reflect and make
in-depth plans regarding how they want to in-
teract with their environment), and ultimately
to spiritual beings on the spectrum’s other
end. Newman sees death as a transformation
point, with a person’s consciousness continu-
ing to develop beyond the physical life, be-
coming a part of a universal consciousness
(Newman, 1994a).
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The process of expanding consciousness is
characterized by the evolving pattern of the
person–environment interaction (Newman,
1994a). The process of expanding conscious-
ness is defined by Newman (2008b) as “a
process of becoming more of oneself, of finding
greater meaning in life, and of reaching new
heights of connectedness with other people and
the world” (p. 6). Nurses and their clients know
that there has been an expansion of conscious-
ness when there is a richer, more meaningful
quality to their relationships. Relationships that
are more open, loving, caring, connected, and
peaceful are a manifestation of expanding con-
sciousness. These deeper, more meaningful re-
lationships may be interpersonal, or they may
be relationships with the wider community or
biosphere. Expanding consciousness is evident
when people transcend their own egos, dedi-
cate their energy to something greater than
the individual self, and learn to build order
against the trend of disorder. The process of ex-
panding consciousness may look differently
with changes in cognitive function; nurses must
carefully discern patterns of meaning when this
is the case. For example, when being present to
people with dementia or to very young chil-
dren, nurses realize that there is no past or
future—there is only the present, and they
must be fully present in the present on a deeper
level than cognitive and verbal processes can
take them (Newman, 2008b). People are best
able to experience expanding consciousness
when they are not chained to linear time.
Time and Presence
The time experienced
In a moment
Expands or diminishes
With consciousness.
If I am fully present
There is
No time.
Only consciousness.
—M. A. NEWMAN (2008A, P. 225)
Newman’s earliest published work pointed to
the ability of nurses to quickly and effectively
attend to what is most important to patients
and, by engaging patients in a dialogue about
what is of utmost importance to them, to dis-
cern the patient’s unique path toward health
(Newman, 1966). Newman’s latest work as-
serts that it is only when nurses move away
from a sense of linear time to a more universal
synchronization with the here and now that
they can be truly present to patients in a mean-
ingful and whole manner (Newman, 2008a).
Newman stated:
There is a need to get back to the natural cycles of
the universe. The time of civilization (clock time and
the Gregorian calendar) is not the same as the time
of the rest of the biosphere, our living planet earth.
Natural time is radial in nature, projecting from the
center, and continuously moving in the direction of
greater consciousness. (2008a, p. 227)
Newman asserted that the artificial time
frame of clinic schedules and hospital shift
work places nurses at odds with the natural
rhythm of nurse–patient relationships, serves
the needs of health systems administrations
more than those of patients, and disrupts a
meaningful nursing practice. She pointed out
that the discipline of nursing has followed a
trajectory from adherence to artificial linear
time to the synchronization of time in inter-
personal relationships, and now must move to
the “instantaneous flow of information in each
center of consciousness” and that “it is time to
opt for practice that reflects this dimension”
(Newman, 2008a, p. 227). When nurses must
move out of a Western sense of time, they can
be more fully present to patients.
Newman (2008b) asserted that it is only in
relationship that people can fully come to
know themselves. She drew on the work of T.
D. Smith (2001), who suggested that “when
the nurse considers the patient a mystery to be
engaged in rather than a problem to be solved, the
relationship is characterized by presence”
(Newman, 2008b, p. 53). Newman further
stated that “presence is enhanced by the nurse’s
openness and sensitivity to the other” and in-
volves the nurse letting go of judgments of
“good” or “bad” in relationship to patients’
health behaviors.
When nurses are truly present to patients
they concentrate more on intuitive knowing
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than on the gathering of facts and health-
related data. They enter into a relaxed alertness
and realize that transforming presence involves
a keen awareness of their oneness with the
patient (Newman, 2008b; Newman, Smith,
Pharris, & Jones, 2008). Understanding the
concept of resonance enables a transforming
presence.
Resonating With the Whole
Newman (2008b) described resonance as the
mechanism for acquiring essential information
to guide nursing actions and to understand
meaning in patients’ lives. She stated, “This is
an important distinction in the explication of
nursing knowledge. Knowledge at the unitary,
transformative level includes and transcends
energy transfer at the sensorial level. It is
nonenergetic, nonlocal, and present everywhere”
(p. 35). She differentiated this information
transfer from the transfer of sensory informa-
tion (like heat and touch, which involve phys-
ical energy transfer) and suggests nurses
continually rely on this information transfer
when intuitive insights arise during the care of
patients. Newman cautioned that “intellectu-
alization breaks the field of resonance. If we
analyze or evaluate an experience before we
have resonated with it, the field is broken—the
resonance is damped” (p. 37). “For instance,
sometimes when we see familiar symptoms of
a disease, we jump into a diagnostic conclusion
and preclude receptivity to other data that
would present a more complete picture. It as-
sumes we are all the same” (p. 45). Resonance
enables nurses to sense the unique situation
and concerns of patients.
To resonate with patients and form open
relationships, nurses must let go of personal
judgments about patients and transcend cul-
tural beliefs and values. In other words, the
nurse needs to free himself or herself of
all “should” and “ought to” attitudes and all
personal preoccupations that might prevent
total presence. Newman states there is no pre-
scriptive way to sense the whole through res-
onance. She recommended that nurses pay
attention to the client at the simplest level,
begin with whatever presents itself, and as-
sume that it is purposeful (Newman, 2008b).
Learning to resonate with patients involves
relational engagement and reflection.
Most conventional education programs
teach analytic processes attending to what is
“logical.” This leads students away from under-
standing the whole. Methods that involve em-
pirical investigation assume that the whole
comes after the parts; these methods tend to
blind investigators to their relationship with the
whole. Newman (2008b) drew on the work of
Bohm (1980) to stress that “wholeness is what
is real, with fragmentation as our response to
fragmentary thought. The whole is irreducible
and omnipresent” (p. 40). Newman (2008b)
differentiated between the general and the uni-
versal. “Seeing comprehensively is concrete and
holistic, whereas generalization is abstract and
analytical; these ways of seeing go in opposite
directions” (p. 47). Resonance is a way to sense
into the whole through attention to one aspect
or part of it, always with an eye on compre-
hending the whole. Resonance enables nurses
to tap into the pattern of the whole.
Attention to Pattern and Meaning
Essential to Margaret Newman’s theory is
the belief that each person exhibits a distinct
pattern, which is constantly unfolding and
evolving as the person interacts with the envi-
ronment. Pattern is information that depicts
the whole of a person’s relationship with the
environment and gives an understanding of the
meaning of the relationships all at once (Endo,
1998; Newman, 1994a). Pattern is character-
ized by meaning (Newman, 2008b) and is a
manifestation of consciousness.
To describe the nature of pattern, Newman
draws on the work of David Bohm (1980), who
said that anything explicate (that which we can
hear, see, taste, smell, touch) is a manifestation
of the implicate (the unseen underlying pattern;
Newman, 1997b). In other words, there is in-
formation about the underlying pattern of each
person in all that we sense about them, such as
their movements, tone of voice, interactions
with others, activity level, genetic pattern, and
vital signs. People can be identified from a dis-
tance by someone who knows them, just from
the way in which they move. There is also in-
formation about their underlying pattern in all
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that they tell us about their experiences and
perceptions, including stories about their life,
recounted dreams, and portrayed meanings.
The HEC perspective sees disease, disorder,
disconnection, and violence as an explication
of the underlying implicate pattern of the per-
son, family, and community. Reflecting on the
meaning of these conditions can be part of the
process of expanding consciousness (Newman,
1994a, 1997a, 1997b).
Pharris (1999) offered the example of a
16-year-old young man placed in an adult cor-
rectional facility after a murder conviction.
This young man was constantly getting into
fights and generally feeling lost. As he and the
nurse researcher met over several weeks to gain
insight into patterns of meaningful people and
events in his life, the process seemed to be
blocked, with no pattern emerging and little
insight gained. He spoke of how he felt he had
lost himself several years back when he went
from being a straight-A student from a stable
family to stealing cars, drinking, getting into
fights, and eventually murdering someone.
One week he walked into the room where the
nurse was waiting, and his movements seemed
more controlled and labored; he sat with his
arms tightly cradling his bloated abdomen, and
his chest was expanded as though he were
about to explode. His palms were glistening
with sweat. His face was erupting with acne.
He talked as usual in a very detached manner,
but his words came out in bursts. The nurse
chose to give him feedback about what she was
seeing and sensing from his body. She re-
flected that he seemed to be exerting a great
deal of energy holding back something that
was erupting within him. With this insight, he
was quiet for a few minutes, and tears began
rolling down his cheeks. Suddenly he began
talking about a very painful family history of
sexual abuse that had been kept secret for
many years. It became obvious that the expe-
rience of covering up the abuse had been so all-
encompassing that his pattern had been
suppressed.
This young man had reached a point at
which he realized his old ways of interacting
with others were no longer serving him, and
he chose to interact with his environment in a
different way. By the next meeting, his move-
ments had become smooth and sure, his com-
plexion had cleared up, he was now able to
reflect on his insights, and he no longer was
involved in the chaos and fighting in his cell-
block. He was able to let go of his need to con-
trol everything and was able to connect with
the emotions of his childhood experiences; he
was also able to cry for the first time in years.
In their subsequent work together, this
young man and the nurse were able to distin-
guish between his implicate pattern, which had
now become clear through their dialogue, and
the impact that keeping the abusive experience
a secret had had on him and on other members
of his family. He was able to free himself of
the shame he was carrying, which did not be-
long to him. Since that time, the young man
has been able to transcend previous limitations
and has become involved in several efforts to
help others, both in and out of the prison en-
vironment. He has entered into several warm
and loving relationships with family members
and friends and has achieved academic success.
This was evidence of expanding consciousness
for the young man. He reflected that he
wished he had had a nurse to talk with before
“catching his case” (being arrested for murder).
He had been seen by a nurse in the juvenile
detention center, who performed a physical
examination and gave him aspirin for a
headache. A few days before the murder, he
saw a nurse practitioner in a clinic who wrote
a prescription for antibiotics and talked with
him about safe sex. These interactions are ex-
plications of the pattern of the U.S. health-
care system and the increasingly task-oriented
role that nursing is being pressured to take as
juxtaposed with the transforming presence of
a nurse whose practice is rooted in partnership
that focuses on what is of utmost importance
to the person (Jonsdottir, Litchfield, & Pharris,
2003, 2004).
The focus of nursing is on pattern and
meaning. That which is underlying makes itself
known in the physical realm. Nurses grounded
in the theory of HEC are able to be in rela-
tionships with patients, families, and commu-
nities in such a way that insights arising in
their pattern recognition dialogue shed light
CHAPTER 16 • Margaret Newman’s Theory of Health as Expanding Consciousness 287
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on an expanded horizon of potential actions
(Litchfield, 1999; Newman, 1997a).
Insights Occurring as Choice Points
of Action Potential
The disruption of disease and other traumatic
life events may be critical points in the expan-
sion of consciousness. To explain this phe-
nomenon, Newman (1994a, 1997b) drew on
the work of Ilya Prigogine (1976), whose the-
ory of dissipative structures asserts that a sys-
tem fluctuates in an orderly manner until some
disruption occurs, and the system moves in a
seemingly random, chaotic, disorderly way
until at some point it chooses to move into a
higher level of organization (Newman, 1997b).
Nurses see this all the time—the patient who
is lost to his work and has no time for his fam-
ily or himself, and then suddenly has a heart
attack, which leaves him open to reflecting on
how he has been using his energy. Insights
gained through this reflection give rise to
transformation and decisions about where en-
ergy will be spent; and his life becomes more
creative, relational, and meaningful. Nurses
also see this in people diagnosed with a termi-
nal illness that causes them to reevaluate what
is really important, attend to it, and then to
state that for the first time they feel as though
they are really living. The expansion of con-
sciousness is an innate tendency of humans;
however, some experiences and processes pre-
cipitate more rapid transformations. Nurse re-
searchers working within the theory of HEC
have clearly demonstrated how nurses can cre-
ate a mutual partnership with their patients to
reflect on their evolving pattern and the points
of transformation. Through this process, ex-
panding consciousness is realized (Barron,
2005; Endo, Minegishi, & Kubo, 2005; Endo
et al., 2000; Endo, Takaki, Nitta, Abbe, &
Terashima, 2009; Flanagan, 2005, 2009;
Hayes & Jones, 2007; Jonsdottir, 1998;
Jonsdottir et al., 2003, 2004; Kiser-Larson,
2002; Lamendola, 1998; Lamendola &
Newman, 1994; Litchfield, 1993, 1999, 2005;
Moch, 1990; Musker, 2008; Neill, 2002a,
2002b; Newman, 1995; Newman & Moch,
1991; Noveletsky-Rosenthal, 1996; Pharris,
2002, 2005, 2011; Pharris & Endo, 2007;
Picard, 2000, 2005; Pierre-Louis, Akoh,
White & Pharris, 2011; Rosa, 2006; Ruka,
2005; Tommet, 2003; Yang, Xiong, Vang, &
Pharris, 2009).
Newman (1999) pointed out that nurse–
client relationships often begin during periods
of disruption, uncertainty, and unpredictability
in patients’ lives. When patients are in a state
of chaos because of disease, trauma, loss, or
other causes, they often cannot see their past
or future clearly. In the context of the nurse–
patient partnership, which centers on the
meaning the patient gives to the health
predicament, insight for action arises, and it
becomes clear to the patient how to get on
with life (Jonsdottir et al., 2003, 2004; Litch-
field, 1999; Newman, 1999). Litchfield (1993,
1999) explained this as experiencing an ex-
panding present that connects to the past and
creates an extended horizon of action potential
for the future.
Endo (1998), in her work in Japan with
women with cancer; Noveletsky-Rosenthal
(1996), in her work in the United States with
people with chronic obstructive pulmonary
disease; and Pharris (2002), in her work with
U.S. adolescents convicted of murder, found
that it is when patients’ lives are in the greatest
states of chaos, disorganization, and uncer-
tainty that the HEC nursing partnership and
pattern recognition process is perceived as
most beneficial to patients (Fig. 16-1).
Many nurses who encounter patients in times
of chaos strive for stability; they feel they have
to fix the situation, not realizing that this disor-
ganized time in the patient’s life presents an op-
portunity for growth. Newman (1999) states:
The “brokenness” of the situation is only a point in
the process leading to a higher order. We need to
join in partnership with clients and dance their
dance, even though it appears arrhythmic, until order
begins to emerge out of chaos. We know, and we
can help clients know, that there is a basic, underly-
ing pattern evolving even though it might not be
apparent at the time. The pattern will be revealed at
a higher level of organization. (p. 228)
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The disruption brought about by the pres-
ence of disease, illness, and traumatic or
stressful events creates an opportunity for
transformation to an expanded level of con-
sciousness (Newman, 1997b, 1999) and repre-
sents a time when patients most need nurses
who are attentive to that which is most mean-
ingful. Newman (1999, p. 228) stated, “Nurses
have a responsibility to stay in partnership with
clients as their patterns are disturbed by illness
or other disruptive events.” This disrupted state
presents a choice point for the person to either
continue going on as before, even though the
old rules are not working, or to shift into a new
way of being. To explain the concept of a choice
point more clearly, Newman drew on Arthur
Young’s (1976) theory of the evolution of
consciousness.
Young suggested that there are seven stages
of binding and unbinding, which begin with
total freedom and unrestricted choice, followed
by a series of losses of freedom. After these
losses come a choice point and a reversal of the
losses of freedom, ending with total freedom
and unrestricted choice. These stages can be con-
ceptualized as seven equidistant points on a
V shape (Fig. 16-2). Beginning at the upper-
most point on the left is the first stage, potential
freedom. The next stage is binding. In this stage,
the individual is sacrificed for the sake of the col-
lective, with no need for initiative because every-
thing is being regulated for the individual. The
third stage, centering, involves the development
of an individual identity, self-consciousness, and
self-determination. “Individualism emerges in
the self’s break with authority” (Newman,
1994b). The fourth stage, choice, is situated at the
base of the V. In this stage, the individual learns
that the old ways of being are no longer working.
It is a stage of self-awareness, inner growth, and
transformation. A new way of being becomes
necessary. Newman (1994b) described the fifth
stage, decentering, as being characterized by a
shift from the development of self (individua-
tion) to dedication to something greater than
the individual self. The person experiences out-
standing competence; his or her works have a
life of their own beyond the creator. The task is
CHAPTER 16 • Margaret Newman’s Theory of Health as Expanding Consciousness 289
Emergence of new
order at higher level of
organization
Period of disorganization,
unpredictability,
uncertainty (response to
disease, trauma, loss, etc.)Normal,
predictable
fluctuation
Giant
fluctuation
Time when partnership with
an HEC nurse can be of
greatest benefit
Fig 16 • 1 Prigogine’s theory of dissipative structures applied to health as expanding consciousness
(HEC) nursing.
3312_Ch16_279-300 26/12/14 4:46 PM Page 289
transcendence of the ego. Form is transcended,
and the energy becomes the dominant feature—
in terms of animation, vitality, a quality that is
somehow infinite. In this stage, the person ex-
periences the power of unlimited growth and has
learned how to build order against the trend of
disorder (pp. 45–46).
Newman (1994b) stated that few experi-
ence the sixth stage, unbinding, or the sev-
enth stage, real freedom, unless they have had
these experiences of transcendence character-
ized by the fifth stage. It is in the moving
through the choice point and the stages of
decentering and unbinding that a person
moves on to higher levels of consciousness
(Newman, 1999). Newman proposed a corol-
lary between her theory of health as expand-
ing consciousness and Young’s theory of the
evolution of consciousness in that we “come
into being from a state of potential con-
sciousness, are bound in time, find our iden-
tity in space, and through movement we
learn ‘the law’ of the way things work and
make choices that ultimately take us beyond
space and time to a state of absolute con-
sciousness” (Newman, 1994b, p. 46).
The Mutuality of the Nurse–Client
Interaction in the Process of Pattern
Recognition
We come to the meaning of the whole not by
viewing the pattern from the outside, but by
entering into the evolving pattern as it unfolds.
—M. A. NEWMAN
Nursing within the HEC perspective involves
being fully present to the patient without judg-
ments, goals, or intervention strategies. It in-
volves being with rather than doing for. It is
caring in its deepest, most respectful sense with
a focus on what is important to the patient.
The nurse–patient interaction becomes like a
pure reflection pool through which both the
nurse and the patient achieve a clear picture of
their pattern and come away transformed by
the insights gained.
To illustrate the mutually transforming
effect of the nurse–patient interaction, New-
man (1994a) offers the image of a smooth lake
into which two stones are thrown. As the
stones hit the water, concentric waves circle
out until the two patterns reach one another
and interpenetrate. The new pattern of their
interaction ripples back and transforms the two
original circling patterns. Nurses are changed
by their interactions with their patients, just as
patients are changed by their interactions with
nurses. This mutual transformation extends to
the surrounding environment and relation-
ships of the nurse and patient.
In the process of doing this work, it is im-
portant that the nurse sense his or her own
pattern. Newman states:
We have come to see nursing as a process of rela-
tionship that coevolves as a function of the interpen-
etration of the evolving fields of the nurse, client, and
the environment in a self-organizing, unpredictable
way. We recognize the need for process wisdom,
the ability to come from the center of our truth and
act in the immediate moment. (Newman, 1994b,
p. 155)
Sensing one’s own pattern is an essential
starting point for the nurse. In her book Health
as Expanding Consciousness, Newman (1994a,
pp. 107–109) outlines a process of focusing to
assist nurses as they begin working in the
HEC perspective. It is important that the
nurse be able to practice from the center of his
or her own truth and be fully present to the
patient. The nurse’s consciousness, or pattern,
becomes like the vibrations of a tuning fork
that resonate at a centering frequency, and the
client has the opportunity to resonate and tune
290 SECTION IV • Conceptual Models and Grand Theories in the Unitary–Transformative Paradigm
Centering De-centering
Binding
Potential freedom Real freedom
Unbinding
Choice
Fig 16 • 2 Young’s spectrum of the evolution of
consciousness.
3312_Ch16_279-300 26/12/14 4:46 PM Page 290
to that clear frequency during their interactions
(Newman, 1994a; Quinn, 1992). The nurse–
patient relationship ideally continues until the
patient finds his or her own rhythmic vibra-
tions without the need of the stabilizing force
of the nurse–patient dialogue. Newman (1999)
points out that the partnership demands that
nurses develop tolerance for uncertainty, dis-
organization, and dissonance, even though it
may be uncomfortable. It is in the state of dis-
equilibrium that the potential for growth ex-
ists. She states, “The rhythmic relating of nurse
with client at this critical boundary is a window
of opportunity for transformation in the health
experience” (Newman, 1999, p. 229).
Relevance of HEC Across Cultures
Margaret Newman’s theory of health as ex-
panding consciousness is being used through-
out the world, but it has been more quickly
embraced and understood by nurses from in-
digenous and Eastern cultures, who are less
bound by linear, three-dimensional thought
and physical concepts of health and who are
more immersed in the metaphysical, mystical
aspect of human existence. Increasingly, how-
ever, HEC is being enthusiastically embraced
by nurses in industrialized nations who are
finding it difficult to nurse in the modern tech-
nologically driven and intervention-oriented
health-care system, which is dependent on
diagnosing and treating diseases (Jonsdottir
et al., 2003, 2004). Practicing from an HEC
perspective involves a holistic approach, which
places what is meaningful to patients back
into the center of the nurse's focus and what
is meaningful to students back into the center
of the focus of nurse educators. This person-
centered approach has wide appeal across
cultures.
HEC Research as Praxis
Margaret Newman’s early research (1966, 1971,
1972, 1976, 1982, 1986, 1987) added to an
understanding of the interrelatedness of time,
movement, space, and consciousness as mani-
festations of health. Newman’s further reflection
on these studies in light of work she did at
Walter Reed Hospital with Richard Cowling
and John Vail related to pattern recognition,
revealed the need to look at health as expanding
consciousness using a research methodology that
acknowledges, understands, and honors the
undivided wholeness of the human health expe-
rience. Newman, Cowling, and Vail’s study par-
ticipants were nurses at Walter Reed Hospital.
Newman described one of the interviews she
conducted as Vail and Cowling watched from
another room. Newman asked the nurse to de-
scribe meaningful events in her life and Newman
diagrammed the unfolding trajectory of the
nurse’s life. When they met the next day to re-
flect the sequential patterns Newman had iden-
tified, the nurse was able to see that experiences
she had previously viewed as being extremely
negative (e.g., a divorce), actually were stepping
stones to expanded possibilities; she was sud-
denly able to view her life in a new way. The
nurse researchers and participants were excited
about the insights they gained. The pattern
recognition research method was a powerful
nursing practice process that shed light on
theory—research, theory, and practice each illu-
minated and developed the other two. Newman
went on to develop her pattern recognition nurs-
ing research method in which theory, practice,
and research are one undivided process, each
aspect shedding greater light on the other two.
Newman realized a need to step inside to
view the whole from within—which is simply
a metaphorical process since the researcher has
been integrally within the whole all along.
Newman’s pattern recognition method cleared
away the murky waters surrounding research,
theory, and practice and what previously ap-
peared to be three separate islands, became
clearly visible as mountaintops on one undi-
vided piece of land, newly emerged but always
there as an undivided whole. HEC research as
praxis unfolded uniquely in various countries
and settings as nurse researcher-practitioner-
theorists engaged in partnerships with individ-
uals, families, and communities to understand
patterns of meaning.
Focusing on the Process of Health
Patterning and the Nurse–Patient
Partnership
Merian Litchfield (1993) from New Zealand
was the first researcher to apply the theory of
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health as expanding consciousness to a nursing
partnership with families. Litchfield (1993,
1999, 2005) has led the way in focusing on the
process of the nursing partnership with pa-
tients and families. In her first study, Litchfield
(1993) described health patterning as “a
process of nursing practice whereby, through
dialogue, families with researcher as practi-
tioner, recognize pattern in the life process
providing opportunity for insight as the poten-
tial for action; a process by which there may
be increased self-determination as a feature
of health” (p. 10). Litchfield (1993) described
her research as a “shared process of inquiry
through which participants are empowered
to act to change their circumstances” (p. 20).
Through her research over several years with
families with complex health predicaments re-
quiring repeated hospitalizations, Litchfield
(1993, 1999, 2005) found that she could not
stand outside of the process of recognizing
pattern to observe a fixed health pattern of the
family. She saw the pattern as continuously
evolving dialectically in the dialogue within the
nursing partnership. The findings are literally
created in the participatory process of the part-
nership (Litchfield, 1999). For this reason,
Litchfield did not use diagrams to reflect pat-
tern because she thought they would imply
that the pattern is static rather than continually
evolving. As the family reflects on the pattern
of their interactions with each other and the
environment, insight into action may involve
a transformative process, with the same events
being seen in a new light. Family health is seen
as a function of the nurse–family relationship.
Many of the families in partnership with
Litchfield (1999, 2005) gained insight into
their own predicaments in such a way that they
required less interaction and service from tra-
ditional health-care services, and thus a cost
saving in such services was realized.
Exploring Pattern Recognition as a
Nursing Intervention
Emiko Endo (1998) explored HEC pattern
recognition as a nursing intervention in Japan
with women living with ovarian cancer. She
asked, “When a person with cancer has an op-
portunity to share meaning in the life process
within the nurse–client relationship, what
changes may occur in the evolving pattern?”
Attending to the flow of meaningful thoughts
for each participant and building on the pre-
vious work of Litchfield (1993), Endo found
four common phases of the process of expand-
ing consciousness for all participants: client–
nurse mutual concern, pattern recognition,
vision and action potential, and transformation.
Participants differed in the pace of evolving
movement toward a turning point and in the
characteristics of personal growth at the turn-
ing point. The characteristics of growth ranged
from assertion of self, to emancipation of self,
to transcendence of self. Reflecting on her
experience, Endo (1998) put forth that pattern
recognition is “not intended to fix clients’
problems from a medical diagnostic stand-
point, but to provide individuals with an op-
portunity to know themselves, to find meaning
in their current situation and life, and to gain
insight for the future” (p. 60).
Endo et al. (2000) conducted a similar
study with Japanese families in which the wife-
mother was hospitalized because of a cancer
diagnosis. Families found meaning in their
patterns and reported increased understanding
of their present situation. In the pattern recog-
nition process, most families reconfigured
from being a collection of separated individuals
to trustful, caring relationships as a family
unit, showing more openness and connected-
ness. The researchers concluded that pattern
recognition as a nursing intervention was a
“meaning-making transforming process in the
family–nurse partnership” (p. 604).
HEC-Inspired Practice
Patricia Tommet (2003) used the HEC
hermeneutic dialectic methodology to explore
the pattern of nurse–parent interaction in fam-
ilies faced with choosing an elementary school
for their medically fragile children. She found
a pattern of living in uncertainty in the families
during the intense period of disruption and
disorganization after the birth of their med-
ically fragile child through the first few years.
After 2 to 3 years, the families exhibited a pat-
tern of order in chaos where they learned how
to live in the present, letting go of the way they
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lived in the past. Tommet found that “families
changed from being passive recipients to active
participants in the care of their children”
(p. 90) and that the “experience of their chil-
dren’s birth and life transformed these families
and through them, transformed systems of
care” (p. 86). Tommet demonstrated insights
gained in family pattern recognition and con-
cluded that a nurse–parent partnership could
have a more profound impact on these fami-
lies, and hence the services they use, during the
first 3 years of their children’s lives.
Working with colleagues in New Zealand,
Litchfield undertook a pilot project that in-
cluded 19 families in a predicament of strife
(Litchfield & Laws, 1999). The goal of the
pilot project, which built on Litchfield’s pre-
vious work (1993, 1999), was to explore a
model of nurse case management incorporat-
ing the use of a family nurse who understands
the theory of health as expanding conscious-
ness. In the context of a family–family nurse
partnership, the unfolding pattern of family
living was attended to. Family nurses shared
their stories of the families with the research
group, who reflected together on the families’
changing predicaments and the whole picture
of family living in terms of how each family
moved in time and place. Subsequent visits
with the families focused on recognition
of pattern and potential for action. The family
nurse mobilized relief services if necessary
and orchestrated services as needs emerged
in the process of pattern recognition. The re-
search group found that families became more
open and spontaneous through the process of
pattern recognition, and their interactions ev-
idenced more focus, purposefulness, and coop-
eration. In analyzing costs of medical care for
one participating family, it was estimated that
a 3% to 13% savings could be seen by employ-
ing the model of family nursing, with greater
savings being possible when family nurses are
available immediately after a family disruption
takes place (Litchfield & Laws, 1999). Based
on Litchfield’s work with families with com-
plex health predicaments, the government
funded a large demonstration project to sup-
port family nurses who would be able to nurse
from unitary-transformative perspective and
partner with families without having predeter-
mined goals and outcomes that the families
and nurses must achieve. These nurses are free
to focus on family health as defined and expe-
rienced by the families themselves.
Endo and colleagues (Endo, Minegishi, &
Kubo, 2005; Endo, Miyahara, Suzuki, &
Ohmasa, 2005) in Japan have expanded their
work to incorporate the pattern recognition
process at the hospital nursing unit level. After
engaging the professional nursing staff in read-
ing and dialogue about the theory of HEC,
nurses were encouraged to incorporate the ex-
ploration of meaningful events and people into
their practice with their patients. Nurses kept
journals and came together to reflect on the ex-
perience of expanding consciousness in their
patients and in themselves. Endo, Miyahara,
Suzuki, and Ohmasa (2005) concluded:
Retrospectively it was found through dialogue in the
research/project meetings that in the usual nurse–
client relationships, nurses were bound by their re-
sponsibilities within the medical model to help clients
get well, but in letting go of the old rules, they en-
countered an amazing experience with clients’ trans-
formations. The nurses’ transformation occurred
concomitantly, and they were free to follow the
clients’ paths and incorporate all realms of nursing
interventions in everyday practice into the unitary per-
spective. (p. 145)
Jane Flanagan (2005, 2009) transformed
the practice of presurgical nursing by develop-
ing the preadmission nursing practice model,
which is based on HEC. The nursing practice
model shifted from a disease focus to a process
focus, with attention being given to the nurses
knowing their patients and what is meaningful
to them so that the surgery experience could
be put in proper context and appropriate care
provided. Nursing presurgical visits were em-
phasized. Flanagan reported that the nursing
staff members were exuberant to be free to be
nurses once again, and patients frequently
stopped by to comment on their preoperative
experience and evolving life changes.
Similarly, Susan Ruka (2005) made HEC
pattern recognition the foundation of care at a
long-term-care nursing facility, transforming the
CHAPTER 16 • Margaret Newman’s Theory of Health as Expanding Consciousness 293
3312_Ch16_279-300 26/12/14 4:46 PM Page 293
nursing practice and the sense of connectedness
among staff, families, and residents: Each be-
came more peaceful, relaxed, and loving.
Application of HEC at the
Community Level
Pharris (2002, 2005) attempted to understand
a community pattern of rising youth homicide
rates by conducting a study with incarcerated
teens convicted of murder. The youth in the
study reported the pattern recognition process
to be transformative, and expanding con-
sciousness was visible in changed behaviors,
increased connectedness, and more loving
attention to meaningful relationships. The ex-
perience of the young men demonstrated that
alterations in movement, time, and space in-
herent in the prison system can intensify the
process of expanding consciousness. When the
experiences of meaningful events and relation-
ships were compared across participants, the
pattern of disconnection with the community
became evident. People from various aspects
of the community (youth workers, juvenile
detention staff, emergency hospital staff, pedi-
atric nurses and physicians, social workers,
educators, etc.) were engaged in dialogues re-
flecting on the youths’ stories and the commu-
nity pattern. Insights transformed community
responses to young people at risk for violent
perpetration. System change ensued.
Pharris (2005) and colleagues extended the
community pattern recognition process through
partnerships within a multiethnic community
interested in understanding and transforming
patterns of racism and health disparities. They
engaged women and girls from all walks of life
in the community in dialogue about their ex-
periences of health, well-being, and racism.
Findings were woven into a spoken word nar-
rative that was presented in various forms (per-
formances at meetings and gatherings, through
community television and radio, and showing
of DVD recordings) to members of the com-
munity so that meaningful dialogue could
ensue. The process of reflecting on the com-
munity pattern generated insight into the na-
ture of the community and what actions could
be taken to dismantle racism and enhance
health and well-being.
In a related study comparing the evolving
patterns of Hmong women living in the
United States with diabetes, Yang et al. (2009)
found that the women’s blood sugars rose and
fell with their experiences of trauma, loss, sep-
aration, and isolation. Women in the study de-
scribed their lives in Laos where they walked
up and down hills carrying large bags of rice
on their backs, picked fresh fruits and vegeta-
bles that grew near their homes, and engaged
in myriad interactions with family and friends
in the community. Then they described their
life in the United States where they sit alone
at home all day watching television in a lan-
guage they do not understand and where they
are fearful to walk outside and are driven by
their sons and daughters to the grocery store,
where they buy food wrapped in plastic. Dia-
logue on these findings, which were presented
by two Hmong students as a play at a commu-
nity dinner for Hmong women living with
diabetes, shed light on needed individual,
family, and community actions so that Hmong
women living with diabetes could lead happy
and healthy lives.
Similarly, Pierre-Louis et al. (2011) con-
ducted an HEC study with African American
women with diabetes. Pattern recognition re-
vealed that blood sugars rose and fell with
stress, depression, and trauma and that spiri-
tual strength, mentors, and sister friends help
to balance energy demands. Findings were
woven into a spoken-word performance by the
Black Story Tellers Alliance to engage African
American women who have diabetes in action
planning so that health can flourish in their
lives.
Pavlish and Pharris (2012) published a
book on community-based collaborative action
research, which is rooted in Newman’s theory
and provides a framework for nurses to engage
communities—whether hospital units, refugee
camps, small towns, or groups of people—in
a process of pattern recognition and action
research to promote human flourishing.
Sharon Falkenstern (2003, 2009) found the
community pattern to emerge as significant
when she studied the process of HEC nursing
with families with a child with special health-
care needs. She emphasized the importance of
294 SECTION IV • Conceptual Models and Grand Theories in the Unitary–Transformative Paradigm
3312_Ch16_279-300 26/12/14 4:46 PM Page 294
nursing partnership with families as they
struggle to make sense of their experiences and
try to discern how to get on with their lives.
The evolving pattern of the families in Falken-
stern’s study illuminated the social and politi-
cal forces on families from the educational,
disabilities support, and health-care systems,
as well as community patterns of caring, prej-
udice, and racism. Falkenstern summarized
her experience of using HEC with families
with children with special health-care needs in
the following way:
My experience with this study has rekindled my pas-
sion for nursing. I felt affirmed that in the world of
managed health care and educational cutbacks, a
movement is growing to recapture the essence and
value of nursing. While there is still much to be done
for nursing within the political realm of health care,
each nurse can control where and how they choose
to practice. Especially, I realized that a nurse can
experience joy and renewed energy by choosing to
practice nursing within health as expanding con-
sciousness. (2003, p. 232)
The pattern of the community is visible
in the stories of individuals and families.
Nurses can play an important role in engag-
ing communities in dialogue as these stories
are shared and their meaning reflected on.
Methods that engage communities in dia-
logue about the meaning of patterns of health
hold great potential. For example, if an HEC
nurse were to take on the task of engaging
nurses at the national level in a dialogue about
what is meaningful in their practice, expand-
ing consciousness would be manifest as the
profession reorganizes at a higher level of
functioning, with resultant health-care sys-
tems change. In the process, the population
would no doubt experience a fuller, more
equitable, and deeper sense of health, inter-
connectedness, and meaning.
Readers who are interested in learning more
about Margaret Newman’s theory of health as
expanding consciousness are referred to an inte-
grative review by Dr. Marlaine Smith (2011)
and to Dr. Newman’s website: healthasexpand-
ingconsciousness.org
CHAPTER 16 • Margaret Newman’s Theory of Health as Expanding Consciousness 295
Practice Exemplar
Sandra is an adult nurse practitioner working
in a community clinic in an urban area of the
United States; she is about to enter the room
of Gloria, a new patient with diabetes and hy-
pertension. Gloria was referred by Anna, a
physician colleague who felt that Gloria was
“noncompliant,” as evidenced by her uncon-
trolled hypertension and hemoglobin A1c lev-
els that consistently hovered around 10. Anna
felt that Gloria needed more care than she
could provide for her.
Sandra’s graduate program in nursing was
based on the theory of health as expanding con-
sciousness; the faculty paid attention to know-
ing her and what was meaningful to her in her
educational and vocational journey. She expe-
rienced a relationship-based education process
where the teacher is seen as “a catalyst to help
students become who they will become rather
than be ‘trained’” and the learning process is
a “dance between content and resonance”
(Newman, 2008b, p. 75). Sandra felt known
and loved by the faculty. She had ample expe-
rience performing problem-solving approaches
through the medical paradigm that leads to di-
agnoses, yet she realized that her nursing ac-
tions were best guided by a dialogue focused on
understanding Gloria’s physical health within
the context of her life situation. She knew that
the focus of her care for Gloria would arise out
of their dialogue; she could not prescribe or
predetermine the best care for Gloria.
Before entering the room where Gloria is
waiting, Sandra consciously attends to freeing
herself of any personal preoccupations or expec-
tations of what might happen. She wants to fully
attend to Gloria and sense what is of greatest
importance to her right now, knowing that this
will guide Sandra’s nursing actions so that they
can be of most benefit to Gloria. Sandra is con-
fident that she will get a sense of this not only
by asking questions and listening deeply but also
through intuitive hunches that will arise through
her resonant presence with Gloria.
Continued
3312_Ch16_279-300 26/12/14 4:46 PM Page 295
296 SECTION IV • Conceptual Models and Grand Theories in the Unitary–Transformative Paradigm
Practice Exemplar cont.
On entering the room, Sandra warmly
greets Gloria and concentrates on what she is
sensing from Gloria’s presence. She sits down
next to Gloria in a relaxing and open manner.
What most strongly calls Sandra’s attention is
that Gloria is wringing her hands, which are
sweaty; and her muscles seem very tense.
After pausing for a moment, Sandra
chooses to reflect back to Gloria what she sees.
“Your muscles seem tense, like you might be
anxious about something. How has life been
going for you?” Gloria looks at Sandra, curious
that Sandra is interested in her life. She re-
sponds, “Well, things have been hard.” Sandra
responds, “Hmm, tell me about that.” Gloria
explains that it has been difficult to take care
of the two children she provides day care for.
She says she doesn’t have the energy but needs
the money to pay her rent, which leaves her
very little money to buy food, and she cannot
afford her medications.
Sandra assures Gloria that the clinic has a
plan that will provide her with her medications
and that she will see that this is taken care of
today—that she will go home with adequate
medications. She tells Gloria that she would
like to learn a little more about what has been
meaningful in her life and asks her to describe
meaningful events. Sandra uses the examina-
tion table paper to draw a diagram of what
Gloria tells her. In very little time, Sandra has
sketched a diagram of the flow of important
events in Gloria’s life. She learns that when
immigrating to the United States from Africa,
Gloria suffered intense abuse and was sepa-
rated from her family and friends. She has
children in the United States who constantly
call her to babysit their children and to help
them out. Gloria has also experienced intimate
partner violence, and her current economic
stress and depression have flowed from this
experience. Gloria lives in a small apartment
in a neighborhood where she would need to
walk 2 miles to get to a store that sells fresh
fruits and vegetables. She tells Sandra she is
hesitant to leave her apartment.
Sandra reflects back to Gloria that she sees
all of Gloria’s energy going out to others and
none coming back to her. She has gone from
being very active to only moving around
within her apartment. Tears run down Gloria’s
cheeks as she listens to Sandra’s reflection.
“That is so true!” They talk about sources of
support, nurturance, and energy. Gloria iden-
tifies a woman in her building whose company
she enjoys. They talk about the possibility of
the two women walking to the supermarket
together and simply getting together to talk.
They identify a neighborhood women’s walk-
ing group, which might be a source of support.
They also talk about a women’s group at the
local library, but Gloria seems hesitant.
During the course of their conversation,
Sandra has tried to clear herself of her own
concerns, yet, as they talk, she keeps thinking
about an experience of racism she witnessed at
that library. She decides that it is important
information and shares the story with Gloria.
This provokes an outpouring of emotion from
Gloria as she recounts her experiences of
racism. They discuss how distorting these ex-
periences are and how to move through them.
They talk about how blood sugar and pressure
respond to these situations and ways in which
Gloria can best cope.
Sandra does all of the things for Gloria that
her medical colleagues would do. She also dis-
cusses the services of the social worker, dieti-
tian, and psychologist at the clinic so that
Gloria can choose what might be most helpful
to her at this time. Gloria hugs Sandra as she
leaves, saying that she feels so much better,
and adding, “You are a very good nurse!” Gloria
leaves with a greater understanding of herself,
of what is meaningful to her, and what actions
she might take. Sandra is left with the same
enhanced understanding of herself and her
practice.
Sandra tucks the diagram they have drawn
into a folder so that it can be elaborated on at
subsequent visits. Sandra knows that Gloria’s
experience of health and well-being will evolve
3312_Ch16_279-300 26/12/14 4:46 PM Page 296
CHAPTER 16 • Margaret Newman’s Theory of Health as Expanding Consciousness 297
Practice Exemplar cont.
and that she can serve as a catalyst, witnessing
and engaging in dialogue about the meaning
of the pattern of Gloria’s evolving health. Sandra
will continue to focus on what she senses as
meaningful to Gloria and engage in a relation-
ship centered on Gloria’s unfolding pattern of
health. Hemoglobin A1c levels and blood
pressure readings are only one aspect of that
pattern.
As Sandra engages with more and more
patients with similar predicaments, she gets a
sense of the community pattern of health. She
brings her insight to the clinic staff meetings
where a rich dialogue about community health
ensues. Sandra joins the CEO for a dialogue
with the clinic’s community board of directors
to offer their insights. Through the subsequent
dialogue, the board of directors and CEO
commit themselves to ensuring that health-
care providers have sufficient time to attend to
patients in a holistic manner, sponsoring com-
munity forums on racism and how to deal with
it, embedding a mental health practitioner
in the medical clinic, partnering with a com-
munity recreational facility so that patients
have a safe place to exercise, encouraging com-
munity microeconomic enterprises for women,
working with a community coop to provide
an affordable source of nutritious food in the
immediate neighborhood, and lobbying for
health-care financing reform.
The circle of dialogue continues for Sandra.
Her attention is on pattern and meaning in the
evolving health of her patients and the com-
munity. She trusts that health is inherently
present in her patients and the community and
that reflection on what is meaningful is a cat-
alyst for its evolving pattern. With this real-
ization, Sandra is able to return home where
she can be fully present to her family.
■ Summary
Margaret Newman’s theory of health as ex-
panding consciousness calls nurses to focus on
that which is meaningful in their practice and
in the lives of their patients. It attends to the
evolving pattern of interactions with the envi-
ronment for individuals, families, and commu-
nities. It is a theory that is relevant across
practice settings and cultures. It informs and
guides nursing practice, health-care adminis-
tration, and education. The theory of HEC
presents a philosophy of being with rather than
simply doing for. It involves a different way of
knowing—of resonating with patients, stu-
dents, and health-care colleagues.
Nurses grounded in the theory of health
as expanding consciousness bring to the pa-
tient encounter all that they have learned in
school and in practice, yet they begin with a
sense of nonknowing to take in what is most
meaningful to the patient. Nurses attend to
the patient’s definition of health and see it in
the context of the patient’s expression of
meaningful relationships and events. The
focus is not on predetermined outcomes
mandated by the health system or on fixing
the patient but rather on partnering with the
patient in his or her experience of health.
Rather than simply using technological tools
and following prescribed clinical pathways,
nurses offer their own transforming presence,
knowing that the direction of their interac-
tion with patients will arise out of the rela-
tionship’s focus on the patient’s evolving
experience of health. Nurses realize that the
process of expanding consciousness involves
transcendence and new possibilities as people
age or encounter a challenging life event. As
nurses come to understand the meaning of
patterns in the lives of individuals, families,
and communities, they gain insights that in-
form population level dialogue for health
policy transformation.
3312_Ch16_279-300 26/12/14 4:46 PM Page 297
funding to review the Margaret A. Newman
archives housed at the University of Ten-
nessee and to interview Dr. Newman. That
work has informed this chapter and her
life. She also thanks Dr. Newman for editing
this chapter and adding the section, “Losing
Our Senses, Finding Our Selves,” which
includes her current thinking related to gero-
trancendence and health as expanding con-
sciousness and can be accessed in the
electronic supplement to this chapter. This
section can be found in the online supple-
mentary materials for the chapter at: http://
davisplus.fadavis.com
298 SECTION IV • Conceptual Models and Grand Theories in the Unitary–Transformative Paradigm
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Section V
Grand Theories about Care
or Caring
301
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302
Three of the grand theories in this book focus on the phenomenon of care or caring
in nursing. These theorists describe care or caring as the central domain of the
discipline of nursing. Rather than place these in either the interactive–integrative
or unitary–transformative paradigm, we situated them in a category of their own.
Madeleine Leininger’s theory of cultural care diversity and universality is cov-
ered in Chapter 17. The theory is described, and practice applications of the
theory are provided. Leininger was the first to define care as the essence of nurs-
ing; she asserted that care or nurturance can be understood only within cultural
contexts.
Jean Watson’s work can be conceptualized as a philosophy, grand theory,
or middle-range theory, depending on the lens of the nurse working with the
theory. Watson’s theory is composed of the ten caritas processes, the transper-
sonal caring relationship, the caring occasion, and caring–healing modalities.
Watson’s theory draws from a spiritual dimension affirming that transpersonal
caring is connecting and embracing the spirit or soul of another. She shares
examples of how her theory is being advanced and applied as a model for
practice through the Watson Caring Science Institute and the International
Caritas Consortium.
The premise of Anne Boykin and Savina Schoenhofer’s theory of nursing as
caring is that the focus of nursing is the person living and growing in caring. The
theory encompasses coming to know the other as caring, hearing and answering
calls for caring, and nurturing the growth of the other as caring person. This theory
has transformed, and is currently transforming, care in a variety of settings.
Section
V Grand Theories about Care or Caring
302
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Chapter 17Madeleine Leininger’s Theory
of Culture Care Diversity and
Universality
HIBA WEHBE-ALAMAH
Introducing the Theorist
Overview of the Theory
Applications of the Theory
Summary
Practice Exemplar
References
Madeleine M. Leininger
303
Introducing the Theorist
Madeleine M. Leininger (1925–2012) founded
the worldwide field of transcultural nursing, the
International Transcultural Nursing Society,
and the Journal of Transcultural Nursing.
Dr. Leininger obtained her initial nursing ed-
ucation at St. Anthony School of Nursing in
Denver, Colorado. She earned her undergrad-
uate degree from Mt. St. Scholastic College in
Atchison, Kansas; her master’s degree in psy-
chiatric and mental health nursing from the
Catholic University of America; and her PhD
in social and cultural anthropology at the Uni-
versity of Washington (Boyle & Glittenberg
Hinrichs, 2013). Dr. Leininger served as dean
at the Universities of Washington and Utah,
where she helped initiate and direct the first
doctoral programs in nursing and facilitated
the development of master’s degree programs
in nursing at American and overseas institu-
tions. Recognized as a Living Legend by the
American Academy of Nursing and a distin-
guished fellow by the Australian Royal College
of Nursing, she served as a professor emerita in
the College of Nursing at Wayne State Uni-
versity and adjunct professor at the University
of Nebraska College of Nursing. Dr. Leininger
passed away at her home in Omaha, Nebraska,
at the age of 87 on August 10, 2012.
In the span of her prolific career, Madeleine
Leininger published 35 books, wrote approxi-
mately 3,000 articles (some of which were
never published), and gave more than 5,000
presentations or public lectures throughout the
United States and abroad, in addition to con-
tributing to numerous books and videos (Boyle
& Glittenberg Hinrichs, 2013). Some of her
well-known books include Basic Psychiatric
3312_Ch17_301-320 26/12/14 5:57 PM Page 303
Concepts in Nursing (Leininger & Hofling,
1960); Caring: An Essential Human Need
(1981); Care: The Essence of Nursing and Health
(1984); Care: Discovery and Uses in Clinical and
Community Nursing (1988); Ethical and Moral
Dimensions of Care (1990d); and Culture Care
Diversity and Universality: A Theory of Nursing
(1991a, 2006a). Nursing and Anthropology: Two
Worlds to Blend (1970) was the first book to
bring together nursing and anthropology. The
first book on transcultural nursing was Trans -
cultural Nursing: Concepts, Theories, and Practices
(1978, 1995, 2002). Her book Qualitative Re-
search Methods in Nursing (1985, 1998) was the
first published qualitative research methods
book in nursing. In 1989, Dr. Leininger
founded the Journal of Transcultural Nursing,
the first transcultural nursing journal in the
world.
Dr. Leininger conducted the first field
study of the Gadsup Akuna of the Eastern
Highlands of New Guinea in the early 1960s
and went on to study more than cultures. She
developed the first nursing research method
called ethnonursing, used by scholars in nursing
and other disciplines. She initiated the idea of
worldwide certification of nurses prepared
in transcultural nursing. Today, Basic (under-
graduate) and Advanced (graduate) certifica-
tions are available through the Transcultural
Nursing Society.
Overview of the Theory
One of Dr. Leininger’s most significant and
unique contributions was the development
of her culture care diversity and universality the-
ory, also known as the culture care theory
(CCT), which she introduced in the early
1960s to provide culturally congruent and
competent care (Leininger, 1991b, 1995,
2006a; McFarland, 2010). She believed that
transcultural nursing care could provide mean-
ingful, therapeutic health and healing out-
comes. As she developed the theory, she
identified transcultural nursing concepts, prin-
ciples, theories, and research-based knowledge
to guide, challenge, and explain nursing prac-
tices. This was a significant innovation in nurs-
ing and has helped open the door to new
scientific and humanistic dimensions of caring
for people of diverse and similar cultures.
The theory of culture care diversity and uni-
versality was developed to establish a substantive
knowledge base to guide nurses in discovery and
use of transcultural nursing practices. During
the post–World War II period, Dr. Leininger
realized nurses would need transcultural knowl-
edge and practices to function with people of
diverse cultures worldwide (Leininger, 1970,
1978). Many new immigrants and refugees
were coming to the United States, and the
world was becoming more multicultural.
Leininger held that caring for people of
many cultures was a critical and essential need,
yet nurses and other health professionals were
not prepared to meet this global challenge.
Instead, nursing and medicine were focused on
using new medical technologies and treatment
regimens. They concentrated on biomedical
study of diseases and symptoms. Shifting to
a transcultural perspective was a major but
critically needed change.
This part of the chapter presents an
overview of the theory of culture care diversity
and universality, along with its purpose, goals,
assumptions, theoretical tenets, predicted
hunches, related general features, and newest
features. The next part of the chapter discusses
applications of the knowledge in clinical and
community settings. For a more in-depth dis-
cussion of the theorist’s perspectives, consult
the primary literature on the theory (Leininger,
1970, 1981, 1989a, 1989b, 1990a, 1990b,
1991a, 1995, 1997a, 1998, 2002, 2006a;
McFarland, 2010).
Factors Leading to the Theory
Dr. Leininger’s major motivation for the de-
velopment of the CCT was the desire to dis-
cover unknown or little-known knowledge
about cultures and their core values, beliefs,
and needs. The idea for the CCT came to
her while she was a clinical child nurse spe-
cialist in a child guidance home in a large
Midwestern city (Leininger, 1970, 1991a,
1995, 2006a). From her focused observations
and daily nursing experiences with the chil-
dren in the home, she became aware that
they were from many cultures, differing in
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their behaviors, needs, responses, and care ex-
pectations. In the home were youngsters who
were Anglo American, African American,
Jewish American, Appalachian, and many
other cultures. Their parents responded to
them differently, and their expectations of
care and treatment modes were different. The
reality was a shock to Leininger because she
was not prepared to care for children of di-
verse cultures. Likewise, nurses, physicians,
social workers, and health professionals in the
guidance home were also not prepared to
respond to such cultural differences.
It soon became evident that she needed
cultural knowledge to be helpful to the chil-
dren. Her psychiatric and general nursing
care knowledge and experiences were inade-
quate. She decided to pursue doctoral study
in anthropology. While in the anthropology
doctoral program, she discovered a wealth
of potentially valuable knowledge that would
be helpful from a nursing perspective.
To care for children of diverse cultures and
link such knowledge into nursing knowledge
and practice was a major challenge. It was
essential to incorporate new cultural knowl-
edge that went beyond the traditional
physical and emotional needs of clients.
Leininger was concerned about whether such
learning would be possible, given nursing’s
traditional norms and orientation toward
medical knowledge.
At that time, she questioned what made
nursing a distinct and legitimate profession.
She declared in the mid-1950s that care is (or
should be) the essence and central domain of
nursing. However, according to Leininger,
many nurses resisted this idea because they
thought care was unimportant, too feminine,
too soft, and too vague and that it would
never explain nursing and be accepted by
medicine (Leininger, 1970, 1977, 1981, 1984).
Nonetheless, Leininger firmly held to the
claim and began to teach, study, and write
about care as the essence of nursing, its unique
and dominant attribute (Leininger, 1970,
1981, 1988, 1991a, 2006a). From both anthro-
pological and nursing perspectives, she held
that care and caring were basic and essential
human needs for human growth, development,
and survival (Leininger, 1977, 1981, 2006a).
She argued that what humans need is human
caring to survive from birth to old age, when
ill or well. Nevertheless, care needed to be
specific and appropriate to cultures.
Her next step in the theory was to con-
ceptualize selected cultural perspectives and
transcultural nursing concepts derived from
anthropology. She developed assumptions of
culture care to establish a knowledge base for
the new field of transcultural nursing. Synthe-
sizing or interfacing culture care into nursing
was a real challenge. (Leininger, 1976, 1978,
1990a, 1990b, 1991a, 2006a). Findings from
the theory could provide the knowledge to care
for people of different cultures. The idea of
providing care was largely taken for granted or
assumed to be understood by nurses, clients,
and the public (Leininger, 1981, 1984). Yet
the meaning of “care” from the perspective of
different cultures was unknown to nurses and
did not appear in the literature before the es-
tablishment of Leininger’s theory in the early
1960s. Care knowledge had to be discovered
with cultures.
Leininger (1981, 1988, 1990a, 1991a,
1995) maintained that before her work, there
were no theories explicitly focused on care and
culture in nursing environments, let alone
research studies to explicate care meanings
and phenomena in nursing. Theoretical
and practical meanings of care in relation to
specific cultures had not been studied, espe-
cially from a comparative cultural perspective.
Leininger saw the urgent need to develop a
whole new body of culturally based care
knowledge to support transcultural nursing
care. Shifting nurses’ thinking and attitudes
from medical symptoms, diseases, and treat-
ments to that of knowing cultures and caring
values and patterns was a major task. But
nursing needed an appropriate theory to
discover care, and Leininger held that her the-
ory was “the only theory focused on develop-
ing new knowledge for the discipline of
transcultural nursing” (Leininger, 2006a, p. 7).
Essential features of the CCT and the eth-
nonursing research method were developed
and/or revisited throughout Leininger’s life
(Leininger, 2006a, 2011).
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Rationale for Transcultural Nursing:
Signs and Need
The rationale for change in nursing in America
and elsewhere (Leininger, 1970, 1978, 1984,
1989a, 1990a, 1995) was based on the following
observations:
1. There were global migrations and interac-
tions of people from virtually every place in
the world due to modern electronics, trans-
portation, and communication. These peo-
ple needed sensitive and appropriate care.
2. There were signs of cultural stresses and
cultural conflicts as nurses tried to care
for clients from diverse Western and
non-Western cultures.
3. There were cultural indications of con-
sumer fears and resistance to health
personnel as they used new technologies
and treatment modes that did not fit their
clients’ values and lifeways.
4. There were signs that some clients from
different cultures were angry, frustrated,
and misunderstood by health personnel
owing to ignorance of the clients’ cultural
beliefs, values, and expectations.
5. There were signs of misdiagnosis and mis-
treatment of clients from diverse cultures
because health personnel did not under-
stand the culture of the client.
6. There were signs that nurses, physicians,
and other professional health personnel
were becoming quite frustrated in caring
for clients from unfamiliar cultures. Cul-
ture care factors were largely misunder-
stood or neglected.
7. There were signs that consumers of dif-
ferent cultures, whether in the home,
hospital, or clinic, were being treated in
ways that did not satisfy them and this
influenced their recovery.
8. There were many signs of intercultural
conflicts and cultural pain among staff
that led to tensions.
9. There were very few health personnel of
diverse cultures caring for clients.
10. Nurses were beginning to work in foreign
countries in the military or as missionar-
ies, and they were having great difficulty
understanding and providing appropriate
caring for clients of diverse cultures. They
complained that they did not understand
the peoples’ needs, values, and lifeways.
Although anthropologists were clearly ex-
perts about cultures, many did not know what
to do with patients, nor were they interested
in nurses’ work, in nursing as a profession, or
in the study of human care phenomena in the
early 1950s. Most anthropologists in those
early days were far more interested in medical
diseases, archaeological findings, and in phys-
ical and psychological problems of culture. For
these reasons and many others, it was clearly
evident in the 1960s that people of different
cultures were not receiving care congruent with
their cultural beliefs and values (Leininger,
1978, 1995). Nurses and other health profes-
sionals urgently needed transcultural knowl-
edge and skills to work efficiently with people
of diverse cultures.
Leininger therefore took a leadership role
in the new field she called transcultural nursing.
She defined transcultural nursing as an area of
study and practice focused on cultural care
(caring) values, beliefs, and practices of partic-
ular cultures. The goal was to provide culture-
specific and congruent care to people of diverse
cultures (Leininger, 1978, 1984, 1995, 2006a).
The central purpose of transcultural nursing
was to use research-based knowledge to help
nurses discover care values and practices and
use this knowledge in safe, responsible, and
meaningful ways to care for people of different
cultures. Today the CCT has led to a wealth
of research-based knowledge to guide nurses
and other health professionals in the care of
clients, families, and communities of different
cultures or subcultures.
Major Theoretical Tenets
In developing the theory of culture care diver-
sity and universality, Leininger identified sev-
eral predictive tenets or premises as essential
for nurses and others to use.
Diversities and Commonalities
A principal tenet was that diversities and sim-
ilarities (or commonalities) in culture care ex-
pressions, meanings, patterns, and practices
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would be found within cultures. This tenet
challenges nurses to discover this knowledge
so that nurses could use cultural data to pro-
vide therapeutic outcomes. It was predicted
there would be a gold mine of knowledge if
nurses were patient and persistent to discover
care values and patterns within cultures, a di-
mension that had been missing from tradi-
tional nursing. Leininger maintained that
human beings are born, live, and die with their
specific cultural values and beliefs, as well as
with their historical and environmental con-
text, and that care is important for their sur-
vival and well-being. Leininger predicted that
discovering which elements of care were cul-
turally universal and which were different
would drastically revolutionize nursing and
ultimately transform health-care systems and
practices (Leininger, 1978, 1990a, 1990b,
1991a, 2006a).
Worldview and Social Structure Factors
Another major tenet of the theory was that
worldview and social structure factors—such
as technology, religion (including spirituality
and philosophy), kinship (family ties), cultural
values, beliefs, and lifeways, political and legal
factors, economic and educational factors,
as well as ethnohistory, language expressions,
environmental context, and generic and pro-
fessional care—influence ways individuals,
families, groups, and/or communities consider
and deal with health, well-being, illness, heal-
ing, disabilities, and death (Leininger, 1995,
2006a). This broad and multifaceted view pro-
vides a holistic perspective for understanding
people and grasping their world and environ-
ment within a historical context. Data from
this holistic research-based knowledge guides
nurses in caring for the health and well-being
of the individual or to help disabled or dying
clients from different cultures. Social structural
factors influencing care of people from differ-
ent cultures provide new insights for culturally
congruent care. Systematic study by nurse re-
searchers rather than superficial knowledge of
culture is required to provide culturally con-
gruent care. These factors, together with the
history of cultures and knowledge of their en-
vironmental factors, were discovered to create
the theory and to bring forth new insights and
new knowledge. These data disclose ways that
clients can stay well and prevent illnesses. In-
deed, to meet the theory’s goal of making de-
cisions that provide culturally congruent care,
holistic cultural knowledge must be discovered
(Leininger, 1991a, 2006a).
Discovering cultural care knowledge re-
quires entering the cultural world to observe,
listen, and validate ideas. Transcultural nursing
is an immersion experience, not a “dip in and
dip out” experience. No longer can nurses rely
only on fragments of medical and psychologi-
cal knowledge. Nurses must become aware of
the social structure, cultural history, language
use, and the environment in which people live
to understand cultural care expressions. Thus,
nurses need to understand the philosophy of
transcultural nursing, the culture care theory,
and ways to discover culture knowledge. Tran-
scultural nursing courses and programs are
essential to provide the necessary instruction
and mentoring.
Professional and Generic Care
Another major and predicted tenet of the the-
ory is that differences and similarities exist
between the practices of two kinds of care:
professional (etic) and generic (emic, tradi-
tional, indigenous, or “folk”; Leininger, 1991a,
2006a; McFarland, 2010). These differences
influence the health, illness, and well-being of
clients. Elucidating these differences identify
gaps in care, inappropriate care, and also ben-
eficial care. Such findings influence the recov-
ery (healing), health, and well-being of clients
of different cultures. Marked differences be-
tween generic and professional care ideas and
actions lead to serious client–nurse conflicts,
potential illnesses, and even death (Leininger,
1978, 1995). Such differences must be identi-
fied and resolved.
Three Modalities
Leininger identified three ways to attain and
maintain culturally congruent care (Leininger,
1991a, 2006a; McFarland, 2010). The three
modalities postulated are (1) culture care
preservation and/or maintenance, (2) culture
care accommodation and/or negotiation, and
CHAPTER 17 • Madeleine Leininger’s Theory of Culture Care Diversity and Universality 307
3312_Ch17_301-320 26/12/14 5:57 PM Page 307
(3) culture care restructuring and/or repattern-
ing (Leininger, 1991a, 1995, 2006a). These
three modes were very different from traditional
nursing practices, routines, or interventions.
They are focused on ways to use theoretical data
creatively to facilitate congruent care to fit
clients’ particular cultural needs. To arrive at
culturally appropriate care, the nurse has to
draw on fresh culture care research and discov-
ered knowledge from the people along with
theoretical data findings. The care is tailored
to client needs. Leininger believed that rou-
tine interventions would not always be appro-
priate and could lead to cultural imposition,
tensions, and conflicts. Nurses need to shift
from relying on routine interventions and
from focusing on symptoms to employing care
practices derived from the clients’ culture and
from the theory. They need to use holistic care
knowledge from the theory as opposed to
relying solely on medical data. Most impor-
tant of all, they need to use both generic and
professional care findings. This was a new
challenge but a rewarding one for the nurse
and the client if thoughtfully done, as it fosters
nurse–client collaboration. Examples of the
use of the three modalities can be found in
several published sources (Leininger, 1995,
1999, 2002; McFarland et al., 2011; Wehbe-
Alamah, 2008a, 2011) and are presented in
the next part of this chapter.
Use of Leininger’s theory has led to the dis-
covery of new kinds of transcultural nursing
knowledge. Culturally based care can prevent
illness and maintain wellness. Methods for
helping people throughout the life cycle, from
birth to death, have been discovered. Cultural
patterns of caring and health maintenance
along with environmental and historical factors
are important. Most important, the use of
Leininger’s theory has helped uncover signifi-
cant cultural differences and similarities.
Theoretical Assumptions: Purpose,
Goal, and Definitions of the Theory
This section discusses some of the major as-
sumptions, definitions, and purposes of the
theory. The theory’s overriding purpose is to
discover, document, analyze, and identify the
cultural and care factors influencing humans
in health, sickness, and dying and to thereby
advance and improve nursing practices.
The theory’s goal is to discover generic
(folk) and professional care beliefs, expressions,
and practices that could be incorporated into
collaborative plans of care designed to provide
culturally appropriate, safe, beneficial, and
satisfying care to people of diverse or similar
cultures, to promote their health and well-
being, and to assist them in facing death or
disabilities. Thus, the ultimate and primary
goal of the theory is to provide culturally con-
gruent care that is tailor-made for the lifeways
and values of people (Leininger, 1991a, 1995,
2006a; McFarland, Mixer, Wehbe-Alamah, &
Burke, 2012).
Theory Assumptions
Leininger postulated several theoretical
assumptions, or basic beliefs, designed to as-
sist researchers exploring Western and non-
Western cultures (Leininger, 1970, 1977,
1981, 1984, 1991a, 1997b, 2006a):
1. Care is the essence and the central
dominant, distinct, and unifying focus
of nursing.
2. Humanistic and scientific care are essen-
tial for human growth, well-being, health,
survival, and to face death and disabilities.
3. Care (caring) is essential to curing or
healing, for there can be no curing with-
out caring. (This assumption was held to
have profound relevance worldwide.)
4. Culture care is the synthesis of two major
constructs that guide the researcher to
discover, explain, and account for health,
well-being, care expressions, and other
human conditions.
5. Culture care expressions, meanings,
patterns, processes, and structural forms
are diverse; but some commonalities
(universalities) exist among and between
cultures.
6. Culture care values, beliefs, and practices
are influenced by and embedded in the
worldview, social structure factors (e.g., re-
ligion, philosophy of life, kinship, politics,
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others with evident or anticipated needs to
ameliorate or improve a human condition
or lifeway. Caring refers to actions, atti-
tudes, and practices to assist or help others
toward healing and well-being (Leininger,
2006a, p. 12). Care is both an abstract and
a concrete phenomenon.
3. Culture care: Subjectively and objectively
learned and transmitted values, beliefs, and
patterned lifeways that assist, support,
facilitate, or enable another individual or
group to maintain well-being and health,
to improve their human condition and
lifeway, or to deal with illness, handicaps,
or death (Leininger, 1991a, p. 47).
4. Culture Care Diversity: The differences or
variabilities among human beings with
respect to culture care meanings, patterns,
values, lifeways, symbols, or other features
related to providing beneficial care to
clients of a designated culture (Leininger,
2006a, p. 16).
5. Culture Care Universality: The commonly
shared or similar culture care phenomena
features of human beings with recurrent
meanings, patterns, values, lifeways, or
symbols that serve as a guide for caregivers
to provide assistive, supportive, facilitative,
or enabling people care for healthy out-
comes (Leininger, 2006a, p. 16).
6. Professional (etic) care: Formal and explicit
cognitively learned professional care knowl-
edge and practices obtained generally
through educational institutions. They are
taught to nurses and others to provide assis-
tive, supportive, enabling, or facilitative
acts for or to another individual or group
in order to improve their health, prevent
illnesses, or to help with dying or other
human conditions (Leininger, 2006a, p. 14).
7. Generic (emic) care: The learned and trans-
mitted lay, indigenous, traditional, or local
folk knowledge and practices to provide
assistive, supportive, enabling, and facilita-
tive acts for or toward others with evident
or anticipated health needs in order to
improve well-being or to help with dying
or other human conditions (Leininger,
2006a, p. 14).
CHAPTER 17 • Madeleine Leininger’s Theory of Culture Care Diversity and Universality 309
economics, education, technology, and
cultural values) and the ethnohistorical and
environmental contexts.
7. Every culture has generic (lay, folk, natu-
ralistic, mainly emic) and usually some
professional (etic) care to be discovered
and used for culturally congruent care
practices.
8. Culturally congruent and therapeutic care
occurs when culture care values, beliefs,
expressions, and patterns are explicitly
known and used appropriately, sensitively,
and meaningfully with people of diverse
or similar cultures.
9. The three modes of care offer therapeutic
ways to help people of diverse cultures.
10. Qualitative research paradigmatic methods
offer important means to discover largely
embedded, covert, epistemic, and ontolog-
ical culture care knowledge and practices.
11. Transcultural nursing is a discipline with
a body of knowledge and practices to at-
tain and maintain the goal of culturally
congruent care for health and well-being
(Leininger, 2006a, pp. 18–19).
Orientational Theory Definitions
To encourage discovery of qualitative knowl-
edge, Leininger used orientational (not oper-
ational) definitions for her theory, to allow the
researcher to discern previously unknown phe-
nomena or ideas. Orientational terms allow
discovery and are usually congruent with the
client lifeways. They are important in using the
qualitative ethnonursing discovery method,
which is focused on how people understand
and experience their world using cultural
knowledge and lifeways (Leininger, 1985,
1991a, 1997b, 1997c, 2002, 2006a). The fol-
lowing are select examples:
1. Culture: The learned, shared, and transmit-
ted values, beliefs, norms, and lifeways of a
particular group that guides their thinking,
decisions, and actions in patterned ways
and often intergenerationally (Leininger,
2006a, p. 13).
2. Care: Those assistive, supportive, and
enabling experiences or ideas toward
3312_Ch17_301-320 26/12/14 5:57 PM Page 309
8. Culture care preservation and/or mainte-
nance: Those assistive, supportive, facilita-
tive, or enabling professional acts or
decisions that help cultures to retain,
preserve, or maintain beneficial care be-
liefs and values or to face handicaps and
death (Leininger, 2006a, p. 8).
9. Culture care accommodation and/or negotia-
tion: Those assistive, accommodating, fa-
cilitative, or enabling creative provider care
actions or decisions that facilitate adapta-
tion to or negotiation with others for cul-
turally congruent, safe, and effective care
for their health, well-being, or to deal with
illness or dying (Leininger, 2006a, p. 8).
10. Culture care repatterning and/or restructur-
ing: Those assistive, supportive, facilita-
tive, or enabling professional actions and
mutual decisions that help people to re-
order, change, modify, or restructure
their lifeways and institutions for better
(or beneficial) health-care patterns, prac-
tices, or outcomes (Leininger, 2006a,
p. 8). These patterns are mutually estab-
lished between caregivers and receivers.
11. Ethnohistory: The past facts, events, in-
stances, and experiences of human beings,
groups, cultures, and institutions that
occur over time in particular contexts
that help explain past and current lifeways
about culture care influencers of health
and well-being or the death of people
(Leininger, 2006a, p. 15).
12. Environmental context: The totality of
an event, situation, or particular experi-
ence that gives meaning to people’s
expressions, interpretations, and social
interactions within particular geophysical,
ecological, spiritual, sociopolitical, and
technological factors in specific cultural
settings (Leininger, 2006a, p. 15).
13. Worldview: The way people tend to look
out on their world or their universe to
form a picture or value stance about life
or the world around them (Leininger,
2006a, p. 15).
14. Cultural and social structure factors: religion
(spirituality); kinship (social ties); politics;
legal issues; education; economics; tech-
nology; political factors; philosophy of
life; and cultural beliefs and values with
gender and class difference. The theorist
has predicted that these diverse factors
must be understood as they directly or
indirectly influence health and well-being
(Leininger, 2006a, p. 14).
15. Culturally congruent care: Culturally based
care knowledge, acts, and decisions used
in sensitive and knowledgeable ways to
appropriately and meaningfully fit the
cultural values, beliefs, and lifeways of
clients for their health and well-being,
or to prevent illness, disabilities, or death
(Leininger, 2006a, p. 15).
The Sunrise Enabler: A Conceptual
Guide to Knowledge Discovery
Leininger developed the sunrise enabler
(Fig. 17-1) to provide a holistic and compre-
hensive conceptual picture of the major factors
influencing culture care diversity and univer-
sality (Leininger, 1995, 1997b; Leininger &
McFarland, 2002, 2006). The model can be a
valuable visual guide to elucidating multiple
factors that influence human care and lifeways
of different cultures. The enabler serves as a
cognitive guide for the researcher to reflect on
different predicted influences on culturally
based care.
The sunrise enabler can also be used as a
valuable aid in cultural and health-care assess-
ment of clients. As the researcher uses the
model, the different factors alert him or her to
find culture care phenomena. Gender, sexual
orientation, race, class, and biomedical condi-
tions are studied as part of the theory. These
determinants tend to be embedded in the
worldview and social structure and take time
to recognize. Care values and beliefs are usually
lodged into environment, religion, kinship,
and daily life patterns.
The nurse can begin the discovery at any
place in the enabler and follow the informant’s
ideas and experiences about care. If one starts
in the upper part of the enabler, one needs to
reflect on all aspects depicted to obtain holistic
or total care data. Some nurses start with
generic and professional care then look at how
religion, economics, and other influences affect
these care modes. One always moves with the
310 SECTION V • Grand Theories about Care or Caring
3312_Ch17_301-320 26/12/14 5:57 PM Page 310
informants’, rather than the researcher’s, inter-
est and story. Flexibility in using the enabler
promotes a total or holistic view of care.
The three transcultural care decisions and
actions (in the lower part of the figure) are very
important to keep in mind. Nursing decisions
and actions are studied until one realizes the
care needed. The nurse discovers with the in-
formant the appropriate decisions, actions, or
plans for care. Throughout this discovery
process, the nurse holds his or her own etic
biases in check so that the informant’s ideas
will come forth, rather than the researcher’s.
Transcultural nurses are mentored in ways to
withhold their biases or wishes and to enter the
client’s worldview.
The nurse begins the study by making
explicit a specific domain of inquiry. For exam-
ple, the researcher may focus on a domain of
inquiry such as “culture care of Mexican
CHAPTER 17 • Madeleine Leininger’s Theory of Culture Care Diversity and Universality 311
Worldview
Cultural Values,
Beliefs &
Lifeways
Care Expressions
Patterns & Practices
Holistic Health / Illness / Death
Cultural Care Decisions & Actions
Culturally Congruent Care for Health, Well-being or Dying
Cultural Care Preservation/Maintenance
Culture Care Accommodation/Negotiation
Culture Care Repatterning/Restructuring
© M. Leininger 2004
--kl
Focus: Individuals, Families, Groups, Communities or Institutions
in Diverse Health Contexts of
Environmental Context,
Language & Ethnohistory
Political &
Legal
Factors
Kinship &
Social
Factors
Economic
Factors
Educational
Factors
Technological
Factors
Generic (Folk)
Care
Code: (Influencers)
Nursing Care
Practices
Professional
Care–Cure
Practices
Religious &
Philosophical
Factors
CULTURE CARE
Cultural & Social Structure Dimensions
Influences
Fig 17 • 1 Leininger’s sunrise enabler to discover culture care. (©M. Leininger 2004.)
3312_Ch17_301-320 26/12/14 5:57 PM Page 311
American mothers caring for their children in
their home.” Every word in the domain state-
ment is important and studied with the sunrise
enabler and the theory tenets. The nurse or re-
searcher may have hunches about the domain
and care, but until all data have been studied
with the theory tenets, she or he cannot prove
them. Informants’ viewpoints, experiences,
and actions are fully documented. Generally,
informants select what they like to talk about
first, and the nurse/researcher accommodates
their interest or stories about care. During in-
depth study of the domain of inquiry, all areas
of the sunrise enabler are identified and con-
firmed with the informants. The informants
become active participants throughout the dis-
covery process in such a way as to feel comfort-
able and willing to share their ideas.
The real challenge is to focus care mean-
ings, beliefs, values, and practices related to
informants’ cultures so that subtle and obvi-
ous differences and similarities about care are
identified among key and general informants.
The differences and similarities are important
to document with the theory. If informants
ask about the researcher’s views, the latter
must be carefully and sparsely shared. The re-
searcher keeps in mind that some informants
may want to please the researcher by talking
about professional medicines and treatments.
Professional ideas, however, often cloud or
mask the client’s real interests and views. If
this occurs, the researcher must be alert to
such tendencies and keep the focus on the in-
formant’s ideas and on the domain of inquiry
studied. The informant’s knowledge is always
kept central to the discovery process about
culture care, health, and well-being. If the re-
searcher finds some factors unfamiliar, such
as kinship, economics, and political and other
considerations depicted in the model, the
researcher should listen attentively to the
informant’s ideas. Obtaining insight into
the informant’s emic (insider’s) views, beliefs,
and practices is central to studying the theory
(Leininger, 1985, 1991a, 1995, 1997b;
Leininger & McFarland, 2002, 2006).
Throughout the study and use of the theory,
the meanings, expressions, and patterns of
culturally based care are important. The nurse/
researcher listens attentively to informants’
accounts about care and then documents the
ideas. What informants know and practice
about care or caring in their culture is signifi-
cant. Documenting ideas from the informants’
emic viewpoint is essential to arrive at accurate
culturally based care. Unknown care meanings,
such as the concepts of protection, respect,
love, and many other care concepts, need to be
teased out and explored in depth, as they are
the key words and ideas in understanding care.
Such care meanings and expressions are not al-
ways readily known; informants ponder care
meanings and are often surprised that nurses
are focused on care instead of medical symp-
toms. Sometimes informants may be reluctant
to share ideas about social structure, religion,
and economics or politics, as they fear these
ideas may not be accepted or understood by
health personnel. Generic folk or indigenous
knowledge often has rich care data and needs
to be explored. Generic care ideas need to be
appropriately integrated into the three tran-
scultural modes of decisions and actions for
culturally congruent care outcomes. Generic
and professional care are integrated so that the
clients benefit from both types of care.
The sunrise enabler was developed with
the idea to “let the sun enter the researcher’s
mind” and discover largely unknown care
factors of cultures. Letting the sun “rise and
shine” is important and offers fresh insights
about care practices. A recent metasynthesis
of 24 doctoral dissertations using Leininger’s
CCT and the ethnonursing research method
led to the discovery of interpretive and ex-
planatory culture care findings, new theoretical
formulations, and evidence-based recommen-
dations to guide nursing practice (McFarland
et al., 2011).
Newest Addition to the Theory
In the summer of 2011, Dr. Leininger intro-
duced collaborative care as a new care construct,
which she offered as the next phase in the evo-
lutionary development of CCT. She main-
tained that diverse cultural values, beliefs,
expressions, actions, and practices within a
312 SECTION V • Grand Theories about Care or Caring
3312_Ch17_301-320 26/12/14 5:57 PM Page 312
family, a group, an institution, or other unit
may present with situations in which conflicts
may arise. She proposed collaborative care as a
means or a strategy to resolve differences and
provide culturally congruent care.
Leininger defined the collaborative care
approach as those values, meanings, expres-
sions, and actions by informants that reveal a
desire and a plan to work with others in order
to identify, attain, and maintain health and
well-being and to resolve conflicts. This care
construct has been published by McFarland
and Wehbe-Alamah (McFarland & Wehbe-
Alamah, 2015).
Current Status of the Theory
Currently, the theory of culture care diversity
and universality continues to be studied and used
in many schools of nursing within the United
States and in other countries, such as Lebanon,
Jordan, Saudi Arabia, Taiwan, China, Japan,
and Finland (Leininger & McFarland, 2002,
2006; Wehbe-Alamah & McFarland; 2012).
Interdisciplinary health personnel are becoming
increasingly aware of transcultural nursing con-
cepts that help them in their work. Several dis-
ciplines including dentistry, medicine, social
work, and pharmacy have reported using the
culturally congruent care theory or teaching it in
their programs (McFarland, 2011).
The theory of culture care will remain of
global interest and significance as nurses and
other health-care professionals continue to
explore cultures and their care needs and prac-
tices worldwide. Transcultural nursing con-
cepts, principles, theory, and findings must
become fully incorporated into professional
areas of teaching, practice, consultation, and
research. When this occurs, one can anticipate
true transcultural health practices and con-
comitant benefits. Unquestionably, the theory
will continue to grow in relevance and use as
our world becomes more intensely multicul-
tural. Nurses and other health professionals are
expected to provide culturally congruent care
to people of diverse cultures. The theory, along
with many transcultural nursing concepts,
principles, and research findings, will continue
to prove indispensable.
Applications of
the Theory
The purpose of this part of the chapter is to
present the implications for nursing practice of
the CCT and related ethnonursing research
findings. Many nursing theories are rather ab-
stract and do not focus on how practicing
nurses might use the research findings related
to a theory. However, with the CCT, along
with the ethnonursing method, there is a built-
in means for discovering and confirming data
with informants in order to make practical
nursing actions and decisions meaningful and
culturally congruent (Leininger, 2002).1
Leininger purposefully avoided using the
phrase nursing intervention because this term
often implies to clients from different cultures
that the nurse is imposing his or her (etic)
views, which may not be helpful. Instead, the
term nursing actions and decisions was used, but
always with the clients helping to arrive at
whatever actions or decisions were planned
and implemented. The care modes fit with the
clients’ or peoples’ lifeways and are both ther-
apeutic and satisfying for them. The nurse can
draw on scientific and evidence-based nursing,
medical, and other knowledge with each care
mode.
Data collected from the upper and lower
parts of the sunrise enabler provide culture care
knowledge for the nurse and other researchers
to discover and establish useful ways to provide
quality care practices. Active participatory in-
volvement with clients is essential to arrive at
culturally congruent care with one or all of the
three action modes to meet clients’ care needs
in their particular environmental contexts. The
use of these modes in nursing care is one of the
most creative and rewarding features of tran-
scultural and general nursing practice with
clients of diverse cultures. Using Leininger’s
care modes in clinical practice shows respect to
clients’ beliefs, values, and expressions and es-
tablishes a partnership between health-care
CHAPTER 17 • Madeleine Leininger’s Theory of Culture Care Diversity and Universality 313
1For additional information about the Ethnonursing
Research Method please go to bonus chapter content
available at FA Davis http://davisplus.fadavis.com
3312_Ch17_301-320 26/12/14 5:57 PM Page 313
providers and clients to ensure safe, beneficent,
and culturally congruent care (McFarland &
Eipperle, 2008).
It is most important (and a shift in nursing)
to carefully focus on the holistic dimensions,
as depicted in the sunrise enabler, to arrive at
therapeutic culture care practices. All the fac-
tors in the sunrise enabler must be considered
to arrive at culturally congruent care. These
include worldview; technological, religious,
kinship, political–legal, economic, and educa-
tional factors; cultural values and lifeways;
environmental context, language, and ethno-
history; and generic (folk) and professional
care practices (Leininger, 2002, 2006a). Care
generated from the CCT will become safe,
congruent, meaningful, and beneficial to
clients only when the nurse in clinical practice
becomes fully aware of and explicitly uses
knowledge generated from the theory and eth-
nonursing method, whether in a community,
home, or institutional context. The CCT, used
with the ethnonursing method, is a powerful
means for exploring new directions and prac-
tices in nursing. Incorporating culture-specific
care into client care is essential to the practice
of professional care and to licensure as regis-
tered nurses. Culture-specific care is the safe
means to ensure culturally based holistic care
that fits the client’s culture—a major challenge
for nurses and other health-care professionals
who practice and provide services in all health-
care settings.
The Use of Culture Care Research
Findings
Over the past 5 decades, Dr. Leininger and
other research colleagues have used the CCT
and the ethnonursing method to focus on the
care meanings and experiences of 100 cultures
(Leininger, 2002). They discovered 187 care
constructs in Western and non-Western cul-
tures between 1989 and 1998 (Leininger,
1998a, 1998b). Leininger listed the 11 most
dominant constructs of care in priority rank-
ing, with the most universal or frequently dis-
covered first: respect for/about, concern
for/about; attention to (details)/in anticipation
of; helping–assisting or facilitative acts; active
helping; presence (being physically there);
understanding (beliefs, values, lifeways, and
environmental); connectedness; protection
(gender related); touching; and comfort meas-
ures (Leininger, 2006b; McFarland, 2002).
These care constructs are the most critical and
important universal or common findings to
consider in nursing practice, but care diversi-
ties will also be found and must be considered.
The ways in which culture care is applied and
used in specific cultures will reflect both simi-
larities and differences among and within
different cultures.
Next, two ethnonursing studies are reviewed
with focus on the findings, which have impli-
cations for nursing practice.
Culture Care of Traditional Syrian
Muslims in the Midwestern United
States
In 2005, the theory of culture care diversity and
universality and the ethnonursing research
method were used to guide a study of the cul-
ture care of traditional Syrian Muslims in the
Midwestern United States (Wehbe-Alamah,
2008b, 2011). The domain of inquiry for this
ethnonursing study was the generic and the
professional care meanings, beliefs, and prac-
tices related to health and illness of traditional
Syrian Muslims living in several urban commu-
nities in the Midwestern United States. The
purpose of this study was to discover, describe,
and analyze the effect of worldview, cultural
context, technological, religious, political, ed-
ucational, and economic factors on the tradi-
tional Syrian Muslims’ generic and professional
care meanings, beliefs, and practices. The goal
was to provide practicing nurses and other
health-care providers with knowledge that can
be turned into care actions and decisions that
facilitate the provision of culturally congruent
care to traditional Syrian Muslims living in
similar contexts (Wehbe-Alamah, 2011).
Findings from this study revealed that the
worldview of traditional Syrian Muslims is
deeply embedded in the Islamic religion and
the Syrian culture. Life is viewed as a test from
God and a journey in which one must attempt
to do as many good deeds as possible and to
behave in a righteous way whether conducting
business, taking care of housework, or engaging
314 SECTION V • Grand Theories about Care or Caring
3312_Ch17_301-320 26/12/14 5:57 PM Page 314
in any other regular daily activity. Kinship and
familial relationships are treasured. Socializing
with family members and friends are consid-
ered important aspects of Syrian lifeway. Vis-
itations and telephone conversations as well as
Friday prayer congregations are major social
activities for Syrians. In Syrian Muslim society,
the man typically assumes the role of the
breadwinner, whereas the woman takes on
other responsibilities, such as managing the
household and raising the children (Wehbe-
Alamah, 2008b).
Some of the discovered traditional cultural
beliefs and practices included modesty, gener-
ous hospitality, segregation of men and women
during social events such as wedding parties
and dinner invitations, wearing of a coat or jil-
bab over clothes for women when in public,
caring for older family members within the
home setting, as well as visiting, praying for,
and cooking for the sick. Normal everyday ac-
tions were considered by many informants as
acts of worship. Engaging in religious practices
such as prayer and Qur’an recitation or mem-
orization was reported as a source of physical,
spiritual, emotional, and mental support by
numerous informants. Religious beliefs were
determined to play an important role in a per-
son’s decision-making involving abortion, ster-
ilization, autopsy, organ donation, birth
control, and other significant health issues
(Wehbe-Alamah, 2008a).
Caring was described as being considerate
of other people’s feelings and respecting their
beliefs. Empathy, sympathy, sensitivity, un-
selfishness, and understanding were other
qualities used to describe caring. Caring can be
expressed by checking on others, being avail-
able to them, offering them help, cooking
healthy food, and keeping a clean body and a
hygienic environment. Caring can additionally
be exemplified by withholding a diagnosis
and/or prognosis from a patient especially if
an impending death was expected and by bury-
ing the dead with 24 hours of their passing.
Caring attributes of nurses were identified as
smiling, responding quickly to the needs of
sick patients, loving the nursing profession and
role, and respecting the patient’s culture
(Wehbe-Alamah, 2008b).
A plethora of generic or folk practices were
discovered and included some that are benefi-
cial to health and others with potentially
harmful ramifications. One such example is
the consumption of raw liver, which is rich in
iron and is used to treat anemia or iron defi-
ciency. Another example is treating head lice
by pouring gasoline over the scalp and massag-
ing it into the hair. Folk practices that are ben-
eficial to health included eating in moderation,
exercising, and taking vitamin C when treating
a cold (Wehbe-Alamah, 2008b).
Such information can be turned into cul-
turally congruent decisions and actions that
can impact clinical practice through the ap-
plication of Leininger’s culture care modes.
Accordingly, nurses and other health-care
providers can preserve and/or maintain the cul-
tural beliefs, expressions, and practices of tra-
ditional Syrian Muslims by respecting the need
for modesty and segregation and assigning
same-sex health-care providers whenever pos-
sible. The cultural belief and practice of visiting
the sick can be accommodated by encouraging
a large number of visitors within the hospital
setting with the negotiation of having only a
few visitors in the patient’s room at a time. The
harmful folk practices of using gasoline to treat
head lice and consuming raw liver to treat ane-
mia can be repatterned and/or restructured
through education of ramifications and discus-
sion of healthier alternatives.
CHAPTER 17 • Madeleine Leininger’s Theory of Culture Care Diversity and Universality 315
Practice Exemplar
A Middle Eastern patient in labor identified
as Mrs. Sarah Islam has just been admitted
to the obstetrics floor. She is accompanied
by her husband and is dressed in loose cloth-
ing that covers all of her body except for her
face and hands. She belongs to the Muslim
faith and wears a head cover. Her husband
requests that only female health-care
providers (HCPs) be assigned to his wife.
The nurse provides culturally congruent care
to this family using Leininger’s culture care
theory.
Continued
3312_Ch17_301-320 26/12/14 5:57 PM Page 315
316 SECTION V • Grand Theories about Care or Caring
Practice Exemplar cont.
According to this theory, the worldview
of every human being is affected by cultural
and social structural dimensions, including but
not limited to cultural values, beliefs, and life-
ways, and kinship, social, and religious factors.
Therefore, professional nursing care must in-
corporate an understanding of these beliefs
and practices. As a result, the nurse proceeds
by conducting a cultural assessment to identify
important needs and prohibitions that need to
be addressed in the plan of care. The nurse be-
gins by explaining that she would like to ask
questions to learn about how to best care for
the client and her family. The cultural assess-
ment reveals the following:
• Modesty and privacy are important values
to Mrs. and Mr. Islam and should be pre-
served whenever possible, according to cul-
tural and religious teachings. The couple
explains that this can be achieved by assign-
ing same-sex HCPs and by preventing
male individuals from entering the patient’s
room without first obtaining permission to
do so.
• Pork-derived products including gelatin are
prohibited in Islam and therefore should
be excluded from diet and medications.
The couple explains that Jello and gelatin-
encapsulated medications contain gelatin
and should be avoided.
• A special prayer needs to be whispered by
the father in the newborn’s ears after birth.
The couple requests that the newborn be
handed to the father as soon as possible
after birth to facilitate this practice.
• Visitation by family members and friends is
to be expected following birth. The couple in-
forms you that they expect at least 30 visitors.
• Smoking the water pipe is a common
cultural practice and is often carried in the
presence of children. Mr. Islam smokes
the water pipe twice a day.
Having identified important cultural and
religious values, practices, needs, and prohibi-
tions, the nurse proceeds to develop a cultur-
ally congruent plan of care using Leininger’s
Culture care modes:
Culture care preservation and/or
maintenance:
• The nurse includes a note in the electronic
health record about identified cultural and
religious values, practices, needs, and pro-
hibitions. This will assist with continuity of
culturally congruent care.
• The nurse is female; therefore she is able to
care for Mrs. Islam.
• The nurse places a sign at Mrs. Islam door
that reads: “No males allowed without
permission.”
• The obstetrician and all nursing staff at-
tending the birth are informed about the
important practice of handing the newborn
to the father within minutes of birth. The
father recites the prayer in the baby’s ears.
The nurse attends the birth and ensures
that this happens.
Culture care accommodation and/or
negotiation:
• The nurse arranges for kitchen staff to pro-
vide vegetarian Jello versus animal-derived
Jello.
• The nurse arranges for medications to be
ordered or dispensed in tablet versus gelcap
format.
• The nurse negotiates with the family to
have visitors come at different times, wait in
waiting room, and visit in numbers of 2 or
3 at a time.
Culture care restructuring and/or
repatterning:
• The nurse educates the client and her
husband about dangers associated with
smoking and secondhand smoking inhala-
tion implications to the newborn. She ad-
vises the discontinuation of this practice.
(Alternatively, the nurse negotiates with
Mr Islam to only smoke outdoors and cut
down to once a day.)
Upon discharge, Mr. and Mrs. Islam thank
you, the nurse, for providing them with the
best care they have ever received in a Western
health-care setting.
3312_Ch17_301-320 26/12/14 5:57 PM Page 316
CHAPTER 17 • Madeleine Leininger’s Theory of Culture Care Diversity and Universality 317
■ Summary
The purpose of the CCT and the ethnonurs-
ing method is to discover culture care knowl-
edge and to combine generic and professional
care. The goal is to provide culturally congru-
ent nursing care using the three modes of
nursing actions and decisions that are mean-
ingful, safe, and beneficial to people of similar
and diverse cultures worldwide (Leininger,
1991b, 1995, 2006a). The clinical use of the
three major care modes (culture care preser-
vation and/or maintenance; culture care ac-
commodation and/or negotiation; and culture
care repatterning and/or restructuring) by
nurses to guide nursing judgments, decisions,
and actions is essential in order to provide cul-
turally congruent care that is beneficial, satis-
fying, and meaningful to the people nurses
serve. The studies presented here substantiate
that the three modes are care-centered and
are based on the use of generic care (emic)
knowledge along with professional care (etic)
knowledge obtained from research using the
CCT along with the ethnonursing method.
This chapter has reviewed only a small selec-
tion of the culture care findings from eth-
nonursing research studies conducted over the
past 5 decades. There is a wealth of additional
findings of interest to practicing nurses who
care for clients of all ages from diverse and
similar cultural groups in many different in-
stitutional and community contexts around
the world. More in-depth culture care find-
ings, along with the use of the three modes,
can be found in the Journal of Transcultural
Nursing (1989–2013), in the Online Journal of
Cultural Competence in Nursing and Healthcare
(www.OJCCNH.org) and in the numerous
books and articles written by Dr. Madeleine
Leininger and researchers using her theory
and method. Nurses in clinical practice can
refer to research studies and doctoral disserta-
tions conceptualized within the CCT for ad-
ditional detailed nursing implications for
clients from diverse cultures (Leininger &
McFarland, 2002; McFarland et al., 2011).
The theory of culture care diversity and uni-
versality is one of the most comprehensive yet
practical theories to advance transcultural and
general nursing knowledge with concomitant
ways for practicing nurses to establish or im-
prove care to people. Nursing students and
practicing nurses have remained the strongest
advocates of the CCT (Leininger, 2002). The
theory focuses on a long-neglected area in
nursing practice—culture care—that is most
relevant to our multicultural world.
The theory of culture care diversity and uni-
versality is depicted in the sunrise enabler as a
rising sun. This visual metaphor is particularly
apt. The future of the CCT shines brightly in-
deed because it is holistic and comprehensive;
and it facilitates discovering care related to
diverse and similar cultures, contexts, and ages
of people in familiar and naturalistic ways. The
theory is useful to nurses and nursing as well
as to professionals in other disciplines such as
physical, occupational, and speech therapy,
medicine, social work, and pharmacy. Health-
care practitioners in other disciplines are
beginning to use this theory because they also
need to become knowledgeable about and
sensitive and responsible to people of diverse
cultures who need care (Leininger, 2002;
McFarland, 2011).
References
Boyle, J., & Glittenberg Hinrichs, J. (2013). Madeleine
Leininger, PhD, LHD, RN, FRCA, FAAN: A re-
membrance. Journal of Transcultural Nursing, 24(1), 5.
Leininger, M. (1970). Nursing and anthropology: Two
worlds to blend. New York: Wiley.
Leininger, M. (1976). Transcultural nursing presents an
exciting challenge. The American Nurse, 5(5), 6–9.
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Chapter 18Jean Watson’s Theory of
Human Caring
JEAN WATSON
Introducing the Theorist
Overview of the Theory
Applications of the Theory
Practice Exemplar by Terri Woodward
Summary
References
Jean Watson
321
Introducing the Theorist
Dr. Jean Watson is distinguished professor
emerita and dean of nursing emerita at the Uni-
versity of Colorado Denver, where she served
for more than 20 years and held an endowed
Chair in Caring Science for more than 16 years.
She is founder of the original Center for
Human Caring at the University of Colorado
Health Sciences, is a Living Legend in the
American Academy of Nursing, and served as
president of the National League for Nursing.
Dr. Watson founded and directs the nonprofit
Watson Caring Science Institute, dedicated to
furthering the work of caring, science, and
heart-centered Caritas Nursing, restoring caring
and love for nurses’ and health-care clinicians’
healing practices for self and others.
Watson earned undergraduate and grad-
uate degrees in nursing and psychiatric–mental
health nursing and holds a doctorate in edu-
cational psychology and counseling from the
University of Colorado at Boulder. She is a
widely published author and is the recipient
of several awards and honors, including
an international Kellogg Fellowship in
Australia; a Fulbright Research Award in
Sweden; and 10 honorary doctoral degrees,
including seven from international universi-
ties in Sweden, the United Kingdom, Spain,
Japan, and British Colombia and Montreal,
Quebec, Canada.
Dr. Watson’s original book on caring was
published in 1979. Her second book, Nursing:
Human Science and Human Care, was written
while on sabbatical in Australia and reflects the
metaphysical and spiritual evolution of her
thinking. A third book, Postmodern Nursing
and Beyond, moves beyond theory to reflect the
3312_Ch18_321-340 26/12/14 4:58 PM Page 321
ontological foundation of nursing as an overar-
ching framework for transforming caring and
healing practices in education and clinical care
(Watson, 1999). Additional empirical and clin-
ical caring research foci developments include
the first and second editions of the book on car-
ing instruments, Assessing and Measuring Caring
in Nursing and Health Sciences (2002, 2008b),
which offers a critique and collation of more
than 20 instruments for assessing and measuring
caring. Her Caring Science as Sacred Science makes
a case for a deep moral–ethical, spirit-filled
foundation for caring science and healing based
on infinite love and an expanding cosmology.
Watson’s 2008(a) theoretical work, Nursing: The
Philosophy and Science of Caring, Revised New
Edition, revisits and reworks her first book,
Nursing: The Philosophy and Science of Caring
(1979, reprinted 1985), bringing the original
publication up to date to include all the changes
made during the past 30 years. This latest update
introduces Caritas nursing as the culmination of
a caring science foundation for professional
nursing. A coauthored educational book, Creat-
ing a Caring Science Curriculum: Emancipatory
Pedagogies by Marcia Hills and Watson, was
published in 2011 followed by two additional
coauthored research and measurement books,
Measuring Caritas. International Research on
Caritas as Healing (Nelson & Watson, 2011) and
Caring Science, Mindful Practice: Implementing
Watson’s Human Caring Theory (Sitzman &
Watson, 2014).
The Watson Caring Science Institute is
developing educational, clinical, and admin-
istrative–leadership and research models that
seek to sustain and deepen authentic caring–
healing practices for self and other, trans-
forming practitioners and patients alike. The
caring science model, integrating Caritas
with the science of the heart in collaboration
with the Institute of HeartMath (www
.heartMath.com), deepens intelligent heart-
centered caring. All of Watson’s latest publica-
tions and innovative educational partnerships,
activities, new programs, speaking calendar,
and directions and developments, including
information about a nontraditional doctorate
in caring science as sacred science can be found
on the website: www.watsoncaringscience.org.
Overview of the Theory
The theory of human caring was developed be-
tween 1975 and 1979 while I was teaching at
the University of Colorado. It emerged from
my own views of nursing, combined and in-
formed by my doctoral studies in educational,
clinical, and social psychology. It was my initial
attempt to bring meaning and focus to nursing
as an emerging discipline and distinct health
profession that had its own unique values,
knowledge, and practices, and its own ethic
and mission to society. The work was also in-
fluenced by my involvement with an integrated
academic nursing curriculum and efforts to
find common meaning and order to nursing
that transcended settings, populations, spe-
cialty, and subspecialty areas.
From my emerging perspective, I make ex-
plicit that nursing’s values, ethic, philosophy,
knowledge, and practices of human caring re-
quire language order, structure, and clarity of
concepts and worldview underlying nursing as
a distinct discipline and profession. The theory
goes beyond the dominant physical worldview
and opens to subjective, intersubjective, and
inner meaning, underlying healing processes
and the life world of the experiencing person.
This original (Watson, 1979) language framed
this orientation that required unique caring–
healing arts. The human caring processes were
named the “10 carative factors,” which com-
plemented conventional medicine but stood in
stark contrast to “curative factors.” At the same
time, this emerging philosophy and theory of
human caring sought to balance the cure ori-
entation of medicine, giving nursing its unique
disciplinary, scientific, and professional stand-
ing with itself and its public.
The early work has continued to evolve dy-
namically from the original writings of 1979,
1981, 1985, and the 1990s to a more updated
view of 10 caritas processes, to caring science
as sacred science, and to a unitary global con-
sciousness for leadership. My work now makes
connections between human caring, healing,
and even peace in our world, with nurses as
caritas peacemakers when they are practicing
human caring for self and others. This shift
moves to more explicit metaphysical/spiritual
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focus on transpersonal caring moment, post-
modern critiques, to metaphysical—from the-
ory to ontological paradigm for caring science.
A broad, evolving unitary caring science
worldview underlies the fluid evolution of the
theory and the philosophical-ethical founda-
tion for this work.
Major Conceptual Elements
The major conceptual elements of the original
(and emergent) theory are as follows:
• Ten carative factors (transposed to ten
caritas processes)
• Transpersonal caring moment
• Caring consciousness/intentionality and
energetic presence
• Caring–healing modalities
Other dynamic aspects of the theory that
have emerged or are emerging as more explicit
components include:
• Expanded views of self and person (unitary
oneness; embodied spirit)
• Caring–healing consciousness and energetic
heart-centered presence
• Human–environmental field of a caring
moment
• Unitary oneness worldview: unbroken
wholeness and connectedness of all
• Advanced caring–healing modalities/
nursing arts as a future model for advanced
practice of nursing qua nursing (consciously
guided by one’s nursing ethical–theoretical–
philosophical orientation)
Caring Science as Sacred Science
The emergence of the work is a more explicit de-
velopment of caring science as a deep moral–
ethical context of infinite and cosmic love. As
soon as one is more explicit about placing the
human and caring within their science model, it
automatically forces a relational unitary world-
view and makes explicit caring as a moral ideal
to sustain humanity across time and space; one
of the gifts and the raison d’être of nursing in the
world, but yet to be recognized within and with-
out. Nevertheless, a caring-science orientation is
necessary for the survival of nursing as well as
humanity at this crossroads in human evolution.
This view takes nursing and healing work
beyond conventional thinking. The latest ori-
entation is located within the ageless wisdom
traditions and perennial ingredients of the dis-
cipline of nursing, while transcending nursing.
Caring science as a model for nursing allows
nursing’s caring–healing core to become both
discipline-specific and transdisciplinary. Thus,
nursing’s timeless, ancient, enduring, and most
noble contributions come of age through a
caring-science orientation—scientifically, aes-
thetically, ethically, and practically.
Ten Carative Factors
The original work (Watson, 1979) was organ-
ized around 10 carative factors as a framework
for providing a format and focus for nursing
phenomena. Although carative factors is still
the current terminology for the “core” of nurs-
ing, providing a structure for the initial work,
the term factor is too stagnant for my sensibil-
ities today. I have extended carative to caritas
and caritas processes as consistent with a more
fluid and contemporary movement of these
ideas and with my expanding directions.
Caritas comes from the Latin word mean-
ing “to cherish and appreciate, giving special
attention to, or loving.” It connotes something
that is very fine; indeed, it is precious. The
word caritas is also closely related to the origi-
nal word carative from my 1979 book. At this
time, I now make new connections between
carative and caritas and without hesitation use
them to invoke love, which caritas conveys.
This usage allows love and caring to come to-
gether for a new form of deep, transpersonal
caring. This relationship between love and car-
ing connotes inner healing for self and others,
extending to nature and the larger universe,
unfolding and evolving within a cosmology
that is both metaphysical and transcendent
with the coevolving human in the universe.
This emerging model of transpersonal caring
moves from carative to caritas. This integrative
expanded perspective is postmodern in that
it transcends conventional industrial, static
models of nursing while simultaneously evok-
ing both the past and the future. For example,
the future of nursing is tied to Nightingale’s
sense of “calling,” guided by a deep sense of
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commitment and a covenantal ethic of human
service, cherishing our phenomena, our subject
matter, and those we serve.
It is when we include caring and love in our
work and in our life that we discover and
affirm that nursing, like teaching, is more than
just a job; it is also a life-giving and life-
receiving career for a lifetime of growth and
learning. Such maturity and integration of past
with present and future now require trans-
forming self and those we serve, including our
institutions and our profession. As we more
publicly and professionally assert these posi-
tions for our theories, our ethics, and our
practices—even for our science—we also locate
ourselves and our profession and discipline
within a new, emerging cosmology. Such
thinking calls for a sense of reverence and
sacredness with regard to life and all living
things. It incorporates both art and science, as
they are also being redefined, acknowledging
a convergence among art, science, and spiritu-
ality. As we enter into the transpersonal caring
theory and philosophy, we simultaneously
are challenged to relocate ourselves in these
emerging ideas and to question for ourselves
how the theory speaks to us. This invites us
into a new relationship with ourselves and our
ideas about life, nursing, and theory.
Original Carative Factors
The original carative factors served as a guide
to what was referred to as the “core of nursing”
in contrast to nursing’s “trim.” Core pointed to
those aspects of nursing that potentiate ther-
apeutic healing processes and relationships—
they affect the one caring and the one being
cared for. Further, the basic core was
grounded in what I referred to as the philos-
ophy, science, and art of caring. Carative is
that deeper and larger dimension of nursing
that goes beyond the “trim” of changing times,
setting, procedures, functional tasks, special-
ized focus around disease, and treatment and
technology. Although the “trim” is important
and not expendable, the point is that nursing
cannot be defined around its trim and what it
does in a given setting and at a given point in
time. Nor can nursing’s trim define and clarify
its larger professional ethic and mission to
society—its raison d’être for the public. That
is where nursing theory comes into play, and
transpersonal caring theory offers another way
that both differs from and complements that
which has come to be known as “modern”
nursing and conventional medical–nursing
frameworks.
The 10 carative factors included in the orig-
inal work are the following:
1. Formation of a humanistic–altruistic
system of values.
2. Instillation of faith–hope.
3. Cultivation of sensitivity to one’s self and
to others.
4. Development of a helping–trusting,
human caring relationship.
5. Promotion and acceptance of the expres-
sion of positive and negative feelings.
6. Systematic use of a creative problem-
solving caring process.
7. Promotion of transpersonal teaching–
learning.
8. Provision for a supportive, protective,
and/or corrective mental, physical,
societal, and spiritual environment.
9. Assistance with gratification of human
needs.
10. Allowance for existential–phenomenological–
spiritual forces. (Watson, 1979, 1985)
Although some of the basic tenets of the
original carative factors still hold and indeed
are used as the basis for some theory-guided
practice models and research, what I am pro-
posing here, as part of my evolution and the
evolution of these ideas and the theory itself,
is to transpose the carative factors into “clinical
caritas processes.”
From Carative Caritas Processes
As carative factors evolved within an expand-
ing perspective and as my ideas and values have
evolved, I now offer the following translation
of the original carative factors into caritas
processes, suggesting more open ways in which
they can be considered.
1. Formation of a humanistic–altruistic sys-
tem of values becomes the practice of loving
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kindness and equanimity within the
context of caring consciousness.
2. Instillation of faith–hope becomes being
authentically present and enabling and sus-
taining the deep belief system and subjective
life world of self and one being cared for.
3. Cultivation of sensitivity to one’s self and
to others becomes cultivation of one’s own
spiritual practices and transpersonal self,
going beyond ego self, opening to others
with sensitivity and compassion.
4. Development of a helping–trusting,
human caring relationship becomes devel-
oping and sustaining a helping–trusting,
authentic caring relationship.
5. Promotion and acceptance of the expres-
sion of positive and negative feelings
becomes being present to, and supportive
of, the expression of positive and negative
feelings as a connection with deeper
spirit of self and the one being cared for
(authentically listening to another’s story).
6. Systematic use of a creative problem-
solving caring process becomes creative use
of self and all ways of knowing as part of
the caring process; to engage in the artistry
of caring-healing practices (creative solu-
tion seeking becomes caritas coach role).
7. Promotion of transpersonal teaching-
learning becomes engaging in genuine
teaching-learning experience that attends
to unity of being and meaning, attempting
to stay within others’ frames of reference.
8. Provision for a supportive, protective,
and/or corrective mental, physical, societal,
and spiritual environment becomes creating
a healing environment at all levels (a phys-
ical and nonphysical, subtle environment
of energy and consciousness, whereby
wholeness, beauty, comfort, dignity, and
peace are potentiated).
9. Assistance with gratification of human
needs becomes assisting with basic needs,
with an intentional caring consciousness,
administering “human care essentials,”
which potentiate wholeness and unity of
being in all aspects of care; sacred acts of
basic care; touching embodied spirit and
evolving spiritual emergence.
10. Allowance for existential–phenomenolog-
ical–spiritual forces becomes opening and
attending to spiritual-mysterious and
existential dimensions of one’s own
life-death; soul care for self and the one
being cared for. “Allowing for miracles.”
What differs in the caritas process frame-
work is that a decidedly spiritual dimension and
an overt evocation of love and caring are
merged for a new unitary cosmology for this
millennium. Such a perspective ironically places
nursing within its most mature framework and
is consistent with the Nightingale model of
nursing—yet to be actualized but awaiting its
evolution. This direction, while embedded
in theory, goes beyond theory and becomes a
converging paradigm for nursing’s future.
Thus, I consider my work more a philo-
sophical, ethical, intellectual blueprint for
nursing’s evolving disciplinary/professional
matrix, rather than a specific theory per se.
Nevertheless, others interact with the original
work at levels of concreteness or abstractness.
If the theory is “read” at the carative factor
level, it can be interpreted as a middle-range
theory. If the theory is “read” at the transper-
sonal unitary caring science/transpersonal
caring consciousness level, the theory can be
interpreted as a grand theory located within
the unitary–transformative context.
The caring theory has been and increasingly
is being used nationally and internationally as
a guide for educational curricula, clinical prac-
tice models, methods for research and inquiry,
and administrative directions for nursing and
health-care delivery.
Reading the Theory
The “theory” can be “read” as a philosophy,
an ethic, a paradigm, an expanded science
model, or a theory. If read as a theory, it can
be “read” as a grand theory within the unitary–
transformative paradigm when understood at
the transpersonal, energetic-field level of caritas-
universal love and evolving consciousness.
It can be “read” as middle-range theory
when read at the carative factors/caritas
process level, which provides the structure and
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language of the theory, as both middle range
and specific. When used in clinical settings,
the theory helps nurses to frame their experi-
ences around the caritas processes to sustain
the caring-science focus, as well as developing
language systems, including computerized
documentation systems, to document and
study caring within a designated language sys-
tem (Rosenberg, 2006, p. 55). The middle-
range focus is also congruent with clinical
caring research projects, utilizing the caring
language of carative/caritas. Indeed, many of
the more formalized caring assessment tools
are based on the language of this structure.
Several multisite research projects are now un-
derway using consistent caring assessment
tools, such as Duffy’s Caring Assessment Tool
and the Nelson, Watson, and Inova Health
Instrument Caring Factor Survey (Persky,
Nelson, Watson, & Bent, 2008). The latest
Watson Caritas Patient Score is being used in
multisite clinical studies as an international re-
search project. (For more information, go to
www.watsoncaringscience.org.) In addition,
most of the current caring-science assessment
tools may be seen in Assessing and Measuring
Caring in Nursing and Health Sciences, 2nd ed.
(Watson, 2008b).
Heart-Centered Transpersonal
Caring Moment: Caritas Field
Whether the “theory” is read at different levels,
used as a language system for documentation,
used as a guide for professional nursing prac-
tice models, or used as the focus of multisite
or individual clinical caring research studies,
the essence of the lived theory is in the transper-
sonal caring moment. The caring moment can
be located within any caring occasion, as a
concept within middle-range or even prescrip-
tive or practice-level theory.
However, the caring moment is most evi-
dent within the transpersonal caritas energetic
field model, in that one’s consciousness, inten-
tionality, energetic heart-centered presence is
radiating a field beyond the two people or the
situation, affecting the larger field. Thus, nurses
can become more aware, more awake, more
conscious of manifesting/radiating a caritas field
of love and healing for self and others, helping
to transform self and system. For more compre-
hensive understanding of this work, see Nursing:
The Philosophy and Science of Caring (revised 2nd
ed.; Watson, 2008a). Indeed, the latest research
based on the science of the heart has demon-
strated that the loving heart-centered person is
radiating love that can be measured several feet
beyond themselves, affecting the subtle environ-
ment of all. Moreover, this research affirms that
the heart is actually sending more messages to
the brain, rather than the other way around. For
more information, please visit www.heartMath
.com; www.heartMath.org
This work posits a unitary oneness world-
view of connectedness of all; it embraces a
value’s explicit moral foundation and takes a
specific position with respect to the centrality
of human caring, “caritas,” and universal love
as an ethic and ontology. It is also a critical
starting point for nursing’s existence, broad
societal mission, and the basis for further
advancement for caring–healing practices.
Nevertheless, its use and evolution are depend-
ent on “critical, reflective practices that must
be continuously questioned and critiqued in
order to remain dynamic, flexible, and end-
lessly self-revising and emergent” (Watson,
1996, p. 143).
Transpersonal Caring Relationship
The terms transpersonal and transpersonal caring
relationship are foundational to the work.
Transpersonal conveys a concern for the inner
life world and subjective meaning of another
who is fully embodied. But the transpersonal
also energetically goes beyond the ego self and
beyond the given moment, reaching to the
deeper connections to spirit and with the
broader universe. Thus, a transpersonal caring
relationship moves beyond ego self and radi-
ates to spiritual, even cosmic, concerns and
connections that tap into healing possibilities
and potentials. Transpersonal caring is both
immanent, fully physical and embodied phys-
ically, while also paradoxically transcendent,
beyond physical self.
Transpersonal caring seeks to connect with
and embrace the spirit or soul of the other
through the processes of caring and healing
and being in authentic relation in the moment.
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Such a transpersonal relationship is influenced
by the caring consciousness and intentionality
and energetic presence of the nurse as she or
he enters into the life space or phenomenal
field of another person and is able to detect the
other person’s condition of being (at the soul
or spirit level). It implies a focus on the
uniqueness of self and other and the unique-
ness of the moment, wherein the coming to-
gether is mutual and reciprocal, each fully
embodied in the moment, while paradoxically
capable of transcending the moment, open to
new possibilities.
The transpersonal caritas consciousness
nurse seeks to “see” the spirit-filled person be-
hind the patient, behind the colleague, behind
the disease or the diagnosis or the behavior or
personality one may not like and connect with
that spirit-filled individual who exists behind
the illusion. This is heart-centered caritas prac-
tice guided by the very first caritas process: cul-
tivation of loving kindness and equanimity
with self and other, allowing for development
of more caring, love, compassion, and authen-
tic caring moments.
Transpersonal caring calls for an authentic-
ity of being and becoming, an ability to be
present to self and others in a reflective frame.
The transpersonal nurse has the ability to cen-
ter consciousness and intentionality on caring,
healing, and wholeness, rather than on disease,
illness, and pathology.
Transpersonal caring competencies are re-
lated to ontological development of the nurse’s
human caring literacy and ways of being and
becoming. Thus, “ontological caring compe-
tencies” become as critical in this model as
“technological curing competencies” to the
conventional modern, Western techno-cure
nursing-medicine model, which is now com-
ing to an end.
Within the model of transpersonal caring,
clinical caritas consciousness is engaged at a
foundational ethical level for entry into this
framework. The nurse attempts to enter into
and stay within the other’s frame of reference
for connecting with the inner life world of
meaning and spirit of the other. Together,
they join in a mutual search for meaning and
wholeness of being and becoming, to potentiate
comfort measures, pain control, a sense of
well-being, wholeness, or even a spiritual tran-
scendence of suffering. The person is viewed as
whole and complete, regardless of illness or
disease (Watson, 1996, p. 153).
Assumptions of the Transpersonal
Caring Relationship
The nurse’s moral commitment, intentionality,
and caritas consciousness exist to protect, en-
hance, promote, and potentiate human dignity,
wholeness, and healing, wherein a person creates
or cocreates his or her own meaning for exis-
tence, healing, wholeness, and living and dying.
The nurse’s will and consciousness affirm
the subjective-spiritual significance of the per-
son while seeking to sustain caring in the midst
of threat and despair—biological, institutional,
or otherwise. This honors the I–Thou rela-
tionship versus an I–It relationship (Buber,
1923/1996).
The nurse seeks to recognize, accurately de-
tect, and connect with the inner condition
of spirit of another through authentic caritas
(loving) presencing and being centered in the
caring moment. Actions, words, behaviors,
cognition, body language, feelings, intuition,
thought, senses, the energy field, and so on—all
contribute to the transpersonal caring connec-
tion. The nurse’s ability to connect with an-
other at this transpersonal spirit-to-spirit level
is translated via movements, gestures, facial
expressions, procedures, information, touch,
sound, verbal expressions, and other scientific,
technical, esthetic, and human means of com-
munication into nursing human art/acts or
intentional caring-healing modalities.
The caring–healing modalities within the
context of transpersonal caring/caritas con-
sciousness potentiate harmony, wholeness, and
unity of being by releasing some of the dishar-
mony, the blocked energy that interferes with
the natural healing processes. As a result, the
nurse helps another through this process to
access the healer within, in the fullest sense of
Nightingale’s view of nursing.
Ongoing personal–professional develop-
ment and spiritual growth and personal spiri-
tual practice assist the nurse in entering
into this deeper level of professional healing
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practice, allowing the nurse to awaken to the
transpersonal condition of the world and to ac-
tualize more fully “ontological competencies”
necessary for this level of advanced practice of
nursing. Valuable teachers for this work include
the nurse’s own life history and previous expe-
riences, which provide opportunities for fo-
cused studies, as the nurse has lived through or
experienced various human conditions and has
imagined others’ feelings in various circum-
stances. To some degree, the necessary knowl-
edge and consciousness can be gained through
work with other cultures and the study of the
humanities (art, drama, literature, personal
story, narratives of illness journeys) along with
an exploration of one’s own values, deep beliefs,
relationship with self and others, and one’s
world. Other facilitators include personal-
growth experiences such as psychotherapy,
transpersonal psychology, meditation, bioener-
getics work, and other models for spiritual
awakening. Continuous growth is ongoing for
developing and maturing within a transper-
sonal caring model. The notion of health pro-
fessionals as wounded healers is acknowledged
as part of the necessary growth and compassion
called forth within this theory/philosophy.
Caring Moment/Caring Occasion
A caring occasion occurs whenever the nurse
and another come together with their unique
life histories and phenomenal fields in a
human-to-human transaction. The coming to-
gether in a given moment becomes a focal
point in space and time. It becomes transcen-
dent, whereby experience and perception take
place, but the actual caring occasion has a
greater field of its own, in a given moment.
The process goes beyond itself yet arises from
aspects of itself that become part of the life his-
tory of each person, as well as part of a larger,
more complex pattern of life (Watson, 1985,
p. 59; 1996, p. 157).
A caring moment involves an action and a
choice by both the nurse and the other. The
moment of coming together presents the two
with the opportunity to decide how to be in
the moment in the relationship—what to do
with and in the moment. If the caring moment
is transpersonal, each feels a connection with
the other at the spirit level; thus, the moment
transcends time and space, opening up new
possibilities for healing and human connection
at a deeper level than that of physical interac-
tion. For example:
[W]e learn from one another how to be human by
identifying ourselves with others, finding their dilem-
mas in ourselves. What we all learn from it is self-
knowledge. The self we learn about . . . is every
self. IT is universal—the human self. We learn to
recognize ourselves in others . . . [it] keeps alive
our common humanity and avoids reducing self or
other to the moral status of object. (Watson, 1985,
pp. 59–60)
Caring (Healing) Consciousness
The dynamic of transpersonal caring (healing)
within a caring moment is manifest in a field
of consciousness. The transpersonal dimen-
sions of a caring moment are affected by the
nurse’s consciousness in the caring moment,
which in turn affects the field of the whole.
The role of consciousness with respect to a
holographic view of science has been discussed
in earlier writings (Watson, 1992, p. 148) and
includes the following points:
• The whole caring–healing–loving con-
sciousness is contained within a single
caring moment.
• The one caring and the one being cared
for are interconnected; the caring-healing
process is connected with the other
human(s) and with the higher energy of the
universe.
• The caring–healing–loving consciousness of
the nurse is communicated to the one being
cared for.
• Caring–healing–loving consciousness exists
through and transcends time and space and
can be dominant over physical dimensions.
Within this context, it is acknowledged that
the process is relational and connected. It
transcends time, space, and physicality. The
process is intersubjective with transcendent
possibilities that go beyond the given caring
moment.
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Implications of the Caring Model
The caring model or theory can be considered a
philosophical and moral/ethical foundation for
professional nursing and is part of the central
focus for nursing at the disciplinary level. A
model of caring includes a call for both art and
science. It offers a framework that embraces and
intersects with art, science, humanities, spiritu-
ality, and new dimensions of mind–body–spirit
medicine and nursing evolving openly as central
to human phenomena of nursing practice.
I emphasize that it is possible to read, study,
learn about, and even teach and research the
caring theory. However, to truly “get it,” one
has to experience it personally. The model is
both an invitation and an opportunity to inter-
act with the ideas, to experiment with and
grow within the philosophy, and to live it out
in one’s personal and professional lives.
Applications of the Theory
The ideas as originally developed, as well as in
the current evolving phase (Watson, 1979,
1985, 1999, 2003, 2005, 2008, 2011), provide
us with a chance to assess, critique, and see
where or how, or even if, we may locate our-
selves within a framework of caring science/
caritas as a basis for the emerging ideas in re-
lation to our own theories and philosophies of
professional nursing and/or caring practice. If
one chooses to use the caring-science perspec-
tive as theory, model, philosophy, ethic, or
ethos for transforming self and practice, or self
and system, the following questions may help
(Watson, 1996, p. 161):
• Is there congruence between the values and
major concepts and beliefs in the model and
the given nurse, group, system, organization,
curriculum, population needs, clinical ad-
ministrative setting, or other entity that is
considering interacting with the caring
model to transform and/or improve practice?
• What is one’s view of “human”? And what
does it mean to be human, caring, healing,
becoming, growing, transforming, and so
on? For example, in the words of Teilhard
de Chardin (1959): “Are we humans having
a spiritual experience, or are we spiritual
beings having a human experience?” Such
thinking in regard to this philosophical
question can guide one’s worldview and
help to clarify where one may locate self
within the caring framework.
• Are those interacting and engaging in the
model interested in their own personal
evolution? Are they committed to seeking
authentic connections and caring–healing
relationships with self and others?
• Are those involved “conscious” of their
caring caritas or noncaring consciousness
and intentionally in a given moment at an
individual and a systemic level? Are they
interested and committed to expanding
their caring consciousness and actions to
self, other, environment, nature, and wider
universe?
• Are those working within the model inter-
ested in shifting their focus from a modern
medical science–technocure orientation
to a true heart-centered authentic caring–
healing–loving model?
This work, in both its original and evolv-
ing forms, seeks to develop caring as an
ontological–epistemological foundation for a
theoretical–philosophical–ethical framework
for the profession and discipline of nursing
and to clarify its mature relationship and dis-
tinct intersection with other health sciences.
Nursing caring theory–based activities as
guides to practice, education, and research
have developed throughout the United States
and other parts of the world. The caring/
caritas model is consistently one of the nurs-
ing caring theories used as a guide in Magnet
Hospitals in the United States and found to
be culturally consistent with nursing in many
other cultures, nations, and countries. Nurses’
reflective-critical practice models are increas-
ingly adhering to a caring ethic and ethos as
the moral and scientific foundation for a pro-
fession that is coming of age for a new global
era in human history.
Latest Developments
The Watson Caring Science Institute (WCSI)
was established in 2007 as a nonprofit founda-
tion. The following statements define and
CHAPTER 18 • Jean Watson’s Theory of Human Caring 329
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describe the goals, missions, and purposes of
the International Caritas Consortium (ICC)
and the WCSI as two interrelated entities.
The general goals and objectives of the WCSI
are to steward and serve the ICC in its activi-
ties and more specifically to:
• Transform the dominant model of medical
science to a model of caring science by
reintroducing the ethic of caring and love,
necessary for healing.
• Deepen the authentic caring–healing rela-
tionships between practitioner and patient
to restore love and heart-centered human
compassion as the ethical foundation of
health care.
• Translate the model of caring–healing/
caritas into more systematic programs and
services to help transform health care one
nurse, one practitioner, one educator, and
one system at a time.
• Ensure caring and healing for the public,
reduce nurse turnover, and decrease costs
to the system.
International Caritas Consortium
Charter
The main purposes of the unfolding and emerg-
ing ICC (Watson, 2008a, pp. 278–280) are as
follows:
1. To explore diverse ways to bring the caring
theory to life in academic and clinical prac-
tice settings by supporting and learning
from each other
2. To share knowledge and experiences so
that we might help guide self and others in
the journey to live the caring philosophy
and theory in our personal and professional
lives.
The consortium gatherings, sponsored by
systems implementing caring theory in practice:
• Provide an intimate forum to renew, re-
store, and deepen each person’s and each
system’s commitment and authentic prac-
tices of human caring in their personal/
professional life and work.
• Learn from each other through shared work
of original scholarship, diverse forms of car-
ing inquiry, and modeling of caring–healing
practices.
• Mentor self and others in using and extend-
ing the theory of human caring to trans-
form education and clinical practices.
• Develop and disseminate caring science
models of clinical scholarship and profes-
sional excellence in the various settings in
the world.
Activities for Caritas Consortium
Gatherings
• Provide a safe forum to explore, create, and
renew self and system through reflective
time out.
• Share ideas, inspire each other, and learn
together.
• Participate in use of appreciative inquiry in
which each member is facilitative of each
other’s work, each participant learning from
others.
• Create opportunities for original scholar-
ship and new models of caring science–
based clinical and educational practices.
• Generate and share multisite projects in
caring theory/caring science scholarship.
• Network for educational and professional
models of advancing caring–healing
practices and transformative models of
nursing.
• Share unique experiences for authentic self-
growth within the caring science context.
• Educate, implement, and disseminate
exemplary experiences and findings to
broader professional audiences through
scholarly publications, research, and
formal presentations.
• Envision new possibilities for transforming
nursing and health care.
Because of the many national and interna-
tional developments and sincere desire for
authentic change, new projects using caring
science, caritas theory, and the philosophy
of human caring are now underway in many
systems. The WCSI and the ICC are examples
of individuals and representatives of systems
convening (in these cases, once a year) to
deepen and sustain what is referred to as caritas
nursing—that is, bringing caring and love and
heart-centered human-to-human practices
back into our personal life and work world
(Watson, 2008a).
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Caring Indicators and Programs
Although these earlier-named systems are
identified as sponsors of the growing ICC, ex-
amples of how these systems are implementing
the theory are captured through identified acts
and processes depicting such transformative
changes.
Caring theory-in-action reflects transfor-
mative processes that are representative of ac-
tions taking place in many of the systems in
the ICC and other systems guided by caring
science and caring theory. The following are
examples of such caring-in-action indicators:
• Make human caring integral to the organi-
zational vision and culture through new
language and documentation of caring,
such as posters.
• Introduce and name new professional car-
ing practice models, leading to new patterns
of delivery of caring/care (e.g., Attending
Caring Nursing Project, Patient Care
Facilitator Role, the 12-Bed Hospital).
• Create conscious intentional meaningful
rituals—for example, hand washing is for
infection control but may also be a mean-
ingful ritual of self-caring—energetically
cleansing, blessing, and releasing the last
situation or encounter, and being open to
the next situation.
• Selectively use of caring–healing modalities
for self and patients (e.g., massage, thera-
peutic touch, reflexology, aromatherapy,
calmative essential oils, sound, music, arts,
a variety of energetic modalities).
• Dim the unit lights and have designated
“quiet time” for patients, families, and staff
alike to soften, slow down, and calm the
environment.
• Create healing spaces for nurses—sanctuaries
for their own time out; this may include
meditation or relaxation rooms for quiet
time.
• Cultivate one’s own spiritual heart-centered
practices of loving kindness and equanimity
to self and others.
• Intentionally pause and breathe, preparing
the self to be present before entering
patient’s room.
• Use centering exercises and mindfulness
practices, individually and collectively.
• Place magnets on patient’s door with
positive affirmations and reminders of
caring practices.
• Explore documentation of caring language
and integration in computerized documen-
tation systems.
• Participate in multisite research assessing
caring among staff and patients.
• Create healing environments, attending to
the subtle environment or caritas field.
• Display healing objects, stones, or a blessing
basket.
• Create Caritas Circles to share caring
moments.
• Perform Caring Rounds at bedside with
patients.
• Interview and select staff on the basis of a
“caring” orientation. Asking candidates to
describe a “caring moment.”
• Develop of “caring competencies” using
caritas literacy as guide to assess and pro-
mote staff development and ensure caring.
These and other practices are occurring in a
variety of hospitals across the United States,
often in Magnet hospitals or those seeking
Magnet recognition, where caring theory and
models of human caring are used to transform
nursing and health care for staff and patients
alike.
The names of other health-care clinical and
educational systems incorporating caring
theory into professional nursing practice mod-
els (many are Magnet hospitals or preparing
to become Magnet hospitals) can be found
at www.watsoncaringscience.org.
These identified system examples are ex-
emplars of the changing momentum today
and are guided by a shift toward an evolved
consciousness. They rely on moral, ethical,
philosophical, and theoretical foundations to
restore human caring and healing and health
in a system that has gone astray—educationally,
economically, clinically, and socially. This
shift is in a hopeful direction and is based
on a grassroots transformation of nursing,
one that emerging from the inside out. The
dedicated leaders who are ushering in these
changes serve as an inspiration for sustaining
nursing and human caring for practitioners
and patients alike.
CHAPTER 18 • Jean Watson’s Theory of Human Caring 331
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Conclusion
Consistent with the wisdom and vision of Flo-
rence Nightingale, nursing is a lifetime journey
of caring and healing, seeking to understand
and preserve the wholeness of human existence
across time and space and national/geographic
boundaries, to offer heart-centered compas-
sionate, informed knowledgeable human car-
ing to society and humankind. This timeless
view of nursing transcends conventional minds
and mindsets of illness, pathology, and disease
that are located in the physical body with cur-
ing as end goal, often at all costs. In nursing’s
timeless model, caring, kindness, love, and
heart-centered compassionate service to hu-
mankind are restored. The unifying focus and
process is on connectedness with self, other,
nature, and God/the Life Force/the Absolute.
This vision and wisdom is being reignited
today through a blend of old and new values,
ethics, and theories and practices of human
caring and healing. These caritas consciousness
practices preserve humanity, human dignity,
and wholeness and are the very foundation of
transformed thinking and actions.
Such a values-guided relational ontology
and expanded epistemology and ethic is em-
bodied in caring science as the disciplinary
ground for nursing, now and in the future. The
advancement of nursing theory, which in-
cludes both ideals and practical guidance, is
increasingly evident as nursing makes its major
contribution to health care and matures as
a distinct caring–healing profession—one that
balances and complements conventional,
medical–institutional practices and processes.
Nevertheless, much work remains to be done.
New transformative, human-spirit–inspired
approaches are required to reverse institutional
and system lethargy and darkness. To create
the necessary cultural change, the human spirit
has to be invited back into our health-care sys-
tems. Professional and personal models are re-
quired that open the hearts of nurses and other
practitioners. New horizons of possibilities
have to be explored to create space whereby
compassionate, intentional, heart-centered
human caring can be practiced. Such authentic
personal/professional practice models of caring
science are capable of leading us, locally and
globally, toward a moral community of caring.
This community will restore healing and health
at a level that honors and sustains the dignity
and humanity of practitioners and patients alike.
The Watson Caring Science Institute is
dedicated to create, conduct, and sponsor
Caring Science/Caritas education, training,
and support to serve the current and future
generations of health-care professionals glob-
ally (www.watsoncaringscience.org; WCSI,
4405 Arapahoe Avenue, Suite 100, Boulder,
CO 80303).
332 SECTION V • Grand Theories about Care or Caring
Practice Exemplar
Practice Exemplar by Terry
Woodward, RN, MSN.
October 2002 presented the opportunity for
17 interdisciplinary health-care professionals
at the Children’s Hospital in Denver, Col-
orado, to participate in a pilot study designed
to (1) explore the effect of integrating caring
theory into comprehensive pediatric pain
management and (2) examine the Attending
Nurse Caring Model® (ANCM) as a care de-
livery model for hospitalized children in pain.
A 3-day retreat launched the pilot study. Par-
ticipants were invited to explore transpersonal
human caring theory (caring theory) as taught
and modeled by Dr. Jean Watson, through ex-
periential interactions with caring–healing
modalities. The end of the retreat opened op-
portunities for participants to merge caring
theory and pain theory into an emerging
caring-healing praxis.
Returning from the retreat to the preexist-
ing schedules, customs, and habits of hospital
routine was both daunting and exciting. We
had lived caring theory, and not as a remote
and abstract philosophical ideal; rather, we
had experienced caring as the very core of our
true selves, and it was that call that had led us
into the health-care professions. Invigorated
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CHAPTER 18 • Jean Watson’s Theory of Human Caring 333
Practice Exemplar cont.
by the retreat, we returned to our 37-bed acute
care inpatient pediatric unit, eager to apply
caring theory to improve pediatric pain man-
agement. Our experiences throughout the re-
treat had accentuated caring as our core value.
Caring theory could not be restricted to a
single area of practice.
Wheeler and Chinn (1991) define praxis as
“values made visible through deliberate action”
(p. 2). This definition unites the ontology,
or the essence, of nursing to nursing actions,
to what nurses do. Nursing within acute care
inpatient hospital settings is practiced depend-
ently, collaboratively, and independently
(Bernardo, 1998). Bernardo described depend-
ent practice as energy directed by and requiring
physician orders, collaborative practice as in-
terdependent energy directed toward activities
with other health-care professionals, and inde-
pendent practice as “where the meaningful role
and impact of nursing may evolve” (p. 43). Our
vision of nursing practice was based in the car-
ing paradigm of deep respect for humanity and
all life, of wonder and awe of life’s mystery, and
the interconnectedness from mind–body–spirit
unity into cosmic oneness (Watson, 1996).
Gadow (1995) described nursing as a lived
world of interdependency and shared knowl-
edge, rather than as a service provided. Caring
praxis within this lived world is a praxis that
offers “a combination of action and reflection
. . . praxis is about a relationship with self, and
a relationship with the wider community”
(Penny & Warelow, 1999, p. 260). Caring
praxis, therefore, is collaborative praxis.
Collaboration and cocreation are key ele-
ments in our endeavors to translate caring the-
ory into practice. They reveal the nonlinear
process and relational aspect of caring praxis.
Both require openness to unknown possibili-
ties, both honor the unique contributions of
self and other(s), and both acknowledge
growth and transformation as inherent to life
experience. These key elements support the
evolution of praxis away from predetermined
goals and set outcomes toward authentic caring–
healing expressions. Through collaboration and
cocreation, we can build on existing founda-
tions to nurture evolution from what is to what
can be.
Our mission—to translate caring theory
into praxis—had strong foundational support.
Building on this supportive base, we commit-
ted our intentions and energies toward creat-
ing a caring culture. The following is not
intended as an algorithm to guide one through
varied steps until caring is achieved but is
rather a description of our ongoing processes
and growth toward an ever-evolving caring
praxis. These processes are cocreations that
emerged from collaboration with other ANCM
participants, fellow health professionals, pa-
tients and families, our environment, and our
caring intentions.
First Steps
One of our first challenges was to make the
ANCM visible. Six tangible exhibits were dis-
played on the unit as evidence of our commit-
ment to caring values. First, a large, colorful
poster titled “CARING” was positioned at the
entrance to our unit. Depicting pictures of di-
verse families at the center, the poster states our
three initial goals for theory-guided practice:
(1) create caring–healing environments, (2) op-
timize pain management through pharmaco-
logical and caring–healing measures, and
(3) prepare children and families for procedures
and interventions. Watson’s clinical caritas
processes were listed, as well as an abbreviated
version of her guidelines for cultivating caring–
healing throughout the day (Watson, 2002).
This poster, written in caring theory language,
expressed our intention to all and reminded us
that caring is the core of our praxis.
Second, a shallow bowl of smooth, rounded
river stones was located in a prominent posi-
tion at each nursing desk. A sign posted by the
stones identified them as “Caring–Healing
Touch Stones,” inviting one to select a stone
as “every human being has the ability to share
their incredible gift of loving–healing. These
stones serve as a reminder of our capacity to
love and heal. Pick up a stone, feel its smooth
Continued
3312_Ch18_321-340 26/12/14 4:58 PM Page 333
334 SECTION V • Grand Theories about Care or Caring
Practice Exemplar cont.
cool surface, let its weight remind you of your
own gifts of love and healing. Share in the love
and healing of all who have touched this stone
before you and pass on your love and healing
to all who will hold this stone after you.”
Third, latched wicker blessing baskets were
placed adjacent to the caring–healing touch
stones. Written instructions invited families,
visitors, and staff to offer names for a blessing
by writing the person’s initials on a slip of
paper and placing the paper in the basket.
Every Monday through Friday, the unit chap-
lain, holistic clinical nurse specialist (CNS),
and interested staff devoted 30 minutes of
meditative silence within a healing space to ask
for peace and hope for all names contained
within the baskets.
Fourth, signs picturing a snoozing cartoon-
styled tiger were posted on each patient’s door
announcing “Quiet Time.” Quiet time was a
midday, half-hour pause from hospital hustle-
bustle. Lights in the hall were dimmed, voices
hushed, and steps softened to allow a pause for
reflection. Staff members tried not to enter
patient rooms unless summoned.
Fifth, a booklet was written and published
to welcome families and patients to our unit,
to introduce health team members, unit rou-
tines, available activities, and define frequently
used medical terms. This book emphasized
that patients, parents, and families are mem-
bers of the health team. A description of our
caring attending team was also included.
Sixth and most recently, the unit chaplain,
child-life specialist, and social worker organ-
ized a weekly support session called “Goodies
and Gathering,” offered every Thursday morn-
ing. It was held in our healing room—a con-
ference room painted to resemble a cozy room
with a beautiful outdoor view and redecorated
with comfortable armchairs, soft lighting, and
plants. Goodies and Gathering extended a safe
retreat within the hospital setting. Offering
1 hour to parents and another to staff, these
professionals provided snacks to feed the body,
a sacred space to nourish emotions, and their
caring presence to nurture the spirit.
Attending Caring Team (ACT)
To honor the collaborative partnership of our
ANCM participants, to include patients and
families as equal partners in the health-care
team, and to open participation to all, we
adopted the name Attending Caring Team
(ACT). The acronym ACT reinforces that our
actions are opportunities to make caring visi-
ble. Care as the core of praxis differs from the
centrality of cure in the medical model. To de-
scribe our intentions to others, we compiled
the following “elevator” description of ACT,
a terse, 30-second summary that rendered the
meaning of ACT in the time frame of a shared
elevator ride:
The core of the Attending Caring Team (ACT)
is caring-healing for patients, families, and
ourselves. ACT cocreates relationships and col-
laborative practices between patients, families
and health care providers. ACT practice enables
health care providers to redefine themselves as
caregivers rather than taskmasters. We provide
Health Care not Health Tasks.
Large signs were professionally produced
and hung at various locations on our unit.
These signs served a dual purpose. The largest,
posted conspicuously at our threshold, identi-
fied our unit as the home of the Attending
Caring Team. Smaller signs, posted at each
nurse’s station, spelled out the above ACT
definition, inviting everyone entering our unit
to participate in the collaborative cocreation of
caring–healing.
Giving ourselves a name and making our
caring intentions visible contributed to estab-
lishing an identity, yet may be perceived as pe-
ripheral activities. For these expressions to be
deliberate actions of praxis, the centrality of
caring as our core value was clearly articulated.
Caring theory is the flexible framework guid-
ing our unit goals and unit education and has
been integrated into our implementation of an
institutional customer-service initiative.
Unit goals are written yearly. Reflective of
the broader institutional mission statement,
each unit is encouraged to develop a mission
3312_Ch18_321-340 26/12/14 4:58 PM Page 334
CHAPTER 18 • Jean Watson’s Theory of Human Caring 335
Practice Exemplar cont.
statement and outline goals designed to
achieve that mission. In 2003, our mission
statement was rewritten to focus on provision
of quality family-centered care, defined as “an
environment of caring-healing recognizing
families as equal partners in collaboration with
all health care providers.” One of the goals to
achieve this mission literally spelled out caring.
We promote a caring-healing environment for
patients, families, and staff through:
• Compassion, competence, commitment
• Advocacy
• Respect, research
• Individuality
• Nurturing
• Generosity
Education
Unit educational offerings were also revised to
reflect caring theory. Phase classes, a 2-year
curriculum of serial seminars designed to sup-
port new hires in their clinical, educational,
and professional growth, now include a unit
on self-care to promote personal healing and
support self-growth. The unit on pain man-
agement was expanded to include use of
caring–healing modalities. A new interactive
session on the caritas processes was added that
asks participants to reflect on how these
processes are already evident in their praxis
and to explore ways they can deepen caring
praxis both individually and collectively as a
unit. The tracking tool used to assess a new
employee’s progress through orientation now
includes an area for reflection on growing in
caring competencies. In addition to changes in
phase classes, informal “clock hours” were of-
fered monthly. Clock hours are designed to re-
spond to the immediate needs of the unit and
encompass a diverse range of topics, from con-
flict resolution, debriefing after specific events,
and professional development, to health treat-
ment plans, physiology of medical diagnosis,
and in-services on new technologies and phar-
macological interventions. Offered on the unit
at varying hours to accommodate all work
shifts, clock hours provide a way for staff
members to fulfill continuing educational
requirements during workdays.
Customer Service to Covenantal
In the practice of human caring as a formal
theory and practice model, there is a philo-
sophical shift from a customer-service mindset
to viewing nursing and human caring as
a covenant with humanity to sustain human
caring in the world.
Within this exemplar, caring theory has
provided depth to an institutional initiative to
use FISH philosophy to enhance customer
service (Lundin, Paul, & Christensen, 2000).
Imported from the Pike Place Fish Market in
Seattle, FISH advocates four premises to im-
prove employee and customer satisfaction:
presence, make their day, play, and choose
your attitude. Briefly summarized, FISH ad-
vocates that when employees bring their full
awareness through presence, focus on cus-
tomers to make their day, invoke fun into the
day through appropriate play, and through
conscious awareness choose their attitude,
work environments improve for all. When the
four FISH premises are viewed from the per-
spective of transpersonal caring, they become
opportunities for authentic human-to-human
connectedness through I–Thou relationships.
The merger of caring theory with FISH
philosophy has inspired the following activi-
ties. A parade composed of patients, their
families, nurses, and volunteers—complete
with marching music, hats, streamers, flags,
and noisemakers—is celebrated two to three
times a week just before the playroom closes
for lunch. This flamboyant display lasts less
than 5 minutes but invigorates participants
and bystanders alike. In addition to being vital
for children and especially appropriate in a
pediatric setting, play unites us all in the life
and joy of each moment. When our parade
marches, visitors, rounding doctors, and all
others on the unit pause to watch, wave, and
cheer us on. A weekly bedtime story is read in
our healing room. Patients are invited to bring
Continued
3312_Ch18_321-340 26/12/14 4:58 PM Page 335
336 SECTION V • Grand Theories about Care or Caring
Practice Exemplar cont.
their pillows and favorite stuffed animal or doll
and come dressed in pajamas. Night- and day-
shift staff members have honored one another
with surprise beginning-of-the-shift meals,
staying late to care for patients and families,
and refusing to give off-going report until
their on-coming coworkers had eaten. Color-
ful caring stickers are awarded when one staff
member catches another in the ACT of car-
ing, being present, making another’s day, play-
ing, and choosing a positive attitude. These
acts are authentic and not performed as hos-
pitality acts and within the customer mindset;
rather, they are a professional covenant nurs-
ing has with humanity around the world.
ACT Guidelines
Placing caring theory at the core of our praxis
supports practicing caring–healing arts to pro-
mote wholeness, comfort, harmony, and inner
healing. The intentional conscious presence of
our authentic being to provide a caring–healing
environment is the most essential of these arts.
Presence as the foundation for cocreating car-
ing relationships has led to writing ACT
guidelines. Written in the doctor order section
of the chart, ACT guidelines provide a formal
way to honor unique families’ values and be-
liefs. Preferred ways of having dressing changes
performed, most helpful comfort measures,
home schedules, and special needs or requests
are examples of what these guidelines might
address. ACT members purposefully use the
word guideline as opposed to order as more con-
gruent with cocreative collaborate praxis and to
encourage critical thinking and flexibility.
Building practice on caring relationships has
led to an increase in both the type and volume
of care conferences held on our unit. Previ-
ously, care conferences were called as a way to
disseminate information to families when
complicated issues arose or when communica-
tion between multiple teams faltered and fam-
ilies were receiving conflicting reports, plans,
and instructions. Now these conferences are
offered proactively as a way to coordinate team
efforts and to ensure we are working toward
the families’ goals. Transitional conferences
provide an opportunity to coordinate conti-
nuity of care, share insight into the unique
personality and preferences of the child, coor-
dinate team effort, meet families, provide them
with tours of our unit, and collaborate with
families. Other caring–healing arts offered on
our unit are therapeutic touch, guided imagery,
relaxation, visualization, aromatherapy, and
massage. As ACT participants, our challenge
is to express our caring values through every ac-
tivity and interaction. Caring theory guides us
and manifests in innumerable ways. Our inter-
view process, meeting format, and clinical
nurse specialist (CNS) role have been transfig-
ured through caring theory. Our interview
process has transformed from an interrogative
three-step procedure into more of a sharing
dialogue. We are adopting another meeting
style that expresses caring values.
Our unit director had the foresight to
budget a position for a CNS to support the
cocreation of caring praxis. The traditional
CNS roles—researcher, clinical expert, collab-
orator, educator, and change agent—have
allowed the integration of caring theory devel-
opment into all aspects of our unit program.
The CNS role advocates self-care and facili-
tates staff members to incorporate caring-healing
arts into their practice through modeling and
hands-on support. In addition to providing
assistance, searching for resources, acting as
liaison with other health-care teams, and
promoting staff in their efforts, the very pres-
ence of the CNS on the unit reinforces our
commitment to caring praxis.
Conclusion
We continue to work toward incorporating
caring ideals in every action. Currently, we are
modifying our competency-based guidelines
to emphasize caring competency within tasks
and skills. Building relationships for support-
ive collaborative practice is the most exciting
and most challenging endeavor we are now
facing as old roles are reevaluated in light
of cocreating caring-healing relationships.
3312_Ch18_321-340 26/12/14 4:58 PM Page 336
CHAPTER 18 • Jean Watson’s Theory of Human Caring 337
Practice Exemplar cont.
Watson and Foster (2003) described the
potential of such collaboration:
The new caring-healing practice environment is
increasingly dependent on partnerships, negoti-
ation, coordination, new forms of communica-
tion pattern and authentic relationships. The
new emphasis is on a change of consciousness, a
focused intentionality toward caring and healing
relationships and modalities, a shift toward a
spiritualization of health vs. a limited medical-
ized view. (p. 361)
Our ACT commitment is to authentic re-
lationships and the creation of caring–healing
environments.
■ Summary
Nursing’s future and nursing in the future
will depend on nursing maturing as the dis-
tinct health, healing, and caring profession
that it has always represented across time but
has yet to fully actualize. Nursing thus iron-
ically is now challenged to stand and mature
within its own caring science paradigm,
while simultaneously having to transcend it
and share with others. The future already re-
veals that all health-care practitioners will
need to work within a shared framework
of caring–healing relationships and human–
environmental energetic field modalities.
Practitioners of the future pay attention to
consciousness, intentionality, energetic human
presence, transformed mind–body–spirit med-
icine, and will need to embrace healing arts
and caring practices and processes and the
spiritual dimensions of care much more com-
pletely.
Thus, nursing is at its own crossroad of
possibilities, between worldviews and para-
digms. Nursing has entered a new era; it is in-
vited and required to build on its heritage and
latest evolution in science and technology but
must transcend itself for a new future, yet to
be known. However, nursing’s future holds
promises of caring and healing mysteries and
models yet to unfold, as opportunities for of-
fering compassionate caritas services at indi-
vidual, system, societal, national, and global
levels for self, for profession, and for the
broader world community. Nursing has a
critical role to play in sustaining caring in hu-
manity and making new connections between
caring, love, healing, and peace in the world.
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3312_Ch18_321-340 26/12/14 4:58 PM Page 340
Chapter 19Theory of Nursing as Caring
ANNE BOYKIN AND SAVINA O.
SCHOENHOFER
Introducing the Theorists
Nursing as Caring: An Overview
Applications of the Theory
Practice Exemplar
Summary
References
341
Introducing the Theorists
Anne Boykin
Anne Boykin is Professor Emerita and past
Dean of the Christine E. Lynn College of
Nursing at Florida Atlantic University. She is
Director of the College’s Anne Boykin Insti-
tute for the Advancement of Caring in Nurs-
ing. This institute provides global leadership
for nursing education, practice, and research
grounded in caring; promotes the valuing of
caring across disciplines; and supports the car-
ing mission of the college. She has demon-
strated a long-standing commitment to the
advancement of knowledge in the discipline,
especially regarding the phenomenon of caring.
Positions she has held within the Interna-
tional Association for Human Caring include:
president-elect (1990–1993), president (1993–
1996), and member of the nominating commit-
tee (1997–1999). As immediate past president,
she served as co-editor of the journal Interna-
tional Association for Human Caring from 1996
to 1999.
Her scholarly work is centered in caring as
the grounding for nursing. This is evidenced in
her coauthored book, Nursing as Caring: A
Model for Transforming Practice (Boykin &
Schoenhofer, 1993, rev. ed. 2001a), and the
book Living a Caring-based Program (Boykin,
1994). The latter book illustrates how caring
grounds all aspects of a nursing education pro-
gram. Dr. Boykin has also authored numerous
book chapters and articles. She is currently re-
tired and serves as a consultant locally, region-
ally, nationally, and internationally on the topic
of caring-based health-care transformations.
Savina O. SchoenhoferAnne Boykin
3312_Ch19_341-356 26/12/14 9:17 AM Page 341
Dr. Boykin is a graduate of Alverno College
in Milwaukee, Wisconsin; she received her
master’s degree from Emory University in
Atlanta, Georgia, and her doctorate from
Vanderbilt University in Nashville, Tennessee.
Savina O. Schoenhofer
Savina O’Bryan Schoenhofer began her initial
nursing study at Wichita State University,
where she earned undergraduate degrees in
nursing and psychology and graduate degrees
in nursing and counseling. She completed a
PhD in educational foundations/administra-
tion at Kansas State University in 1983. In
1990, Schoenhofer cofounded Nightingale
Songs, an early venue for communicating the
beauty of nursing in poetry and prose. In ad-
dition to her work on caring, she has written
on nursing values, primary care, nursing edu-
cation, support, touch, personnel management
in nursing homes, and mentoring. Her career
in nursing has been significantly influenced
by three colleagues: Lt. Col. Ann Ashjian
(Ret.), whose community nursing practice in
Brazil presented an inspiring model of nursing;
Marilyn E. Parker, PhD, a faculty colleague
who mentored her in the idea of nursing as a
discipline, the academic role in higher educa-
tion, and the world of nursing theories and
theorists; and Anne Boykin, PhD, who intro-
duced her to caring as a substantive field of
nursing study.
Schoenhofer coauthored the book, Nurs-
ing as Caring: A Model for Transforming Prac-
tice (1993, 2001a) with Boykin. Boykin and
Schoenhofer, together with Kathleen Valentine,
coauthored the book, Health Care System Trans-
formation for Nursing and Health Care Leaders:
Implementing a Culture of Caring (2013).
Nursing As Caring:
Overview
This chapter is intended as an overview of the
theory of nursing as caring, a general theory,
framework, or disciplinary view of nursing. A
general theory or framework of nursing presents
an abstract, integrated, comprehensive picture
of nursing as a practiced discipline. The theory
of nursing as caring offers a view that permits a
broad, encompassing understanding of any and
all situations of nursing practice (Boykin &
Schoenhofer, 1993, 2001a). This theory serves
as an organizing framework for nursing scholars
in the various roles of practitioner, researcher,
administrator, teacher, and developer.
Initially, we present the theory in its most
abstract form, addressing assumptions and key
themes. We then illustrate the meaning of the
theory of nursing as caring through exemplars
in the role dimensions of nursing care, nursing
education, nursing administration and nursing
research.
Nursing as Caring: Historical
Perspective
The theory of nursing as caring is an outgrowth
of the curriculum development work in the
Christine E. Lynn College of Nursing at Florida
Atlantic University, where both authors were
among the faculty group revising the caring-
based curriculum for initial program accredi-
tation. When the revised curriculum was in
place, each of us recognized the potential and
even the necessity of continuing to develop and
structure ideas and themes toward a compre-
hensive expression of the meaning and purpose
of nursing as a discipline and a profession. The
point of departure was the acceptance that car-
ing is the end, rather than the means, of nursing,
and that caring is the intention of nursing, rather
than merely its instrument. This work led to the
statement of focus of nursing as “nurturing
persons living caring and growing in caring.”
Further work to identify foundational as-
sumptions about nursing clarified the idea of
the nursing situation, a shared lived experience
in which the caring between nurse and nursed
enhances personhood, with personhood un-
derstood as living grounded in caring. The
clarified focus and the idea of the nursing sit-
uation are the key themes that draw forth the
meaning of the assumptions underlying the
theory and permit the practical understanding
of nursing as both a discipline and a profes-
sion. As critique of the theory and study of
nursing situations progressed, the notion of
nursing being primarily concerned with health
was seen as limiting, and we now understand
nursing to be concerned with human living.
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Three bodies of work significantly influ-
enced the initial development of nursing as
caring. Roach’s (1987/2002) basic thesis that
caring is the human mode of being was incor-
porated into the most basic assumption of the
theory. We view Paterson and Zderad’s (1988)
existential phenomenological theory of hu-
manistic nursing as the historical antecedent
of nursing as caring. Seminal ideas from hu-
manistic nursing such as “the between,” “call
for nursing,” “nursing response,” and “person-
hood” serve as substantive and structural bases
for our conceptualization of nursing as caring.
Mayeroff’s (1971) work, On Caring, provided
a language that facilitated the recognition and
description of the practical meaning of caring
in nursing situations. Roach’s (1987/2002) five
Cs (described in detail later) of caring expand
on that basic language. In addition to the work
of these thinkers, both authors are long-standing
members of the community of nursing schol-
ars whose study focuses on caring and are sup-
ported and undoubtedly influenced in many
subtle ways by the members of this community
and their work.
Fledgling forms of the theory of nursing as
caring were first published in 1990 and 1991,
with the first complete exposition of the theory
presented at a conference in 1992 (Boykin &
Schoenhofer, 1990, 1991; Schoenhofer &
Boykin, 1993), followed by the publication of
Nursing as Caring: A Model for Transforming
Practice in 1993 (Boykin & Schoenhofer, 1993),
which was revised with the addition of an epi-
logue in 2001 (Boykin & Schoenhofer, 2001a).
Assumptions and Key Themes
of Nursing as Caring
Assumptions
Certain fundamental beliefs about what it
means to be human underlie the theory of
nursing as caring. The following assumptions
reflect a particular set of values that provide a
basis for understanding and explicating the
meaning of nursing and are key to understand-
ing the practical meaning of the theory of
nursing as caring.
• Persons are caring by virtue of their
humanness.
• Persons are whole and complete in the
moment.
• Persons are caring, moment to moment.
• Personhood is a way of living grounded in
caring.
• Personhood is enhanced through participa-
tion in nurturing relationships with caring
others.
• Nursing is both a discipline and a profession.
Key Themes
Caring
Caring is an altruistic, active expression of love
and is the intentional and embodied recogni-
tion of value and connectedness. Caring is not
the unique province of nursing. However, as a
discipline and a profession, nursing uniquely
focuses on caring as its central value, its pri-
mary interest, its focus for scholarship, and the
direct intention of its practice. “As an expres-
sion of nursing, caring is the intentional and au-
thentic presence of the nurse with another who is
recognized as person living caring and growing in
caring” (Boykin & Schoenhofer, 2001a, p. 13).
The full meaning of caring cannot be restricted
to a definition but is illuminated in the expe-
rience of caring and in dynamic reflection on
that experience.
Focus and Intention of Nursing
Disciplines as identifiable entities or “branches
of knowledge” grow from the holistic “tree of
knowledge” as need and purpose develop. A
discipline is a community of scholars with a
particular perspective on the world and on
what it means to be in the world. The discipli-
nary community represents a value system that
is expressed in its unique focus on knowledge
and practice. The focus of nursing, from the per-
spective of the theory of nursing as caring, is
person living caring and growing in caring. The
general intention of nursing as a practiced dis-
cipline is nurturing persons living caring and
growing in caring.
Nursing Situation
The practice of nursing, and thus the practical
knowledge of nursing, lives in the context of
person-with-person caring. The nursing situa-
tion involves particular values, intentions, and
actions of two or more persons choosing to live
a nursing relationship. Nursing situation is
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understood to mean the shared lived experience
in which caring between nurse and nursed en-
hances personhood. Nursing is created in the
“caring between.” All knowledge of nursing is
created and understood within the nursing sit-
uation. Any single nursing situation has the po-
tential to illuminate the depth and complexity
of nursing knowledge. Nursing situations are
best communicated aesthetically to preserve the
lived meaning of the situation and the openness
of the situation as text. Storytelling, poetry,
graphic arts, dance, and other expressive modes
effectively represent the lived experience of
nursing and allowing for reflection and creativ-
ity in advancing understanding.
Personhood
Personhood is understood to mean living
grounded in caring. From the perspective of
the theory of nursing as caring, personhood is
the universal human call. A profound under-
standing of personhood communicates the
paradox of person-as-person and person-in-
communion all at once.
Direct Invitation
The concept of direct invitation was briefly
introduced in the epilogue of the 2001 revised
edition of nursing as caring (Boykin &
Schoenhofer, 2001a). It evolved from a con-
vergence of ontology and aesthetics as a way
to more effectively communicate nursing as
caring in practice.
The context for understanding direct invi-
tation is the nursing situation. Direct invitation
communicates clearly that the core service of
nursing is to offer caring and to invite the one
nursed to share that which matters most to
them in that moment. It is through this invi-
tation that the call for nursing is heard and
nursing responses are created. Direct invitation
establishes an openness between the nurse
and one nursed and strengthens the caring
between.
Call for Nursing
“A call for nursing is a call for acknowledg-
ment and affirmation of the person living car-
ing in specific ways in the immediate situation”
(Boykin & Schoenhofer, 2001a, p. 13). Calls
for nursing are calls for nurturance through
personal expressions of caring. Calls for nurs-
ing originate within persons as they live caring
uniquely, expressing personally meaningful
dreams and aspirations for growing in caring.
Calls for nursing are individually relevant ways
of saying, “Know me as caring person in the
moment and be with me as I try to live fully
who I truly am.” Intentionality and authentic
presence open the nurse to hearing calls for
nursing. Because calls for nursing are unique
situated personal expressions of that which
matters to the person nursed, they cannot be
predicted, as in a “diagnosis.” Nurses develop
sensitivity and expertise in hearing calls through
intention, experience, study, and reflection in
a broad range of human situations.
Nursing Response
As an expression of nursing, “caring is the in-
tentional and authentic presence of the nurse
with another who is recognized as living caring
and growing in caring” (Boykin & Schoenhofer,
2001a, p. 13). The nurse enters the nursing
situation with the intentional commitment
of knowing the other as caring person, and in
that knowing, acknowledging, affirming, and
celebrating the person as caring. The nursing
response is a specific expression of caring nurtu-
rance to sustain and enhance the one nursed in
ways that matter as he or she lives caring and
grows in caring in the situation of concern.
Nursing responses to calls for caring evolve as
nurses clarify their understandings of calls
through presence and dialogue. Nursing re-
sponses are uniquely created for the moment and
cannot be predicted or automatically applied as
preplanned protocols. Sensitivity and skill in
creating unique and effective ways of commu-
nicating caring are developed through intention,
experience, study, and reflection in a broad
range of human situations.
The “Caring Between”
The caring between is the source and ground of
nursing. It is the loving relation into which
nurse and nursed enter and which they cocre-
ate by living the intention to care. Without the
loving relation of the caring between, unidirec-
tional activity or reciprocal exchange can occur,
but nursing in its fullest sense does not occur.
It is in the context of the caring between that
personhood is enhanced, each expressing self
as caring and recognizing the other as caring
person.
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Dance of Caring Persons
The relational model for organizational design
involving nursing is analogous to the dancing
circle, the dance of caring persons. What this cir-
cle represents is the commitment of each
dancer to understand and support the study of
the discipline of nursing. Core dimensions of
caring illustrated in the dance of caring persons
model include the following:
• Acknowledgment that all persons have the
capacity to care by virtue of their humanness
• Commitment to respect for person in all in-
stitutional structures and processes
• Recognition that each participant in the
enterprise has a unique valuable contribu-
tion to make to the whole and is present in
the whole
• Appreciation for the dynamic though
rhythmic nature of the dance of caring
persons, enabling opportunities for human
creativity
Persons making up the dance of caring per-
sons in any given situation involving nursing
are the one nursed and family, nurses and
other health-care workers, administrative and
support staff, and relevant corporate, govern-
mental, and social communities. Regardless of
the role, the “responsibility of all is to recog-
nize, value, and celebrate the unique ways car-
ing is lived by colleagues, as well as to support
each other in the growth of caring” (Pross,
Hilton, Boykin, & Thomas, 2011, p. 28).
Lived Meaning of Nursing as Caring
Abstract presentations of assumptions and
themes lay the groundwork and provide an ori-
enting point. However, the lived meaning of
nursing as caring can best be understood by the
study of a nursing situation. The following
poem is one nurse’s expression of the meaning
of nursing, situated in one particular experi-
ence of nursing and linked to a general con-
ception of nursing.
I CARE FOR HIM
My hands are moist,
My heart is quick,
My nerves are taut,
He’s in the next room,
I care for him.
The room is tense,
It’s anger-filled,
The air seems thick,
I’m with him now,
I care for him.
Time goes slowly by,
As our fears subside,
I can sense his calm,
He softens now,
I care for him.
His eyes meet mine,
Unable to speak,
I feel his trust,
I open my heart,
I care for him.
It’s time to leave.
Our bond is made,
Unspoken thoughts,
But understood,
I care for him!
—J. M. COLLINS (1993)
Each encounter—each nursing experience—
brings with it the unknown. In reflection, Jim
Collins shares a story of practice that illuminates
the opportunity to live and grow in caring. In
the nursing situation that inspired this poem,
the nurse and nursed live caring uniquely. Ini-
tially, the nurse experiences the familiar human
dilemma, aware of separateness while choosing
connectedness as he responds to a yet unknown
call for nursing: [“My] hands are moist,/my
heart is quick/my nerves are taut . . . I care for
him.” As he enters the situation and encounters
the patient as person, he is able to “let go” of his
presumptive knowing of the patient as “angry.”
The nurse enters with the guiding perspective
that all persons are caring. This allows Nurse
Jim to see past the “anger-filled” room and to
be “with him” (Stanza 2). As they connect
through their humanness, the beauty and
wholeness of one nursed is uncovered and nur-
tured. By living caring moment to moment,
hope emerges and fear subsides. The nurse is-
sues a direct invitation as “I open my heart”
(Stanza 4) to hear that which matters most in
the moment. Through this experience, both
nurse and nursed live and grow in their under-
standing and expressions of caring.
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In the first stanza, the nurse prepares
to enter the nursing relationship with the
formed intention of offering caring in au-
thentic presence. Perhaps he has heard a re-
port that the person he is about to encounter
is a “difficult patient” and this is a part of his
awareness; however, his nursing intention to
care reminds him that he and his patient are,
above all, caring persons. In the second
stanza, the nurse enters the room, experiences
the challenge that his intention to nurse has
presented, and responds to the call for au-
thentic presence and caring: “I’m with him
now,/I care for him.” Patterns of knowing are
called into play as the nurse brings together
intuitive, personal knowing, empirical know-
ing, and the ethical knowing that it is right
to offer care, creating the integrated under-
standing of aesthetic knowing that enables
him to act on his nursing intention (Boykin,
Parker, & Schoenhofer, 1994; Carper, 1978).
Mayeroff’s (1971) caring ingredients of
courage, trust, and alternating rhythm are
clearly evident.
Clarity of the call for nursing emerges as the
nurse begins to understand that this particular
man in this particular moment is calling to be
known as a uniquely caring person, a person of
value, worthy of respect and regard. The nurse
listens intently and recognizes the unadorned
honesty that sounds angry and demanding and
is a personal expression of a heartfelt desire to
be truly known and worthy of care. The nurse
responds with steadfast presence and caring,
communicated in his way of being and of
doing. The caring ingredient of hope is drawn
forth as the man softens and the nurse takes
notice.
In the fourth stanza, the “caring between”
develops and personhood is enhanced as
dreams and aspirations for growing in caring
are realized: “His eyes meet mine . . . I open
my heart.” In the last stanza, the nursing situ-
ation is completed in linear time. But each one,
nurse and nursed, goes forward newly affirmed
and celebrated as caring person, and the nurs-
ing situation continues to be a source of living
caring and growing in caring.
Assumptions Underlying Nursing as
Caring in the Context of the Nursing
Situation
In Collins’s (1993) poem, the power of the
basic assumption that all persons are caring by
virtue of their humanness enabled the nurse to
find the courage to live his intentions. The idea
that persons are whole and complete in the
moment permits the nurse to accept conflict-
ing feelings and to be open to the nursed as a
person, not merely as an entity with a diagnosis
and superficially understood behavior. The
nurse demonstrated an understanding of the
assumption that persons live caring from
moment to moment, striving to know self and
other as caring in the moment with a growing
repertoire of ways of expressing caring. Per-
sonhood, a way of living grounded in caring
that can be enhanced in relationship with car-
ing other, comes through in that the nurse is
successfully living his commitment to caring in
the face of difficulty and in the mutuality and
connectedness that emerged in the situation.
The assumption that nursing is both a disci-
pline and a profession is affirmed as the nurse
draws on a set of values and a developed
knowledge of nursing as caring to actively offer
his presence in service to the nursed.
Nursing practice guided by the theory of
nursing as caring entails living the commit-
ment to know self and other as living caring in
the moment and growing in caring. Living this
commitment requires intention, formal study,
and reflection on experience. Mayeroff’s
(1971) caring ingredients offer a useful starting
point for the nurse committed to knowing
self and other as caring persons. These ingre-
dients include knowing, alternating rhythm,
honesty, courage, trust, patience, humility, and
hope. Roach’s (1992) five Cs—commitment,
confidence, conscience, competence, and
compassion—provide another conceptual
framework that is helpful in providing a lan-
guage of caring. Coming to know self as caring
is facilitated by:
• Trusting in self; freeing self up to become
what one can truly become, and valuing self.
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• Learning to let go, to transcend—to let go
of problems, difficulties, in order to remem-
ber the interconnectedness that enables us
to know self and other as living caring, even
in suffering and in seeking relief from suf-
fering.
• Being open and humble enough to experi-
ence and know self to be at home with one’s
feelings.
• Continuously calling to consciousness that
each person is living caring in the moment
and we are each developing uniquely in our
becoming.
• Taking time to fully experience our human-
ness, for one can only truly understand in
another what one can understand in self.
• Finding hope in the moment. (Schoenhofer
& Boykin, 1993, pp. 85–86)
Applications of
the Theory
Nursing Practice
The nursing as caring theory, grounded in the
assumption that all persons are caring, has as
its focus a general call to nurture persons as
they live caring uniquely and grow as caring
persons. The challenge for nursing, then, is not
to discover what is missing, weakened, or
needed in another but to come to know the
other as caring person and to nurture that per-
son in situation-specific, creative ways. We no
longer understand nursing as a “process” in the
sense of a complex sequence of predictable acts
resulting in some predetermined desirable end
product. Nursing, we believe, is inherently a
process, in the sense that it is always unfolding
and guided by intention.
An everyday understanding of the meaning
of caring is obviously challenged when the
nurse is presented with someone for whom it
is difficult to care. “Difficult to care” situations
are those that demonstrate the extent of knowl-
edge and commitment needed to nurse effec-
tively. In these extreme (although not unusual)
situations, a task-oriented, non–discipline-
based concept of nursing may be adequate to
ensure the completion of certain treatment and
surveillance techniques. Still, in our eyes, that
is an insufficient response—it certainly is not
the nursing we advocate. The theory of nursing
as caring calls on the nurse to reach deep within
a well-developed knowledge base that has been
structured using all available patterns of know-
ing, grounded in the obligations inherent in the
commitment to know persons as caring. These
patterns of knowing may develop knowledge as
intuition; scientifically quantifiable data emerg-
ing from research; and related knowledge from
a variety of disciplines, ethical beliefs, and many
other types of knowing. All knowledge held by
the nurse that may be relevant to understanding
the situation at hand is drawn forward and in-
tegrated into practice in particular nursing sit-
uations (aesthetic knowing). Although the
degree of challenge presented from situation to
situation varies, the commitment to know self
and other as caring persons is steadfast.
All persons are caring, even when not all
chosen actions of the person live up to the ideal
to which we are all called by virtue of our hu-
manness. In discussions of hypothetical situa-
tions involving child molesters, serial killers,
and even political figures who have attempted
mass destruction and racial annihilation, certain
ethical systems permit and even call for making
judgments. However, when such a person pres-
ents to the nurse for care, the nursing ethic of
caring supersedes all other values. The theory
of nursing as caring asserts that it is only
through recognizing and responding to the
other as a caring person that nursing is created
and personhood enhanced in that nursing sit-
uation. Caring effectively in “difficult-to-care”
situations is the most challenging prospect a
nurse can face. It is only with sustained inten-
tion, commitment, study, and reflection that
the nurse is able to offer nursing in these situ-
ations. Falling short in one’s commitment does
not necessitate self-deprecation nor warrant
condemnation by others; rather, it presents an
opportunity to care for self and other and to
grow in personhood. Making real the potential
of such an opportunity calls for seeing with
clarity, reaffirming commitment, and engaging
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in study and reflection, individually and in con-
cert with caring others.
To know the other as caring, the nurse must
find some basis for respectful human connec-
tion with the person. Does this mean that the
nurse must like everything about the person,
including personal life choices? Perhaps not;
however, the nurse as nurse is not called on to
judge the “other,” only to care for the other. A
concern with judging or censuring another’s ac-
tions is a distraction from the real purpose for
nursing—that is, coming to know the other as
caring person, as one with dreams and aspira-
tions of growing in caring, and responding to
calls for caring in ways that nurture person-
hood, that matter to the one nursed.
Nurses are frequently heard to say they have
no time for caring, given the demands of the
role (Boykin & Schoenhofer, 2000). All nurs-
ing roles are lived out in the context of a con-
temporary environment, and the environment
for practice, administration, education, and re-
search is fraught with many challenges. Some
of these challenges are the following:
• technological advancement and prolifera-
tion that can promote routinization and
depersonalization on the part of the care-
giver as well as the one seeking care;
• demands for immediate and measurable
outcomes that favor a focus on the simplistic
and the superficial;
• organizational and occupational configura-
tions that tend to promote fragmentation
and alienation; and
• economic focus and profit motive (“time is
money”) as the apparent prime institutional
value.
Nurses express frustration when evaluating
their own caring efforts against an idealized,
rule-driven conception of caring. Practice
guided by the theory of nursing as caring re-
flects the assumption that caring is created
from moment to moment and does not de-
mand idealized patterns of caring. Caring in
the moment (and from moment to moment)
occurs when the nurse is living a committed
intention to know and nurture the other as car-
ing person (Boykin & Schoenhofer, 2000). No
predetermined ideal amount of time or form
of dialogue is prescribed. Simple examples of
living this intention to care follow.
When the nurse goes first to the person,
rather than going directly to the IV or the
monitor, it becomes clear that the use of tech-
nology is one way the nurse expresses caring
for the person (Schoenhofer, 2001). In propos-
ing his model of machine technologies and
caring in nursing, Locsin (1995, 2001) distin-
guishes between mere technological compe-
tence and technological competence as an
intentional expression of caring in nursing.
Simply avowing an intention to care is not
sufficient; the committed intention to care is
supported by serious study of caring and on-
going reflection if nurses are to communicate
caring effectively from moment to moment. As
Locsin (1995, p. 203) so aptly stated:
as people seriously involved in giving care know, there
are various ways of expressing caring. Professional
nurses will continue to find meaning in their technolog-
ical caring competencies, expressed intentionally and
authentically, to know another as a whole person.
Through the harmonious coexistence of machine tech-
nology and caring technology the practice of nursing
is transformed into an experience of caring.
Another example of living the commitment
to care is witnessed in caring for the uncon-
scious person. How is this commitment lived?
It requires that all ways of knowing be brought
into action. The nurse must make self as caring
person available to the one nursed. The fullness
of the nurse as caring person is called forth.
This requires use of Mayeroff’s caring ingredi-
ents: the alternating rhythm of knowing about
the other and knowing the other directly
through authentic presence and attunement;
the hope and courage to risk opening self to
one who cannot communicate verbally, pa-
tiently trusting in self to understand the other’s
mode of living caring in the moment; honest
humility as one brings all that one knows and
remains open to learning from the other. The
nurse attuned to the other as person might for
example experience the vulnerability of the per-
son who lies unconscious from surgical anes-
thetic or traumatic injury. In that vulnerability,
the nurse recognizes that the one nursed is
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living caring in humility, hope, and trust. In-
stead of responding to the vulnerability, merely
“taking care of” the other, the nurse practicing
nursing as caring might respond by honoring
the other’s humility, by participating in the
other’s hopefulness, by steadfast trustworthi-
ness. Creating caring in the moment in this sit-
uation might come from the nurse resonating
with past and present experiences of vulnera-
bility. Connected to this form of personal
knowing might be an ethical knowing that
power as a reciprocal of vulnerability can de-
velop undesirable status differential in the
nurse–patient role relationship. As the nurse
sifts through myriad empirical data, the most
significant information emerges—this is a
person with whom I am called to care. Ethical
knowing again merges with other pathways as
the nurse forms the decision to go beyond
vulnerability and engage the other as caring per-
son, rather than as helpless object of another’s
concern. Aesthetic knowing comes in the praxis
of caring, in living chosen ways of honoring
humility, joining in hope, and demonstrating
trustworthiness in the moment (Schoenhofer
& Boykin, 1993, pp. 86–87).
A third example of living the intention to
care is evidenced in postmortem care. “Nurses
speak of caring for their deceased patients as
nursing those who have gone and who are still
in some way present” (Boykin & Schoenhofer,
2001a, p. 19). Nurses who practice in end-
of-life situations offer genuine presence, con-
tinue to feel the human connection to the per-
son who has recently died and to the family
circle that is part of that person’s life, and rec-
ognize postmortem care as truly nursing. One
nurse was moved by the beauty of post-mortem
nursing care offered by her colleagues in the
operating room and shared this poetic expres-
sion of connectedness.
Journey’s End
The chaos has stopped,
The journey from birth to death has ceased,
Your body lies on the OR table, alone,
We cluster at the end of the room,
Making the necessary phone calls,
Starting the paperwork,
Telling the young resident:
“Yes, you must complete the paperwork.” And
“Go talk to the family now,”
Then we turn back to you
And begin our reverent and loving care:
Covering your wound, removing the lines,
cleansing your body,
One of us says, “We are being good nurses,”
And another quips back, “It’s because we are
old nurses,”
And we laugh
(But we know we will teach the young ones
how to do this too),
We place you on a stretcher (not the gruesome
morgue gurney)
And take you to the viewing room,
One of us goes and brings your family to you,
Murmuring comfort, “We are so sorry for
your loss.”
After a few minutes, we leave
And return to the OR
To take care of another patient.
—FLORENCE N. COOPER, RN
The nurse practicing within the caring con-
text described here will most often be interfac-
ing with the health-care system in two ways:
first, communicating nursing so that it can be
understood; second, articulating nursing serv-
ice as a unique contribution within the system
in such a way that the system itself grows to
support nursing. Recognizing these system re-
lationships as aspects of the dance of caring
persons involving the nursed and family and
encompassing all who are part of the system is
crucial for creating the kind of environment in
which caring is expressed effectively and per-
ceived as growth-promoting.
Nursing Administration
From the viewpoint of nursing as caring, the
nurse administrator makes decisions through a
lens in which the focus of nursing is on nurtur-
ing persons living caring and grow in caring.
All activities in the practice of nursing admin-
istration are grounded in a concern for creating,
maintaining, and supporting an environment
in which calls for nursing are heard and nur-
turing responses are given. From this point of
view, the expectation arises that nursing ad-
ministrators participate in shaping a culture
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that evolves from the values articulated within
nursing as caring and recognized as the dance
of caring persons.
Although often perceived to be “removed”
from the direct care of the nursed, the nursing
administrator is intimately involved in multiple
nursing situations simultaneously, hearing calls
for nursing and participating in responses to
these calls. As calls for nursing are known, one
of the unique responses of the nursing admin-
istrator is to enter the world of the nursed ei-
ther directly or indirectly, to understand special
calls when they occur, and to assist in securing
the resources needed by each nurse to nurture
persons living and growing in caring (Boykin
& Schoenhofer, 1993). All administrative ac-
tivities should be approached with this goal in
mind. Here, the nurse administrator reflects
on the obligations inherent in the role in rela-
tion to the nursed. The presiding moral basis
for determining right action is the belief that
all persons are caring. Frequently, the nurse
administrator may enter the world of the
nursed through the stories of colleagues who
are assuming another role, such as that of nurse
manager. Policy formulation and implementa-
tion allow for the consideration of unique situ-
ations. The nursing administrator assists others
within the organization to understand the
focus of nursing and to secure the resources
necessary to achieve the goals of nursing.
Nursing Education
From the perspective of nursing as caring, all
nursing structures and activities should reflect
the fundamental assumption that persons are
caring by virtue of their humanness. This view
applies in nursing education as in practice and
administrative role engagement. Other as-
sumptions and values reflected in the education
program include knowing the person as whole
and complete in the moment and living caring
uniquely; understanding that personhood is a
way of living grounded in caring and is en-
hanced through participation in nurturing re-
lationships with caring others; and, finally,
affirming nursing as a discipline and profession.
The curriculum, the foundation of the edu-
cation program, asserts the focus and domain
of nursing as nurturing persons living caring
and growing in caring; thus, all activities of the
program of study are directed toward develop-
ing, organizing, and communicating nursing
knowledge, that is, knowledge of nurturing
persons living caring and growing in caring.
The dance of caring persons relational
model is relevant for organizational design
of nursing education, as well as for nursing
practice. Participants in the dance of caring
persons include administrators, faculty, col-
leagues, students, staff, community, and the
nursed and their families. What the dance of
caring persons represents in nursing education
settings is the commitment of each dancer
to understand and support the study of the
discipline of nursing. The role of educational
administrator in the circle is more clearly un-
derstood through reflection on the origin of
the word. The term administrator derives from
the Latin ad ministrare, to serve (according to
Webster’s New World Dictionary of the American
Language; Guralnik, 1976). This definition con-
notes the idea of rendering service. Administra-
tors within the circle are by the nature of their
role obligated to ministering, to securing, and
to providing resources needed by faculty, stu-
dents, and staff to meet program objectives.
Faculty, students, and administrators dance to-
gether in the study of nursing. Faculty support
an environment that values the uniqueness
of each person and sustains each person’s
unique way of living and growing in caring.
This process requires trust, hope, courage, and
patience. Because the purpose of nursing edu-
cation is to study the discipline and practice of
nursing, the nursed must be in the circle. The
community created is that of persons living car-
ing in the moment and growing in personhood,
each person valued as special and unique.
(Boykin & Schoenhofer, 1993, pp. 73–74)
In teaching nursing as caring, faculty assist
students to come to know, appreciate, and
celebrate self and “other” as caring persons.
Students, as well as faculty, are in a continual
search to discover greater meaning of caring as
uniquely expressed in nursing. Examples of a
nursing education program based on values
similar to those of nursing as caring are illus-
trated in the book Living a Caring-based
Program (Boykin, 1994).
350 SECTION V • Grand Theories about Care or Caring
3312_Ch19_341-356 26/12/14 9:17 AM Page 350
Nursing Research and Development
The roles of researcher and developer in nurs-
ing take on a particular focus when guided by
the theory of nursing as caring. The assump-
tions and focus of nursing explicated in the
theory provide an organizing value system that
suggests certain key questions and methods.
Research questions lead to exploration and
illumination of patterns of living caring per-
sonally (Schoenhofer, Bingham, & Hutchins,
1998) and in nursing practice (Schoenhofer
& Boykin, 1998b). Dialogue, description, and
innovations in interpretative approaches char-
acterize research methods. Development of
systems and structures (e.g., policy formula-
tion, information management, nursing deliv-
ery, and reimbursement) to support nursing
necessitates sustained efforts in reframing
and refocusing familiar systems as well as
creating novel configurations (Schoenhofer,
1995; Schoenhofer & Boykin, 1998a; Boykin,
Schoenhofer, & Valentine, 2013).
The practicality of the theory of nursing as
caring has been tested in various nursing
practice settings. Nursing practice models
have been developed in acute and long-term
care settings. Research studies focused on
designing, implementing and evaluating a
theory-based practice model using nursing as
caring on a telemetry unit of a for-profit hos-
pital (Boykin, Schoenhofer, Smith, St. Jean,
& Aleman, 2003); the emergency department
of a community hospital (Boykin, Bulfin,
Baldwin, & Southern, 2004; Boykin, Schoen-
hofer, Bulfin, Baldwin, & McCarthy, 2005);
and the intensive care unit of a for-profit hos-
pital (Dyess, Boykin, & Bulfin, 2013) have
demonstrated that when nursing practice is
intentionally focused on coming to know a
person as caring and on nurturing and support-
ing those nursed as they live their caring, trans-
formation of care occurs. Within these practice
models based on nursing as caring, those
nursed could articulate the “experience of being
cared for”; patient and nurse satisfaction in-
creased dramatically; nurse retention increased;
and the environment for care became grounded
in the values of and respect for person.
Touhy, Strews, and Brown (2005) described
a project to transform an entire for-profit
health-care organization by intentionally
grounding it in nursing as caring. Caring from
the heart—the model for interdisciplinary prac-
tice in a long-term care facility and based on
the theory of nursing as caring—was designed
through collaboration between project person-
nel and all stakeholders. Foundational values of
respect and coming to know ground the model,
which revolves around the major themes of
responding to that which matters, caring as a
way of expressing spiritual commitment, devo-
tion inspired by love for others, commitment to
creating a home environment, and coming to
know and respect person as person (2005). The
major building blocks of the nursing model for
an acute care hospital and for a long-term care
facility each reflect central themes of nursing
as caring, but those themes are drawn out in
ways unique to the setting and to the persons
involved in each setting. The differences and
similarities in these two practice models demon-
strate the power of nursing as caring to trans-
form practice in a way that reflects unity without
conformity, uniqueness within oneness.
CHAPTER 19 • Theory of Nursing as Caring 351
PRACTICE EXEMPLAR
Nursing administration, nursing practice, nurs-
ing education, and nursing research require a
full understanding of nursing as nurturing per-
sons living caring and growing in caring. This
online supplemental resource for this chapter
contains four practice exemplars, illustrating
the use of the nursing as caring theory to guide
practice in nursing administration, clinical
simulation laboratory in nursing education,
and nursing research.1 The exemplars were
drawn from the practice experience of the
nurses who wrote them, and most illustrate
stories of actual nursing situations. A nursing
administration exemplar addresses health-care
Continued
1For additional practice exemplars please go to bonus
chapter content available at FA Davis http://davisplus
.fadavis.com
3312_Ch19_341-356 26/12/14 9:17 AM Page 351
352 SECTION V • Grand Theories about Care or Caring
Practice Exemplar cont.
system leadership and caring. The nursing ed-
ucation exemplar illustrates the use of the sim-
ulation laboratory in teaching nursing from the
perspective of nursing as caring. Two research
exemplars are also provided online, one focus-
ing on the development of a research approach
compatible with nursing as caring, and a
second addressing the use of nursing as caring
as the nursing theoretical perspective under-
pinning a doctoral dissertation study. The
following advanced practice nursing exemplar
illuminates advanced nursing practice grounded
in nursing as caring.
Advanced Nursing Practice Exemplar:
Primary Care Clinic Grounded in
Nursing as Caring
Two nurse practitioners, Kathi Voege Harvey,
FNP, and Elizabeth Tsarnas, FNP, whose
practice setting is a primary care clinic, shared
their way of creating nursing as caring in a
community-based program of nursing for per-
sons living with diabetes.
Our primary care clinic serves the popula-
tion of patients who are considered the under-
served and fall within the lower socioeconomic
level, including those individuals labeled by
society as the working poor, uninsured, unem-
ployed, illiterate, disabled, homeless, and re-
cent migrants from many parts of the world.
This vulnerable population creates greater
challenges, yet we are empowered by our dis-
ciplinary view of the theory of nursing as car-
ing to deliver quality and evidence-based
health care to all who come.
Call for Nursing
As a result of our observation that individuals
with diabetes struggled to incorporate a dia-
betic-friendly diet and exercise into their
lifestyles, we developed a collaborative program
that brought experts in nursing and fitness to-
gether in a world outside of the clinic setting.
This innovative program supports participants
in their endeavor to develop a new health-care
plan through an exercise, education, and
support-group curriculum. The first group to
be formed was limited to women because the
lived experiences of some of the early partici-
pants were very “fragile” and dealt with personal
issues such as domestic violence and depres-
sion. As these women’s personhood and their
struggle with obesity and diabetes emerged, we
felt a need to protect them in this, their first
venture of sharing. These women’s lives had
been grounded in caring, but circumstances
seemingly beyond their control had affected
their personhood. A safe, nurturing relation-
ship with other caring individuals was needed
to allow them to trust and grow again.
Nursing Situation
One of the champions of this program, named
BP, a 42-year-old woman, was diagnosed with
insulin-dependent diabetes 10 years ago. Be-
cause of the rapid progression of her disease
process, she had bilateral arterial bypass sur-
gery that resulted in limited mobility. BP took
a 2-year sabbatical from our clinic and has re-
cently returned. She had been without med-
ications and supplies for months, which
increased the neuropathic pain to her lower
extremities. She also shared with us that she
was under increased stress while preparing for
her upcoming wedding. Our conversations
would always include the importance of look-
ing into the future at 10, 20, and 30 years to
visualize the many disabilities she could de-
velop within that time which would reduce her
quality of life and how she could alter that
future. Over the past several months, she has
taken control of her disease by checking her
sugars more often and regularly taking her in-
sulin. She married a month ago and noticed
that her husband, KP, had symptoms of dia-
betes. After checking his blood sugar, which
consistently was very elevated, she brought
him to the clinic to receive health care. Her
enthusiasm for improving her heath was con-
tagious, and she was excited that she could
share her journey with her new husband.
Several weeks later, BP introduced us
to her mother-in-law, SP, who has prediabetes
and with whom BP, her new husband, and her
young nephew were living. SP was feeling like
she could not take control of her life, so she
3312_Ch19_341-356 26/12/14 9:17 AM Page 352
CHAPTER 19 • Theory of Nursing as Caring 353
Practice Exemplar cont.
was referred to us for evaluation, and we
invited her to join our group of women. One
evening after a support group, which BP and
her mother-in-law attended, we walked them
to the front of the building where they met
BP’s husband, who had been exercising in the
gym, and his nephew, who was only 12 years
old and had been abandoned by his natural
parents. As we introduced ourselves to this
shy, very thin, 12-year-old young man, we en-
gaged him in conversation so that we could
come to know him. We learned that he had
been made to come but was angry because he
was too young to be in the gym. His grand-
mother had previously confided in us that he
did not have any friends or participate in any-
thing and that he was beginning to have anger
outbursts. We identified yet another call for
nursing and decided to explore possible sports
or activities in which this young man would
like to participate. After some investigation,
we were able to include him in an adolescent
“boot camp” that met at the same time as his
family’s exercise classes and also a soccer team
right on the premises. As he experiences car-
ing through nurturing with his family and us,
it is our hope that his fears will subside and
allow him to realize the beauty of his unique-
ness and his boundless potential.
In this situation BP’s nurturing lived expe-
rience enabled her to enhance her personhood
and touch the lives of those she loved in a way
that she had been touched. BP was living in
caring and growing in caring, and the com-
pleteness she experienced empowered her to
care for others, like her family, so that they too
could be whole and complete in the moment.
Nursing Response
All persons are caring by virtue of their human-
ness. As nurses, we readily recognize calls for
nursing that others might easily miss. Our per-
sonhood as nurses grounded in caring and
equipped with the wisdom of knowledge about
nurturing relationships and human well-being
that we have pursued passionately through our
advanced education arm us with the confidence
to be intentionally and authentically present
with others in their situations of concern. We
feel comfortable to respond to calls for nursing
without preplanned protocols or preconceived
solutions because we are responding uniquely
to each situation with the “other” with the in-
tention to communicate caring and commit-
ment to work with them to achieve their goals.
Our nursing situation with the P family
began with one member, who sought help to
improve her health, which had been ravaged
by diabetes. Over time, the loving relationship
of “caring between” developed among BP, her
nurse practitioners, her trainer, and her class-
mates. Boundaries of roles disappeared in this
relationship, and BP began to experience
wholeness and completeness in the moment
that was so healing that she invited her family
members into her dance of caring persons so
that they, too, could experience well-being.
We have all grown through this lived experi-
ence, and as nurse practitioners, our way of liv-
ing grounded in caring has been reaffirmed.
Lived Meaning of Nursing As Caring
A patient first enters the doors of our free clinic
appearing as an unopened rosebud with many
thorns. The closed bud represents security and
protection from the unknown. Many who have
limited exposure to a health-care system enter
our world with fear of what will be discovered
and doubts about the competency of those giv-
ing something without cost. The thorns repre-
sent the patients’ defense system if they should
encounter threats to their safety. The rose
petals gradually begin to open as the patient ex-
periences each caring moment through the au-
thentic presence of the nurse whose intention
is to promote health and healing through phys-
ical, emotional, and spiritual discovery and
restoration. After the rose completely opens
and the thorns soften, the patient begins an ac-
ceptance process, and true healing begins. Each
room within the clinic resembles a beautiful
vase that is full of roses of all shapes, sizes, and
colors, representing the uniqueness of each in-
dividual the nurse encounters. Others within
the room help to achieve the same goals as the
nurses and caregivers and represent oxygen,
Continued
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354 SECTION V • Grand Theories about Care or Caring
Practice Exemplar cont.
sunlight, and water needed to foster growth
and strength. Reflecting on the beauty and
uniqueness of each rose prepares the nurse for
a new unopened rosebud.
Ways of Knowing
Although we must be skilled in both science
and clinical experience, the nurse is always
nurturing and growing in caring to provide a
new dimension of healing that allows us to
enter the patient’s world to experience and
understand their needs in a way that is more
than just a prescription or treatment modal-
ity. This story reinforces the requisite not
only to have the knowledge to properly treat
the disease process but also to offer encour-
agement through dialogue and physical avail-
ability to help patients engage in exercise,
classroom instruction, and healthy behaviors
that produce positive results in patient out-
come measures.
Personally, as we listened to the stories of all
of the participants in this program, we realized
how lucky we were to experience this intensely
caring bond between what once were patients
and nurse practitioners and now were persons,
whole and complete in the moment. We came
to realize that our ability to care for others living
with chronic illnesses was being viewed through
a much more realistic lens. We had always
known that changes in lifestyle to improve
health outcomes were difficult to implement,
no matter how much clinical sense they made.
But dwelling in the moment with these women
who were struggling to maintain well-being
while life just kept happening and who were
still able to lose weight, decrease their medica-
tions, and make difficult decisions about their
lives as our “caring between” relationship
evolved, made us realize that wherever we are,
whatever we do, we never stop caring, and we
never stop being nurses. As others who oversaw
this pilot program began to express amazement
at what we saw as nursing, we knew our secret
was out: Others in the community were begin-
ning to identify nursing as caring, and one by
one they asked to join in the dance of caring
persons.
The nurse administrator is subject to chal-
lenges similar to those of the practitioner and
often walks a precarious tightrope between
direct caregivers and corporate executives
(Boykin & Schoenhofer, 2001b). The nurse
administrator, whether at the executive or
managerial level of the organization chart, is
held accountable for “customer satisfaction”
as well as for the “bottom line.” Nurses who
move up the executive ladder may be sus-
pected of disassociating from their nursing
colleagues on the one hand and of not being
sufficiently cognizant of the harsh realities of
fiscal constraint on the other hand. Admin-
istrative practice guided by the assumptions
and themes of nursing as caring can enhance
eloquence in articulating the connection be-
tween caregiver and institutional mission: the
person seeking care. Nursing practice leaders
who recognize their care role, indirect as it
may be, are in an excellent position to act on
their committed intention to promote caring
environments. Participating in rigorous ne-
gotiations for fiscal, material, and human re-
sources and for improvements in nursing
practice calls for special skill on the part of
the nurse administrator, skill in recognizing,
acknowledging, and celebrating the other
(e.g., CEO, CFO, nurse manager, or staff
nurse) as a caring person. The nurse admin-
istrator who understands the caring ingredi-
ents (Mayeroff, 1971) recognizes that caring
is neither soft nor fixed in its expression. A
developed understanding of the caring ingre-
dients helps the nurse administrator mobilize
the courage to be honest with self and
“other,” to trust patience, and to value alter-
nating rhythm with true humility while living
a hope-filled commitment to knowing self
and “other” as caring persons.
Health Care System Transformation for
Nursing and Health Care Leaders: Implement-
ing a Culture of Caring (Boykin, Schoenhofer,
& Valentine, 2013) proposes practical strate-
gies for total, integrated system transforma-
tion based on the tenets of the dance of caring
persons and grounded in the assumptions of
3312_Ch19_341-356 26/12/14 9:17 AM Page 354
CHAPTER 19 • Theory of Nursing as Caring 355
Practice Exemplar cont.
nursing as caring. Many of the challenges of
nurse managers and nurse administrators as
well as those experienced by other health-
care system leaders are currently being ad-
dressed by the Institute of Medicine, the
Joint Commission, and other health policy
groups. Solutions implied in the Hospital
Consumer Assessment of Healthcare Providers
and Systems are congruent with the values of
nursing as caring and are amplified and given
substance by specific assumptions and con-
cepts of nursing as caring.
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■ Summary
The theory of nursing as caring is grounded in
assumptions that persons are caring by virtue
of their humanness, that caring unfolds mo-
ment to moment, that personhood is living
grounded in caring, and that personhood is en-
hanced in relationships with caring persons.
From that basic philosophical perspective, the
focus of nursing as a discipline and a profes-
sional practice is nurturing persons living car-
ing and growing in caring. The nurse enters
into the world of the other with the intention
of knowing the other as person living caring
and growing in caring. In authentic presence,
the nurse offers a direct invitation to the one
nursed to express what matters most in the
situation. In nursing situations, shared lived
experiences of caring, the nurse hears calls for
caring and creates effective caring responses.
In the caring between nurse and nursed, per-
sonhood is enhanced.
The theory of nursing as caring is used by
practitioners and administrators of nursing
services in a range of institutional and commu-
nity-based nursing practice settings. The the-
ory is also used to guide nursing education,
nursing education administration and nursing
research. More detailed information about the
theory, an extensive bibliography, and exam-
ples of use of the theory are available at http://
nursingascaring.com.
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Section VI
Middle-Range Theories
357
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358
Twelve middle-range theories in nursing are presented in the final section. Each
chapter is written by the scholars who developed the theory. Although we deter-
mine all to be at the middle range because of their more circumscribed focus on
a phenomenon and more immediate relationship to practice and research, they
still vary in level of abstraction.
Transitions are part of the human experience, and how we negotiate these
transitions affects health and well-being. Afaf Meleis’ transitions theory appears
in Chapter 20. The theory includes the elaboration of transition triggers, properties
of transitions, the conditions of change, and patterns of responses to transitions.
Nursing interventions to promote a smooth passage during transitions are
described.
Comfort is an important concept to nursing practice. Kolcaba’s middle-range
theory of comfort is presented in Chapter 21. She defines comfort as “to
strengthen greatly” and identifies relief, ease, and transcendence as types of com-
fort, and physical, psychospiritual, environmental, and sociocultural as contexts
in which comfort occurs.
Duffy’s quality-caring model, described in Chapter 22, is being used in many
health-care settings to address the issues of patient satisfaction, including patients’
perceptions of not feeling cared for in the acute care environment. In this model
the goal of nursing is to engage in a caring relationship with self and others to
engender feeling “cared for.”
Reed’s theory of self-transcendence is presented in Chapter 23. The focus of
the theory is on facilitating self-transcendence for the purpose of enhancing well-
being. Reed defines self-transcendence as the capacity to expand the self-bound-
ary intrapersonally (toward greater awareness of one’s beliefs, values, and
dreams), interpersonally (to connect with others, nature, and surrounding environ-
ment), transpersonally (to relate in some way to dimensions beyond the ordinary
and observable world), and temporally (to integrate one’s past and future in a
way that expands and gives meaning to the present).
Smith and Liehr present story theory in Chapter 24. They posit that story is a
narrative happening wherein a person connects with self-in-relation through nurse–
person intentional dialogue to create ease. This theory has already been applied
in a number of practice and research initiatives.
Parker and Barry’s community nursing practice model has guided nursing prac-
tice in community settings in several countries. The model is represented by con-
centric circles with the nursing situation as core and connected with the outer
spheres of influence in the community and environment.
Chapter 26 contains Locsin’s theory of technological competency-caring. This
theory dissolves the artificial and often assumed dichotomy between technology
and caring, and asserts that technology is a way of coming to know the person
as whole.
Ray and Turkel authored Chapter 27 on Ray’s theory of bureaucratic caring.
The theory uses a multidimensional, holographic model to facilitate the under-
standing of caring within complex healthcare environments.
In Chapter 28 Troutman-Jordan describes her theory of successful aging. The
theory was informed by Roy’s adaptation model and Tornstam’s theory of gero-
transcendence. Successful aging is characterized by living with meaning and
Section
VI Middle-Range Theories
358
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359
purpose. Intrapsychic factors, functional performance and spirituality contribute
to gerotranscendence and successful aging.
Elizabeth Barrett details her theory of power as knowing participation in
change in Chapter 29. This middle range theory is derived from Rogers’ science
of unitary human beings. Barrett identifies the dimensions of power as: awareness,
choices, freedom to act intentionally, and involvement in creating change.
In Chapter 30 Smith presents her theory of unitary caring. The theory evolved
from viewing caring through the lens of Rogers’ science of unitary human beings.
The concepts of the theory are: manifesting intentions, appreciating pattern, at-
tuning to dynamic flow, experiencing the Infinite and inviting creative emergence.
In Chapter 31 Swanson describes her trajectory and the process of developing
of her middle-range theory of caring from research. The chapter provides insight
to the evolution of theory. Swanson’s theory of caring includes the concepts of
knowing, being with, doing for, enabling, and maintaining belief.
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Chapter 20Transitions Theory
AFAF I. MELEIS
Introducing the Theorist
Overview of the Theory
Application of the Theory
Practice Exemplar by Diane Gullett
Summary
References
Afaf I. Meleis
361
Introducing the Theorist
Dr. Afif I. Meleis is a Professor of Nursing and
Sociology and the former Margaret Bond
Simon Dean of Nursing at the University of
Pennsylvania School of Nursing and the former
Director of the School’s WHO Collaborating
Center for Nursing and Midwifery Leadership.
Before coming to Penn, she was a Professor on
the faculty of nursing at the University of
California Los Angeles and the University of
California San Francisco for 34 years. She is a
Fellow of the Royal College of Nursing in the
United Kingdom, the American Academy
of Nursing, and the College of Physicians of
Philadelphia; a member of the Institute of
Medicine, the George W. Bush Presidential
Center Women’s Initiative Policy Advisory
Council, and the National Institutes of Health
Advisory Committee on Research on Women’s
Health; a Board Member of the Consortium of
Universities for Global Health; and cochair of
the IOM Global Forum on Innovation for
Health Professional Education and the Harvard
School of Public Health-Penn Nursing-Lancet
Commission on Women and Health. Dr.
Meleis is also President Emerita and Counsel
General Emerita of the International Council
on Women’s Health Issues and the former
Global Ambassador for the Girl Child Initiative
of the International Council of Nurses.
Dr. Meleis’s research scholarship is focused
on the theoretical development of the nursing
discipline, structure and organization of nurs-
ing knowledge, transitions and health, and
global immigrant and women’s health. She is
the originator of the transitions theory, a central
concept of nursing phenomenon. This theory
continues to be translated into policy, research,
3312_Ch20_357-380 26/12/14 6:00 PM Page 361
and evidence-based practice and better quality
care in the 21st century.
She has mentored hundreds of students,
clinicians, and researchers from around the
world who, under her guidance, have achieved
prominent leadership positions. She is the au-
thor of more than 175 articles in social sci-
ences, nursing, and medical journals; more
than 40 chapters; 7 books; and numerous
monographs and proceedings. Her award-
winning book, Theoretical Nursing: Develop-
ment and Progress, now in its 5th edition (1985,
1991, 1997, 2007, 2012), is used widely
throughout the world.
Overview of Transition Theory
A patient is admitted to the hospital; another
is being discharged to a home, to a rehabilita-
tion center, or to an assisted living facility; a
third has just been diagnosed with a life-
threatening disease; a fourth is preparing for
an intrusive surgery; a fifth just got the news
that her spouse has a long-term illness, and
finally, a sixth is a new graduate from a nursing
school beginning his first position as a nurse.
What do they all have in common? Each
of these scenarios is about the experience and
responses of patients, families to health and
illness situations; the experience of coping with
changes from one phase, site, identity, posi-
tion, role, or situation to another. The change
event itself—whether it is birthing a baby, start-
ing a new position, receiving a life-changing
diagnosis, facing impending death, hospital-
ization, or surgery—is a turning point, but the
experience is more fluid and longitudinal. The
transition experience starts before the event
and has an ending point that is fluid, that
varies based on many variables. Understand-
ing the nature of and responses to change, fa-
cilitating and supporting the experience and
responding to it at different phases, and re-
maining or becoming healthy before, during or
at the end of the event, wherever that elusive
ending point is, is what transitions theory is
about. This theory provides a framework to
generate research questions and to serve as a
guide to effective nursing care before, during,
and after the transition.
Origins of the Theory
Three paradigms guided the development of
transitions theory in more than 40 years of clin-
ical research and theoretical work. The first is role
theory, a dynamic and interactionist paradigm
developed by Dr. Ralph Turner, whom I con-
sider the father of interactive role theory. Role
theory framed the type and nature of questions
about how to help patients, clients, and families
in their transition from one role to another, how
to take on a new role, or change behaviors in a
role. I wondered about the mechanisms and the
processes that new mothers and fathers learned
and negotiated as they become adept at per-
forming the behaviors of parenting, at picking
up the cues that differentiate the meaning of the
different crying episodes or different patterns of
sleep. From that theoretical heritage, I devel-
oped a framework for intervention that I called
role supplementation (Meleis, 1975). This frame-
work requires the nurse to accurately analyze the
goals, sentiments, and behaviors necessary for
the role he or she wishes to help the client de-
velop. Such roles might include parenting roles,
patient roles, or wellness roles. The desired out-
come of applying role theory is the client’s mas-
tery of the role. Nurses help people acquire or
change roles by modeling behaviors, allowing
their clients to rehearse roles, and providing
them with support while they are developing
these roles.
A second paradigm that influenced the de-
velopment of transitions theory is the lived ex-
perience, which contrasts the perceived views
with the received views. As we, in nursing, began
questioning what we know and how we know it,
it became apparent that other ways of knowing
(Carper, 1978) that complement and, perhaps,
transcend empirical knowing. This personal, ex-
periential knowing is by its nature subjective. It
is more holistic and encompassing, embedded in
practice, and framed by history. On the basis of
the writing of many illuminating nonnurse au-
thors (Polanyi, 1962) and nurse authors (among
them Benner, Tanner, & Chesla, 1996;
Munhall, 1993; Sarvimaki, 1994), I described
the perceived view (Meleis, 2012) and used it as
a driving paradigm for the development of the
concept of transitions (Chick & Meleis, 1986).
This paradigm helped us focus on questions
362 SECTION VI • Middle-Range Theories
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related to the nature and lived experience of the
response to change and the experience of being
in transition.
The third paradigm that informs transitions
theory is that of feminist postcolonialism. The
tenets of this paradigm encompass an epis-
temic system that questions power relation-
ships in societies and institutions and that links
societal and political oppressions that shape
the responses to change events. This paradigm
gave us a framework for understanding the ex-
perience of transition through the multiple
lenses of race, ethnicity, nationality, and gen-
der. Each of these qualities creates power dif-
ferentials that must be considered if we truly
want to understand how people experience and
cope with transition and to provide preventive
and therapeutic interventions to help them
achieve health and wellness outcomes. Using
a feminist postcolonialist framework helps us
consider the conditions shaped by power in-
equities in a society or in institutions of healing
(e.g., hospitals, nursing homes, community
agencies) and how these power inequities can
shape the allocation of resources as well as the
provision of nursing care through transitions.
The delineation of conditions surrounding the
transition experience was illuminated by em-
ploying a feminist postcolonialist framework.
These three paradigms—roles theory, per-
ceived views on lived experiences, and femi-
nist postcolonialism—shaped the evolution of
transitions theory through some 40 years of
its development.
Assumptions of the Theory
• A human being’s responses are shaped by
interactions with significant others and
reference groups.
• Change through health and illness events
and situations trigger a process that begins at
or before and extends beyond the event time.
• Whether aware or not aware, individuals
and/or families experience a process trig-
gered by changes with varied responses and
outcomes.
• Outcomes of the experience of the transition
are shaped by the nature of the experience.
• Preventative and therapeutic actions can
influence outcomes.
• Individuals have the capacity to learn
and enact new roles influenced by their
environment..
• By producing critical and well-supported
evidence, inequities in health care can be
changed to more equitable systems of
delivery.
• Gender, race, culture, heritage, and sexual
orientation are contexts that shape people’s
experiences and outcomes of health–illness
events as well as the health care provided.
• Nursing perspective is defined by humanism,
holism, context, health, well-being, goals,
and caring.
• Environment is defined as physical, social,
cultural, organizational, and societal and
influences experience, interventions, and
outcomes.
• Individuals, families, and communities are
partners in the care processes.
Concepts and Propositions of
Transitions Theory
The transitions theory provides a framework to
describe the experience of individuals who are
confronting, living with, and coping with an
event, a situation, or a stage in growth and de-
velopment that requires new skills, sentiments,
goals, behaviors, or functions. Transition is
defined as “a passage from one life phase, con-
dition, or status to another” (Chick & Meleis,
1986). It is a complex and multifaceted con-
cept embracing several components, including
process, time span, and perception.1
CHAPTER 20 • Transitions Theory 363
1This section of the chapter borrows heavily from the
many publications about this theory, which evolved and
was transformed by many mentees and collaborators
over the years (Chick & Meleis, 1986; Schumacher &
Meleis, 1994; Meleis, Sawyer, Im, et al., 2000; and Meleis,
2010). Without the partnerships, the co-authorship, and
collaboration of many mentees, I would not have been
able to develop transitions theory. It is an integration
of all the previous writings about transition theory.
Their influence is manifested in the many co-authored
publications. Among my mentee collaborators are
Drs. DeAnne Messias, Eun-Ok Im, Kathy Dracup,
Linda Sawyer, Karen, Schumacher, Pat Jones, Norma
Chick, Leslie Swendsen, and Patrician Tragenstein.
While I acknowledge and respect the co-opted contribu-
tions of all my collaborators, the liberty I have taken in
integrating the theory from all previous work is entirely
my responsibility.
3312_Ch20_357-380 26/12/14 6:00 PM Page 363
Transition Triggers
Four types of situations trigger a transition expe-
rience (Fig. 20-1). All are characterized by some
type of change. Change is related to an external
event while transition is an internal process
(Chick & Meleis, 1986). The first trigger is a
change in health or an illness situation that could
initiate a diagnosis or an intervention process,
particularly the kinds that require prolonged di-
agnostic procedures or treatment protocols, for
example, cancer, schizophrenia, autism, diabetes,
or Alzheimer’s disease, among others. Each of
these diagnoses is preceded by many unknowns,
uncertainties about the processes that follow, and
fears about consequences. They all also require
new behaviors, resources, and coping strategies,
and they involve sets of relationships, newly es-
tablished, changed, or severed.
A second trigger is developmental transi-
tions, which are exemplified by life phases as
manifested by age (e.g., adolescence, aging,
menopause) or by roles (e.g., mothering, father-
ing, marrying, divorcing). Developmental tran-
sitions influence the health and well-being of
people and may or may not require interfacing
with health-care professionals and the health-
care system. Developmental phases and roles in-
fluence health and illness behaviors as well as
inform the responses of individuals to such events
as birthing, breastfeeding, among many others.
These examples of developmental transitions are
of interest to nursing because of the evidence in
the literature that demonstrates how nurses deal
with, what they write about and research, as well
as how they care for individual health-care needs
during the many phases in their development.
Similarly, the third change trigger for a
transition is what we call situational transi-
tions, all of which have health-care implica-
tions. These are exemplified by experiences
and responses to situational changes such as
the admission to or discharge from a hospital
or rehabilitation institution, as well as the
changes that a new graduate nurse experi-
ences becoming a manager or an expert or
that a student nurse learning the ropes of his
or her first clinical rotation experiences at a
new hospital.
364 SECTION VI • Middle-Range Theories
Time span
Process
Disconnectedness
Awareness
Critical points
Properties
Intervention
Personal
Community
Society
Global
Change Triggers
Developmental
Situational
Health-illness
Organizational
Patterns of Response
Process
Engaging
Locating and
being situated
Seeking and
receiving support
Acquiring
confidence
Outcome
Mastery
Fluid and
integrative identity
Resourcefulness
Healthy interaction
Perceived
well-being
• Clarify roles,
competencies,
and meanings
• Identify milestones
• Mobilize support
• Debrief
Modified from Transitions: A Middle-Range Theory,
Meleis, Sawyer, Im, Messias, Schumacher, 2000)
Conditions
TherapeuticPreventitive
Fig 20 • 1 Transitions: A middle-range theory. Modified from Meleis, A.I., Sawyer, L., Im, E., Schumacher, K., and
Messias D. (2000). Experiencing transitions: An emerging middle range theory. Advances in Nursing Science, 23(1), 12.
3312_Ch20_357-380 26/12/14 6:00 PM Page 364
The fourth type of change trigger that starts
a process of transition is linked to organizational
rules and functioning (Schumacher & Meleis,
1994). There are many examples of organiza-
tional transitions: the arrival of a new chief ex-
ecutive officer, chief nursing officer, or any other
new leader; the implementation of electronic
health records; a different system of care; use of
new technology throughout an organization; or
moving nursing practice to the community. The
experience of transition here is for a whole or-
ganization as opposed to individuals or families.
Properties of Transition
Besides a triggering change event, transitions
are characterized by properties that we de-
scribed in 1986 (Chick & Meleis 1986; see
Table 20-1). The first is a time span, which
could begin from the moment an event or a sit-
uation comes to the awareness of an individual.
It could be a symptom, a diagnosis, an emer-
gency room visit, a flood, an earthquake, an ac-
cident, or a decision to undergo surgery. Unlike
its beginning, the end of a transition is fluid. The
end may be determined when a final goal is
achieved, be it mastery of new roles, developing
certain competencies, feeling a sense of well-
being, or acquiring a desired quality of life.
Another property that defines transition is
that it is a process. The change event itself is
static, but the experience that ensues is a dynamic
and fluid process. The distance between the be-
ginning of this process and when it exactly ends
may correspond with other similar processes or
may be unique. Bridges (1980, 1991) character-
ized the process following change events as re-
quiring at first an ending period followed by an
experience of confusion or a neutral period fol-
lowed by a period he calls the new beginning.
That is when the process is completed.
Disconnectedness is an additional character-
istic of transition. Whether the triggering change
is health related, developmental, situational, or
organizational, one of the properties of the tran-
sition experience is a sense of impending or actual
disconnectedness. A clear example is the imple-
mentation of electronic health records in a school
or hospital. Those who will be experiencing the
change will manifest responses that could reflect
a level of disconnect from their current mode of
recording patients’ health data and maintaining
continuity in patients’ files. The transition expe-
rience reflects a disruption in a person’s feeling
of security associated with what is known and fa-
miliar. There is a sense of loss—of familiar sign-
posts, reference points, or state of health—and a
feeling of incongruity between past, present, and
future expectations. Those who are responding
to the change experience a discontinuity of reg-
ular patterns disrupted by the unfamiliar.
Another important property of transitions is
awareness—awareness of the change event, of
the situation, of triggers, and of the internal ex-
perience of transition. The difference between
change and transition is the difference between
external and internal experience. Perception,
awareness, and the defining and redefining of
the meaning of the change for the self and others
are properties of a transition experience. They
make transition dynamic, incorporating meaning
and changing interpretation over a span of time.
The presence of milestones that may be turn-
ing points is yet another property of transitions.
Identifying milestones is essential to under-
standing the phases in the transition experience
as well as to identifying the appropriate assess-
ment points and intervention points. The goals
of transition theory are to describe triggers, to
anticipate experience, to predict outcomes, and
to provide guidelines for interventions.
Conditions of Change
Change triggers initiate a process with patterns
of responses that are both observable and
nonobservable behaviors and either functional or
dysfunctional. These responses start from the
moment a change trigger is anticipated and are
influenced by personal, community, societal, or
global conditions. Among the personal condi-
tions are the meaning and the values attributed
to the change and the context of it. A person’s
experience and responses are also influenced by
the expectations of how self or others will react,
CHAPTER 20 • Transitions Theory 365
• Time
• Process
• Experiences
• Milestones
• Conditions
Table 20 • 1 Concepts
3312_Ch20_357-380 26/12/14 6:00 PM Page 365
the level of knowledge and skills related to the
change, and the belief about what is expected of
those undergoing the change. Other personal
conditions that influence the experience and re-
sponses are the level of planning and the level of
existing health and well-being of the person, the
family, the organization, the community, or the
country at large (Schumacher & Meleis, 1994).
In addition, the responses are mediated by the
level of vulnerability and sense of marginaliza-
tion those experiencing the transition find them-
selves in or are subjected to (Hall, Stevens, &
Meleis, 1994; Stevens, Hall, & Meleis, 1994).
Community conditions, such as support from
partners and the availability of role models and
resources, promote or inhibit effective healthy
transitions. Community norms about and re-
sources for dealing with sexism, homophobia,
poverty, ageism, and nationalism also could pro-
mote or inhibit healthy experiences and out-
comes of transitions. Global conditions that
could influence the experience of transitions, in-
cluding policies and mandates developed by in-
ternational organizations, define how certain
triggers are viewed and appear at the global con-
sciousness. For example, the transition of the
HIV/AIDS patient through the diagnosis and
treatment process could be mediated by the
global attention and resources that have been
given to researchers, clinicians, and patients who
have or are associated with the disease. There are
vast differences between how infected individu-
als experienced the diagnosis and treatment of
HIV/AIDS before the global attention to it and
post–President’s Emergency Plan for AIDS Re-
lief aid offered by the Western world.
Patterns of Responses
How do individuals, families, and organizations
respond to a change event? What questions
should be asked to define and understand their
responses? This is an area of knowledge that is
ripe for systematic investigation. Many theories
can describe responses. Among them are grief
theories (Kübler-Ross, 1969) and crisis theories
(Lindemann, 1979). We have proposed two sets
of responses from a nursing perspective: process
patterns and outcome patterns.
Process Patterns
Process patterns are measured by the degree
of engagement in the particular change event
as well as in the actions and intervention
plans (Schumacher, Jones, & Meleis, 1999).
Levels of engagement could be assessed
through patterns of questions, types of re-
sponses, and the congruency between actions,
sentiments, and goals of those who are experi-
encing the transition and those who are guid-
ing and advising about these actions. Following
directions, accuracy of perceived information,
the consistency of meanings of the event, and
the degree of involvement in all aspects of tran-
sition experience and actions related to the
change event are indicators of engagement
levels.
A second process pattern of response is
called location and being situated (Meleis,
Sawyer, Im, Schumacher, & Messias, 2000).
Recognizing one’s position in a complex system
of relationships and being connected and able
to interact with a web of different interactions
is a pattern of response that should be examined
to uncover the nature of responses to a transi-
tion trigger. How a person sees, initiates, and
relates to teams of health professionals follow-
ing a diagnosis of cancer or to a new immi-
grant’s environment determines a pattern
of response. How and when a person, a family,
or a community confronted by a change trigger
seek support from health-care providers, are
indicators of the extent that they understand the
needs and timeliness in seeking the support. It
is also an indication of realizing their position
within the health-care system.
Another process pattern is the level of
confidence in handling the new, multiple, and
sometimes conflicting demands on a person,
family, or organization in the midst of attempt-
ing to deal with a triggering event. Similarly, the
level of confidence may be determined by the
individual’s ability to identify priorities of needs
and to outline different levels of actions or inter-
ventions. The actions could be as simple as
describing from whom they should seek help to
more complex self-care interventions.
Outcome Patterns
Although patterns in process responses are
assessed at different points in dealing with a
change trigger, outcome responses are assessed
at a point determined to be at the end of the
transition process. Five patterns of responses are
defined as outcomes—mastery, fluid integrative
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identities, resourcefulness, healthy interactions,
and perceived well-being (Meleis et al., 2000).
Mastery includes role mastery, which is mani-
fested by integrating the sentiment, goals, and
behaviors in one’s identity, and behaving with
confidence, knowledge, and expertise. Exam-
ples are becoming a mother (Hattar-Pollara,
2010; Mercer, 2004; Shin & Whitetraut 2007),
accepting hospice or end-of-life care (Larkin,
Dierckx de Casterlé, & Schotsmans, 2007),
or becoming adept at being at risk while
continuing to function in other roles.
Mastery goes beyond roles, however, and
includes mastery of one’s environment as mani-
fested in seeking and utilizing appropriate re-
sources and co-opting supportive environmental
conditions. Learning to cope with technology
at home, living with it, and reformulating
one’s identity to incorporate it in one’s daily
repetitions is an example of this mastery (Fex,
Gullvi, Ik, & Soderhamn, 2010).
Fluid and integrative identity is another out-
come response pattern (Meleis et al., 2000).
This pattern is characterized by the ability to
swing back and forth between the multiple
identities a person in transition experiences.
Let’s consider a person who must undergo kid-
ney dialysis and who emerges from her dialysis
session to assume other identities, without any
one of the identities dominating her time and
energy. A person with an integrative identity
is able to live, function, and be well, despite
the uncertainties and ambiguities of living with
a chronic illness, a nagging pain, or a set of
essential treatments. This pattern of outcome
response is characterized by the ability to carry
the sentiments, the goals, the actions, and the
baggage of different ways of being (Messias,
1997). It is the ability to “navigate unknown
waters” (Duggleby et al., 2010). One indicator
for an outcome pattern of response is current
compared with previous quality of life.
Another outcome pattern of response is
healthy interactions and connections as mani-
fested in maintaining relationships and or
developing new connections or relationships
that affirm the completion of a transition.
Questions to be investigated are the extent to
which caregivers burdened by extensive health-
care needs of patients with heart failure are able
to develop relationships with health-care
providers while maintaining meaningful sup-
portive relationships in their lives. For example,
telehealth can play a significant role in facilitat-
ing caregivers’ abilities to meet the needs of
heart failure patients by maintaining continuous
communication with family and caregivers. Te-
lenurses can then deliver the evidence-based
professional consulting and supportive care
based on technology that improves patients’
self-care behaviors. These interventions can also
alleviate caregivers’ burdens and improve their
health outcomes, allowing them time to meet
their own needs (e.g., health or social needs;
Chiang, Chen, Dai, & Ho, 2012).
These types of questions are important to an-
swer because some research has demonstrated
that the health of partners or caregivers is inter-
twined with that of seriously ill patients, that is,
the more an illness affects the patient’s physical
and mental ability, the greater the impact
this will have on the health of their partner or
caregiver due to insurmountable stress, disrup-
tion in their relationships, and neglect of their
own health. These unintended health conse-
quences may be further exacerbated by the lack
of social, emotional, or practical support the
partner or caregiver experiences (Christakis &
Allison, 2006). For this reason, having strong
social networks in place during these periods
of transition could play a significant role in
promoting positive health outcomes for the
caregiver, which would in turn positively affect
the health of the patient. For major areas of
investigation, see Table 20-2.
Intervention Framework
The goal of intervention within transitions the-
ory is to facilitate and inspire healthy process
and outcome responses. Nursing interventions
that support healthy process behaviors as well
as healthy outcome behaviors include the fol-
lowing: clarifying meanings, providing expert-
ise, setting goals, modeling the role of others;
providing resources, opportunities for rehearsal,
access to reference groups and role models, and
debriefing.
Clarifying Roles, Meanings, Competen-
cies, Expertise, Goals, and Role Taking
Through interaction, dialogue, and interviews,
the nurse probes for the values of the person
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experiencing the transition process, as well as
those of their significant others, and determines
the meanings they attribute to the event and
the different stages in the transition. Compe-
tencies and the extent to which the person is
able to master each of the competencies are
identified, as well as the ease in performing the
competency and the level of engagement in
learning or modifying the competency—be it
testing blood sugar levels, bathing a baby,
changing a nursing unit, or reaching out for
new connections in a nursing home.
Similarly, observing, questioning or inter-
viewing significant others—whether they are
partners or friends—to determine levels of
engagement and the extent of competency
mastery is another significant component of a
program for intervention during transition
process, especially at critical milestones. Signif-
icant others or reference groups to be included
in the assessment or the intervention are those
whose viewpoints are used as a frame of refer-
ence. Roles, whether they are new ones, at-risk
ones, or those that may be lost, are formed and
imputed through a process of definition and
redefinition. Similarly, new competencies are
acquired through a process of teaching, learn-
ing, rehearsing, modeling, and reinforcement
by those who are in the support or network
systems (Petch, 2009; Swendsen, Meleis, &
Jones, 1978; van Staa, 2010).
Identifying Milestones and Using
Critical Points
A critical point is the time when questions tend
to arise about a care trajectory or when signs and
symptoms tend to manifest themselves. It is a
point when healing progresses or there is a
relapse, a point when infection, inflammation,
distress, anxiety, noncompliance, or other con-
ditions may begin appearing and when an
appropriate intervention may advance the treat-
ment and healing course. Care is maximized at
such a point. A 6-week check-up for a postpar-
tum mother has always been designated a critical
point or a milestone, but this milestone is driven
by the biomedical model as it relates to when the
uterus reverts to its normal size. However, it is
imperative to identify milestones from a nursing
perspective when our goals are self-care, quality
of life, role mastery, and managed care. Identi-
fying milestones or turning points is essential
in the trajectory of managing and facilitating
transitions. This area of the theory invites
research to provide evidence to identify and
support those points where there is a need for
intervention to enhance both a healthy transition
process and outcomes. Biomedical driven goals
are not inclusive of goals driven by a nursing
perspective and holistic approach.
Providing Supportive Resources,
Rehearsals, Reference Groups, and
Role Models
Mobilizing partnerships, resources, and support-
ive groups is another component in intervention
strategies. Clarifying roles, competencies, values,
and abilities to understand what others are ex-
periencing are important processes for facilitat-
ing a healthy transition and in achieving healthy
outcomes at the termination of a transition.
These may be accomplished by identifying a
nurse as a go-to person for questions, observing
patients who may have gone through a similar
368 SECTION VI • Middle-Range Theories
• Describe and interpret the different transition experiences and responses.
• Identify transition properties.
• Develop and test preventative and therapeutic interventions.
• Identify milestones and turning points associated with different change triggers.
• Describe and test determinants of process and outcome responses.
• Develop instruments and investigative tools for properties, conditions, processes, and outcome
responses.
• Explore strategies to modify policies essential to mitigate, facilitate or inhibit healthy processes
and outcome responses.
Table 20 • 2 Major Areas of Investigation
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event, and being afforded opportunities to imag-
ine, mentally enact, or actually practice what the
person may encounter, do, or feel during the
different phases of transition. Having a support
group, rehearsing competencies, becoming in
touch with feelings about events or competen-
cies, visualizing different scenarios, and de-
scribing the different if–then situations may
enhance healthy transitions and outcomes. We
have called these processes role modeling and role
rehearsal, as well as defining and identifying refer-
ence groups (Meleis, 1975; Meleis & Swendsen,
1978). An example of this type of intervention
is an interdisciplinary mentoring program that
the Hospital of the University of Pennsylvania
implemented, which pairs nurses with medical
students starting their first clinical rotations
to facilitate the transitional adjustment of
the medical students to their new environment.
This program also highlights the important
role nurses play in patient care, which fosters a
sense of teamwork and collegiality between
medical students and nurses from the beginning
(Sapega, 2012).
Debriefing
Debriefing is a well-researched, core nursing
intervention used at critical points during
transition experiences. “Debriefing is defined
as a process of communicating to others the
experiences that a person or group encountered
around a critical event” (Meleis, 2010, p. 457).
It is a tool used in nursing to help a person
come to terms with the transition experience
and attain psychological well-being (Steele &
Beadle, 2003). Nurses ask their patients ques-
tions after birthing, traumatic events, disasters,
surgical procedures, during a new admissions
process, and at discharge. The patient may
recount his or her story emotionally, relate to
it cognitively, describe it, interpret its meaning,
reflect on it, or share feelings. The story usually
includes the context, the before, the during,
and the subsequent responses related to the ex-
perience. Nurses engage in dialogues with their
patients about the events, ask questions, and
provide patients and families with the oppor-
tunity to process the events and the aftermath.
For example, a number of maternity units
provide postnatal debriefing services for new
mothers. Postnatal debriefing is a psychological
intervention that enables women to come to
terms with their experience and promotes
psychological well-being. Through postnatal
debriefing, health-care professionals can iden-
tify the emotional and psychological needs of
the patient and refer them to appropriate
resources or other mental health specialists.
This service gives new mothers the opportunity
to ask questions, debrief about their experi-
ences, describe their feelings, and receive infor-
mation and reasons for care they have been
provided or need (Steele & Beadle, 2003).
In addition to patients, nurses themselves, as
well as other health-care providers, also benefit
from debriefing. Hospitals have implemented
debriefing, or critical incident stress manage-
ment, programs to help their staff cope with
stress and sorrow at work and to mitigate the
impact of traumatic events. For example, Chil-
dren’s Memorial Hospital in Chicago launched
a mentor program that matched new nursing
graduates with seasoned nurses to help them
cope with the stress and heartache of caring
for sick children and interacting with distressed
parents and family members. This program
significantly reduced the high turnover rate
among new nursing graduates that the hospital
had been experiencing (Huff, 2006).
Applications of Transitions
Theory
Research
Transitions theory has been used extensively
as a theoretical framework in research all
around the world to examine a broad spectrum
of transition experiences resulting from
health–illness, developmental, situational, and
organizational transitions and the effect of
these transitions on the health of individuals,
families, and communities. It has been used to
develop strategies and interventions to facili-
tate healthy transitions and has served as a
conceptual basis and guide to
• understand and examine teenager’s concerns
as they transition through high school in the
United States (Rew, Tyler, & Hannah,
2012).
CHAPTER 20 • Transitions Theory 369
3312_Ch20_357-380 26/12/14 6:00 PM Page 369
• demonstrate in Taiwan that nurse-led transi-
tional care combining telehealth care and
discharge planning significantly alleviates
family caregiver burden and stress and im-
proves family function (Chiang et al., 2012).
• study the impact on self-care of people with
heart failure and develop strategies to imple-
ment a therapeutic regimen in Portugal
(Mendes, Bastos, & Paiva, 2010).
• explore in greater depth chronic obstructive
pulmonary disease (COPD) patients’ experi-
ences during and after pulmonary rehabilita-
tion in Norway (Halding & Heggdal, 2011).
• analyze Finnish women’s hysterectomy expe-
riences as a process of transition in their lives
and describe representations of hysterectomy
in Finnish women’s and health magazines
(Nykanen, Suominen, & Nikkonen, 2011).
• assess the cultural factors that may contribute
to the low diagnosis rate of postpartum
depression in Asian American (e.g., Asian
Indian, Chinese, Filipina) mothers (Goyal,
Wang, Shen, Wong, & Palaniappan, 2012).
These research studies demonstrate how
transitions theory has supported and aided
nurse researchers and scholars to describe the
transition experiences and responses, confirm
the components of the transition experience,
and identify the essential properties of transi-
tion, including the critical points and events,
to ultimately reach the goal of promoting
healthy outcomes and easing transitions for
their clients, families, and communities.
• As indicated by Kralik, Visentin, and van
Loon (2006) in their comprehensive litera-
ture review of transitions theory, future
research to advance knowledge about
transitions should include longitudinal
comparative and longitudinal cross
sectional designs.
• In 2007, at the University of Pennsylvania,
we established the New Courtland Center on
Transitions and Health. Transitions theory
provided the foundation for its theoretical
basis. Driven by Dr. Mary Naylor’s scholar-
ship, a current focus of the center is on the
transitional care model for the elderly popu-
lation. Although independently developed
on the East Coast of the United States as an
intervention using advanced practice nurses,
the transitional care model reflects the com-
ponents of transition theory (Naylor, 2002).
Practice
Transitions theory has been applied in practice
by nurses to aid clients, families, and communities
in preparing for, navigating through, and adapt-
ing to transition experiences to enhance health
outcomes. The operationalization of transitions
theory enhances nurses’ understanding of patient
and caregiver transitions and leads to the devel-
opment of nursing therapeutics, interventions,
and resources that are tailored to the unique
experiences of clients and their families in order
to promote successful, healthy responses to tran-
sition. As mentioned earlier in this chapter, the
illness of patients can take a heavy toll on the
health of their caregivers due to the stress, role
transitions, disruption in relationships, and
bereavement they may experience. Transitions
theory has been used as a conceptual framework
in practice to help health-care providers gain a
holistic understanding of the caregiver’s beliefs,
views, unique experiences, and desired outcomes,
which in turn enables nurses and health-care
providers to allocate resources and implement
interventions targeted to the caregivers’ specific
needs to optimize the health of both the patient
and the caregiver (Blum & Sherman, 2010).
It helps identify the barriers to, as well as facili-
tators of, the transition, unique to each individual
patient and caregiver, which in turn enhances
the nurses’ or health-care providers’ ability to
effectively guide them through the transition
experiences.
The conceptual underpinnings of transi-
tions theory have also been used to analyze the
transitions that intensive care unit (ICU) pa-
tients and their families encounter after they are
discharged from ICU and the provision of nurs-
ing services needed for continuity of care. By
digging deeper to fully comprehend the stress
patients and families experience when being
discharged from ICU, including their potential
feelings of abandonment, unimportance, or am-
bivalence, nurses can better assist patients and
families in the ICU transfer process and ensure
the provision of optimum health-care services
to continue care (Chaboyer, 2006).
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Transitions theory has also been used to
understand and characterize the personal expe-
riences of perimenopausal and menopausal
women. Findings from this research have been
translated into practice in the clinical setting.
Understanding women’s personal experiences
using transitions theory equips nurses to proac-
tively educate women on what to expect before
perimenopausal or menopausal symptoms begin,
thus decreasing anxiety and confusion and in-
stead “normalizing the experience” (Marnocha,
Bergstrom & Dempsey, 2011).
Education
Transitions theory is used in graduate and
undergraduate curricula in countries around
the world. Universities that have integrated
transitions theory in their nursing education
programs include the University of Connecticut
in Storrs and Clayton State University in Mor-
row, Georgia. Clayton State University has used
transitions theory in its curriculum, and has
made it central to their nursing program’s phi-
losophy. On its website, transitions theory is de-
fined, and it is emphasized that “[n]egotiating
successful transitions depends on the develop-
ment of an effective relationship between the
nurse and client. This relationship is a highly re-
ciprocal process that affects both the client and
nurse” (Clayton State University, 2012). With
regard to the graduate curriculum in nursing
at the university,
The culmination of graduate nursing education is the
synthesis of advanced skills in order to provide excel-
lent nursing care and to foster ongoing professional
development in order to promote nursing research,
ethical decision-making reflecting an appreciation of
human diversity in health and illness among individ-
uals, families, and communities experiencing life tran-
sitions. (Clayton State University, 2012)
At the University of California San Fran-
cisco (UCSF), I taught a graduate course on
transitions and health to respond to an increas-
ing educational demand of graduate students.
Additionally, many doctoral students in
nursing and other disciplines around the
world, including Sweden and the United
States, have used transitions theory as a basis
for their doctoral dissertations.
Developing Situation-Specific Theories
Transitions theory continues to be further
developed, tested, and refined to understand
and describe the relationships among the
major beliefs, patterns, and concepts of diverse
groups of populations undergoing various
types of transition experiences. A number of
situation-specific theories have evolved from
transitions theory. A situation-specific theory
is a coherent representation and depiction of a
set of concepts and their interrelationships to
a set of outcomes related to health and illness
experiences and responses, as well as to nursing
actions to prevent the effects of illness or ame-
liorate the effects of interventions (Meleis,
2010). For example, a situation-specific the-
ory explaining the menopausal symptom
experiences of Asian immigrant women
within the sociocultural contexts in the United
States was grounded in transitions theory
(Im, 2010). Others include Transitions and
Health: A Framework for Gerontological Nursing
(Schumacher, Jones, & Meleis, 1999) and
Situation-Specific Theory of Pain Experience for
Asian American Cancer Patients (Im, 2008).
CHAPTER 20 • Transitions Theory 371
Practice Exemplar by Diane Lee Gullett, MSN, MPH
The following Practice Exemplar is framed with
Afaf Meleis’ Transition Theory.
I met Wayne when I was volunteering as
a nurse in a free clinic in New Orleans (N.O.)
in 2012. He was a 26-year-old young man
who appeared gaunt with dark circles under
his eyes. Wayne presented with a chief com-
plaint of insomnia, depression, nighttime
sweating, and a lack of energy for the past
10 months. He informed me that the other
practitioners he visited had given him med-
ications for sleep and depression. He stated
Continued
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372 SECTION VI • Middle-Range Theories
Practice Exemplar by Diane Lee Gullett, MSN, MPH cont.
these had been unsuccessful in relieving his
symptoms. I asked Wayne if any blood work
had been done. He suddenly became very
anxious, stood up and began pacing the
room, wringing his hands, looking at the
floor, and refusing to make eye contact. He
started for the door and told me he didn’t
need to have any blood drawn and that this
was a mistake. I assured him that I would
not draw any blood without his consent and
gently asked him if he would be willing to
stay and speak with me a bit further.
Nurse: Can you remember when you first
started noticing your symptoms?
Wayne: I guess it was in August or maybe
September.
Nurse: Thinking back can you remember any
significant changes in your life at that time?
Wayne: You know, I have wracked my brain
thinking about that. The only thing I can
think of is that this was about the time
Hurricane Katrina hit.
Nurse: Were you living in New Orleans (N.O.)
when Hurricane Katrina hit the city?
Wayne: Yeah, I was starting my freshman year
of college.
Nurse: Would you mind sharing some of your
experiences about that time in your life
with me?
(Intervention: Debriefing).
Wayne: I was a 19-year-old honors student
(Condition: Personal). I had just moved to
N.O. to major in international business
10 days before the storm (Change trigger:
Situational). The apartment community
where I lived was evacuated, so I was forced
to leave the city and go to my stepfather’s house
in Arkansas (Property: Time span). I didn’t
understand the severity of the situation at the
time, I mean I had never been through a hurri-
cane before (Condition: Personal). I thought it
would be an opportunity to get ahead with my
schoolwork and visit with my family. I didn’t
take much, two pairs of pants and some books. I
mean it never occurred to me that I would need
more than that. You know you have to leave, so
you take what you think you need which you
later realize isn’t enough and isn’t what you
should have taken, but no one prepares you for
that (Condition: Personal). I enrolled in classes
at Louisiana State University in Baton Rouge
3 weeks after Katrina, since my old college
wasn’t offering classes at that time. I lasted
5 minutes. I went through the whole process
and I just dropped out (Property: Milestone)
immediately after doing it because I just
couldn’t wrap my mind around it.
Nurse: Could you explain a bit more about
what you mean when you say you “couldn’t
wrap your mind around it.” (Clarifying
meaning)
Wayne: I, it, was everything from my social
life, to what I was studying, to my financial
situation. I was on this path of what I was
going to do and when I came back, I just
couldn’t do it. I just, honestly, I just didn’t
care. It seemed like there were so many other
more important things than worrying about
my grades or what I was studying. I dropped
out of school with a 1.5 GPA and decided to
return to N.O. It was only about 3 months
after Katrina and too soon. My thought
process, though, was just I need to get my life
back to normal, I need to get things to be the
way that they were. Even 7 years later, they
are not. It is, you acknowledge on some level,
that it is never going to be the way that it
was, but it’s like your driving force, this need
to get your life back to normal (Property:
Process). And then you get the new normal,
so it’s not what you had before, it’s not even
close. It’s not even, it's, I can’t even describe
how different it is.
Change Triggers
Hurricane Katrina serves as the situational
change trigger for Wayne’s transitioning
experience. The hurricane generated situa-
tional changes including relocating to a new
city, enrolling at a new college, and living in a
new community. The nature of Wayne’s tran-
sitional experience; however, must also be con-
sidered within the context of other possible
change triggers. Wayne is simultaneously
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CHAPTER 20 • Transitions Theory 373
Practice Exemplar by Diane Lee Gullett, MSN, MPH cont.
experiencing a developmental life phase
change moving from late adolescence to early
adulthood manifested in his role transition
from high school student to independent col-
lege student. Limited worldly experience and
youth are personal conditions that inhibit
Wayne’s ability to cope with the reality of the
changes triggered by Hurricane Katrina. His
inexperience is evident in his initial response
to Hurricane Katrina as a mini-vacation for
which he took only a few articles of clothing,
never thinking he wouldn’t be able to return
to resume his college life or collect those
things he held personally valuable. Wayne’s
inability to effectively reconcile his previous
life with his new one inhibits a healthy out-
come response leading to his failure to main-
tain his GPA and eventually dropping out of
school. The nurse recognizes Hurricane Kat-
rina as the situational change trigger that con-
textually situates Wayne’s unique transition
experience and serves as the foundation for
mutual meaning making between the nurse
and Wayne.
Nurse: Could you tell me a little bit more about
your feelings during that time and your ‘need
to get your life back to normal’ (Clarifying
meaning).
Wayne: I came back with no plan other than
to try and resume my life, and without real-
izing that all of the things that were in my
life before might not be there after (Prop-
erty: Disconnectedness). That is, even down
to grocery stores, you know for a long time
you had to drive to the suburbs just to make
groceries. Like, for example when my old
apartment community reopened, I was
adamant that I wanted to move back. I had
to move back into that same apartment, and
I did ultimately, but it wasn’t the same. It
wasn’t physically the same because it had
been gutted and then it wasn’t the same
because it wasn’t the same circumstances, it
wasn’t the same people. So I did not realize,
I just wanted to move back and continue my
life, I didn’t realize that the things that were
part of my life may not be there like they
were before (Property: Disconnectedness).
Nurse: This must have been a very difficult
time for you. How did you cope with all
these changes in your life? (Intervention:
Questioning)
Wayne: Things during the first year or two after
I returned to the city are still a little hazy. I
do remember totaling three cars within 2
weeks after returning to N.O., you know I
don’t know where my head was (Property:
Critical point). I haven’t been in an accident
since. I haven’t even had a speeding ticket,
but literally within this period I totaled three
cars. I can say speaking in honesty that you
know for a long time after the storm that my
way of dealing with my day to day life really
was sex and drugs (Property: Critical point).
What started with just every now and then
became like weeks-long binges, and when you
get involved with those things, it brings a
completely new element into your life that
you probably wouldn’t have considered
before. I mean, I will be the first to say I have
done things since the storm that I never
would have considered before. Such as
certain substances, sexually, bath houses. . . .
(Property: Critical point). I think it was an
escape; it was because when you are high,
when you are messed up, and you’re not
thinking about the things around you . . . you
are not thinking at all really, you are just you
know, you are getting away from all these
pressures that are on your mind (Property:
Awareness).
Nurse: What did you feel like you needed to
escape from (Intervention: Clarifying
meaning)?
Wayne: At the time, I had new financial strug-
gles that I hadn’t had before. Things like
work, some family problems, and the way
things were in the city. Everything was so
different than it had been before Katrina
(Conditions: Personal and Community).
Properties of Transition
Properties of transition (i.e., time span, process,
disconnectedness, awareness, and critical points)
Continued
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374 SECTION VI • Middle-Range Theories
Practice Exemplar by Diane Lee Gullett, MSN, MPH cont.
assist the nurse in describing change triggers,
specific milestones and ascertaining the differ-
ent phases of a person’s transition experience.
This knowledge assists the nurse in identifying
interventions and support mechanisms impor-
tant in facilitating healthy transition experiences
or recognizing those factors inhibiting healthy
transitions. Wayne encounters the property of
time span when he first becomes aware of Hur-
ricane Katrina. The nurse recognizes Hurricane
Katrina as an external trigger of change which
in and of itself is static. Wayne’s process of tran-
sition, on the other hand, signifies a dynamic
internal change evident in his struggle to regain
his old life, his inability to do so and his reluc-
tance to accept the new normal. Disconnected-
ness manifests in Wayne’s recognition of the
disruption Hurricane Katrina brought to his fa-
miliar way of being in the world; from where
he shopped, where he lived, who his friends
were, and who he understood himself to be. He
sincerely yearns to return to the familiar only to
find his environment (personal, community,
and societal conditions) irrevocably changed.
The dynamic nature of awareness is reflected in
Wayne’s continual reinterpretation and willing-
ness to find meaning in his experiences follow-
ing Katrina. His story is filled with a sense of
movement from trying to return to normal to
acknowledging the “new normal” and from par-
ticipating in risk-taking behaviors as coping
strategies to recognizing these as ineffective.
The nurse recognizes many turning points or
milestones within Wayne’s transition experi-
ence starting with his dropping out of school,
crashing multiple cars, using drugs and alcohol,
and engaging in unprotected sex. Without
appropriate interventions, all of these played a
role in inhibiting a healthy transition experience
for Wayne.
Nurse: Did you have anyone who was able to
support you or who you felt like you could go
to for help during this time (Intervention:
Assessing support systems)?
Wayne: I wasn’t getting the support from my
family because they couldn’t relate, they . . . I
suppose on some level they were like this sucks
but they couldn’t at all understand what I
was going through (Property: Disconnected-
ness). There weren’t many people who stayed
in the city and those who became my friends
ended up being the wrong crowd. I mean the
city was a disaster there was a curfew, mili-
tary presence, no garbage pickup for months,
no grocery stores, and certainly no counseling
or places to go to for help (Condition: Com-
munity). It was as if those of us who stayed
in the city were on our own. I think a lot of
people were in bad shape. I remember hear-
ing about a lot of people committing suicide.
Nurse: Do you think you made the wrong deci-
sion returning to N.O. so soon after Hurri-
cane Katrina?
Wayne: Absolutely. You know, even now, if it
were going to happen again, I couldn’t, I
would leave, I would leave my stuff, and I
would not come back. It wasn’t the experience
itself, it was the after effect. And the way it
affected my life. . . . I can’t go back to trying
to fit the pieces of my life back together or try-
ing to resume a sense of normalcy that will
never return because even though I know
better now, while you intellectually know
better, emotionally you are still going to be
going through the processes (Process patterns:
Engagement). There is nothing you can do
about that, you can’t control that. . . . I just
can’t do it. I am a pretty strong person, I al-
ways have been, but that was one time in my
life that I can sincerely say I had a mental
and emotional breakdown. It was what it
was, and I can’t do anything about that
(Properties: Awareness).
Conditions of Change
There are multiple personal, community, and
societal conditions influencing Wayne’s pat-
terns of response to Hurricane Katrina and are
important for the nurse to recognize as part of
his transition process. Personal conditions are
those, which center on an individual’s experi-
ence with the change trigger and other personal
conditions that influence the well-being of the
individual within the broader framework of
family and community. Wayne’s youth and lack
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CHAPTER 20 • Transitions Theory 375
Practice Exemplar by Diane Lee Gullett, MSN, MPH cont.
of experience with natural disasters are personal
conditions that influenced Wayne’s responses
to the situational change. Wayne naively re-
turned to N.O. with the intent of getting his
life back to normal only to be confronted with
the reality of an irrevocably changed reality and
his place in it. Wayne also expresses feelings of
isolation when discussing his belief that others
including his family could not relate to what he
was going through. Wayne’s lack of knowledge
and skills, poor planning, and increased sense
of marginalization reflect personal and commu-
nity conditions that inhibited rather than facil-
itated a healthy transition experience. The
limited level of existing community and social
resources available within the city following
Hurricane Katrina also inhibited Wayne’s tran-
sition experience. Katrina created catastrophic
conditions within the city that left a nonexistent
social, political, and economic infrastructure.
Employment, housing, medical care and men-
tal health services were virtually nonexistent
within the city. Wayne was not aware of the
fact that he needed help during this time and
states the reality of limited access to even basic
services within the city. Community conditions
including cultural and social norms were also
dramatically altered by the catastrophic condi-
tions that existed in the city. These conditions
for a young person such as Wayne may have
presented a loss of positive role-modeling es-
sential to developing effective coping strategies
following such a traumatic experience. Wayne
admits to engaging in homosexual behavior,
unprotected sex, doing drugs, and hanging
out with the wrong crowd. Societal conditions
stigmatizing homosexuality may have prohib-
ited him from seeking support from his family
or friends, further perpetuating his feelings of
marginalization.
Nurse: Are you able to think about your future
at all, envision what you want to do moving
forward (Intervention: Visualizing different
scenarios).
Wayne: One thing I can say moving forward, I
have, I really want to get out of N.O. It’s
that still even today, it is such a major part
of, and I know I am not alone in this, your
everyday mental process. Your life is sepa-
rated into before Katrina and after Katrina.
And you refer to things like that, on a daily
basis your life before the storm and after the
storm and you think about it every day. I
can’t imagine, I can’t imagine living some-
where that you don’t think about that, I can’t
imagine living somewhere where that is
not a part of your daily process, it’s not a
part of your shared experience (Patterns of
response: Locating).
Nurse: After listening to your story, it seems
that the changes brought about by Hurricane
Katrina greatly affected your life. I think
some of the symptoms you described to me
could be related to what you experienced
during this very difficult time in your life.
Speaking with others who have experienced
similar circumstances may provide a way to
express what you have been through. I know
of a local support group not far from here that
has some members who were also in college at
the time that Hurricane Katrina hit. Would
you be interested in attending one of these
groups (Intervention: Mobilizing support)?
Wayne: I would like that. (Patterns of response:
Receiving support) I feel better just talking
with someone about all of this. Can I tell you
something and you won’t judge me (Patterns
of response: Seeking support)?
Nurse: Of course. I want you to feel this is a
safe environment and that I am not here to
judge you.
Wayne: You know when I told you about the
bathhouses; well it happened a lot and with
men. I didn’t use protection most of the time.
I am so ashamed and so scared.
Nurse: Wayne, you do not need to be ashamed.
A lot of young men and women experiment
sexually throughout their lives, but it is
important to practice safe sex. Can you tell
me more about what you are scared of specifi-
cally (Intervention: Clarifying meaning)?
Wayne: I am scared that I may have AIDS.
I took a home HIV test a couple of months
ago, the kind that uses your saliva. It was
Continued
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Practice Exemplar by Diane Lee Gullett, MSN, MPH cont.
positive, but I have been too afraid to do
anything about it or tell anyone. I know, I
am stupid, right (Properties: Critical point)?
Nurse: No, I don’t think you are stupid. I think
you are rather brave for telling me and for
making the decision to talk about this
(Intervention: providing expertise).
Wayne: I feel relieved but really scared, that is
the reason I was going to leave when you
mentioned the blood test. I don’t know what
to do. It was my fault. I don’t even remember
most of it. I wasn’t like this before Katrina, I
don’t know what has happened to me since
then, I am a mess (Patterns of response:
Being situated).
Nurse: I realize you are scared, but the first step
is setting up a time for you to get an HIV
blood test, if you feel you are okay with that
(Intervention: Setting goals). I have the
phone number of a local clinic, we can call
together and schedule an appointment for
you. There are counselors who will be there
to support you through the process (Interven-
tion: Providing resources). You will not be
alone. Are you still engaging in unprotected
sex with other partners or using drugs
that place you or someone else at risk
(Intervention: Providing expertise)?
Wayne: No, I haven’t done any of those things
in over a year. I stopped hanging out with
that crowd and I don’t have any desire to go
back to doing any of those things (Patterns of
response: Awareness).
Nurse: I believe it is important for you to explore
your feelings and experiences before and after
Hurricane Katrina in a safe environment. I
think it would be helpful for you to meet with
a counselor in addition to attending a couple
of support groups. We can talk about your
options and decide together how you would
like to move forward, does that sound like a
plan (Intervention: Mobilizing support and
setting goals)? Are you close to anyone you feel
would be supportive right now (Intervention:
Assessing support systems)?
Wayne: I don’t want anyone else to know about
this for right now, if that is okay? I would
prefer to see a counselor and maybe go to a
support group but not with anyone else.
Thank you so much for listening to me and
for taking the time to help me.
Nurse: You are welcome. Thank you for sharing
your experience with me, for being brave
enough to talk about what you are going
through, for trusting me and allowing me
to support you as you journey through this
process.
Patterns of Response
The nature of Wayne’s transition experience can
be gleaned through his dialogue with the nurse.
Process patterns are assessed at different points
during the transition experience while outcome
patterns are assessed at a point determined to
be at the end of the transition process. Wayne’s
responses indicate he is still engaged in the
transition process despite the 7 years that had
passed since Hurricane Katrina. He informs the
nurse that he no longer hangs out with the
wrong crowd or participates in risky behaviors
such as unprotected sex. Wayne’s willingness to
stop engaging in risk-taking behaviors indicates
a conscious choice to modify his behavior.
Additionally, he opens up to the nurse about
taking a home HIV test and decides to take a
HIV blood test, indicating an active search for
information by which to address his concerns.
Both modifying his behavior and seeking out
information suggests Wayne is actively involved
or engaged in the process of transition. The
nurse is aware that he is consistently comparing
his actions using a before Katrina and after
Katrina perspective as a way to create new
meaning from his experience or ‘locate’ himself.
He is attempting to understand his new way of
being in the world by comparing it to his old
way of being in the world. These comparisons
also provide Wayne with a way of “situating”
himself or a way to assist him with explaining
why he engaged in the high-risk behaviors. The
nurse inquires about Wayne’s family and
friends to determine his support system. Wayne
indicates that he does not have a close relation-
ship with either his family or friends at this
time. He seeks support from the nurse by
expressing his concerns and fears about the
3312_Ch20_357-380 26/12/14 6:00 PM Page 376
CHAPTER 20 • Transitions Theory 377
Practice Exemplar by Diane Lee Gullett, MSN, MPH cont.
HIV testing. Additionally, he demonstrates a
willingness to receive support by agreeing to at-
tend groups and see a counselor. Acquiring
confidence is usually a progressive movement in
the transition process marked by increasing
confidence in dealing with the triggering event.
This is accomplished by developing strategies
for prioritizing needs and developing a sense of
wisdom generated through the lived experience.
This can be seen in Wayne’s decision to make
an appointment to take an HIV blood test and
seek support.
The nurse will assess for completion of the
transition process when Wayne is able to
demonstrate outcome responses including
mastery, fluid and integrative identity, re-
sourcefulness, health interactions, and per-
ceived well-being. He may demonstrate
mastery by integrating the skills he previously
had in order to be an honors student in inter-
national business with the new skills he devel-
ops to positively cope with the changes
brought about by Hurricane Katrina. A fluid
and integrative identity may be assessed by
asking Wayne to describe his previous quality
of life compared with his current quality of
life following intervention strategies. Wayne
would demonstrate healthy interaction and
thereby affirm the completion of his transition
process by developing and maintaining mean-
ingful and supportive relationships.
Intervention Framework
The goal of interventions is to facilitate and
inspire healthy process and outcome re-
sponses. These interventions include clarifying
roles, meanings, and expertise; identifying
milestones; mobilizing support; and debrief-
ing. The nurse dialogues and interacts with
Wayne to clarifying his statements as a way
of determining the meaning he attributes to
Hurricane Katrina. This interaction also as-
sists the nurse in determining where in the
transition process Wayne is; for instance, the
nurse is able to determine that Wayne re-
mains in the process of transitioning his
experience. Identifying the process Wayne
uses to define and redefine his various roles
including his new one as a potentially HIV-
positive patient; his at-risk ones, including
partaking in drugs, alcohol, and unprotected
sex; and his old ones as college student offer
insight about his coping strategies and pat-
terns of response. Milestones or critical points
are periods of heightened vulnerability in
which a person experiences difficulty with
self-care. Although Wayne’s story is rife with
critical points, the one the nurse is most im-
mediately concerned with is Wayne’s symp-
toms of depression and his anxiety over taking
an HIV blood test. Recognizing that Wayne
has a limited support system, the nurse’s in-
terventions to address his feelings of depres-
sion are aimed at identifying a counselor and
encouraging participation in reference or sup-
port groups. To address Wayne’s anxiety and
uncertainty over taking an HIV blood test the
nurse provides supportive dialogue, expertise
about where to get tested, offers to schedule
an appointment at a local clinic, discusses the
process of taking the test, and identifies a
counselor. Debriefing serves to provide con-
text and meaning about Wayne’s experiences
with Hurricane Katrina as a traumatic change
trigger. The nurse uses clarifying questions
and authentic presence to encourage Wayne
to share his personal experiences, and in doing
so, Wayne is able to find meaning in his
experience.
Summary
Using authentic presence and awareness in this
nursing situation created a space where Wayne
and I could connect and develop a relationship
grounded in trust and caring. This caring rela-
tionship provided an opportunity for Wayne to
share his experiences, fears, and anxieties with
me. A caring-based philosophy of nursing
guided by Meleis’s transitions theory served as
the lens through which I was able to recognize
Wayne’s symptoms as critical points or mile-
stones rather than medical diagnoses. I was also
able to understand Hurricane Katrina as a
major change trigger in Wayne’s life, which
guided my nursing interventions. Without this,
Wayne could easily have left the clinic not
Continued
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378 SECTION VI • Middle-Range Theories
Practice Exemplar by Diane Lee Gullett, MSN, MPH cont.
receiving the care he needed, resulting in de-
layed testing for HIV, prolonged illness, and
perhaps suicide. Through clarifying questions,
I was able to gain insight into the meaning
of Wayne’s lived experience with Hurricane
Katrina and identify his current and past cop-
ing strategies for adjusting to these changes.
Not recognizing Katrina as a change trigger
may have led me to assume Wayne’s symptoms
were a result of other factors in his life. Wayne
has experienced multiple transitions in the
7 years since Hurricane Katrina, resulting in
many unhealthy outcomes. His transition from
living and attending school in N.O. to having
to do the same in Baton Rouge resulted in him
going from an honors student to a college
dropout. His transition from living in N.O.
before Katrina to living in N.O. after Katrina
caused Wayne to have an emotional and men-
tal breakdown. Without appropriate interven-
tions or support, Wayne was unprepared
for the reality of the multiple changes in his
life following Hurricane Katrina. Wayne re-
sponded with ineffective coping strategies
identified as milestones or critical points and
included unprotected homosexual sex, using
drugs and alcohol, and dropping out of
school. These responses generated unhealthy
outcomes manifested in Wayne’s current
complaints of depression, insomnia, lethargy,
and possibly HIV. Recognizing Wayne’s cur-
rent symptoms as a critical point, I was able
to develop appropriate nursing interventions.
These included debriefing, providing re-
sources, and setting goals. Contemporary ap-
proaches to disaster remain, dominated by
biomedical models of care grounded in objec-
tive rather than subjective perspectives. This
approach may work in the short term when
the physical needs are paramount; however,
when the needs of individuals transitioning a
disaster extend beyond the physical, biomed-
ical approaches will fail to address their more
holistic needs. Preventing unhealthy out-
comes such as those Wayne experienced will
require a more holistic approach to nursing in
disaster. Framing individual and collective re-
sponses to natural disaster using a nursing
theoretical lens such as Meleis’s transition
theory serves as a foundation for generating
disciplinary specific knowledge and research
on nursing in disaster.
■ Summary
Transitions theory continues to be used to ad-
vance nursing knowledge about the experience
and the responses of the many transitions that
individuals, families, communities, and organ-
izations encounter as well as the experiences,
the responses, and the therapeutics that nurses
use, translating the theory to policy, research,
and evidence-based practice and better quality
care in the 21st century. It is for its potential,
its utility, and for the research programs that
have and could emanate from it that we have
defined nursing as “facilitating transitions to
enhance a sense of well-being” (Meleis &
Trangenstein, 1994).
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Chapter 21Katharine Kolcaba’s
Comfort Theory
KATHARINE KOLCABA
Introducing the Theorist
Overview of the Theory
Application of the Theory
Practice Exemplar
References
Appendix A
381
Introducing the Theorist
Katharine Kolcaba was born and educated
in Cleveland, Ohio. In 1965, she received a
diploma in nursing and practiced part time
for many years in the operating room, medical–
surgical units, long-term care, and home care
before returning to school. In 1987, she gradu-
ated with the first RN to MSN class at the
Frances Payne Bolton School of Nursing, Case
Western Reserve University (CWRU), with a
specialty in gerontology. While attending grad-
uate school, Kolcaba maintained a head nurse
position on a dementia unit. In the context of
that unit, she began theorizing about comfort.
After graduating with her master’s degree
in nursing, Kolcaba joined the faculty at the
University of Akron (UA) College of Nursing,
where her clinical expertise was gerontology
and dementia care. She returned to CWRU to
pursue her doctorate in nursing on a part-time
basis while teaching full time. Over the next 10
years, she used course work from her doctoral
program to further develop her theory. During
that time, Kolcaba published a framework for
dementia care (1992a), diagrammed the aspects
of comfort (1991), operationalized comfort as an
outcome of care (1992b), contextualized comfort
in a middle range theory (1994), tested the
theory in several intervention studies (Kolcaba
& Fox, 1999; Kolcaba, 2003; Kolcaba, Dowd,
Steiner, & Mitzel, 2004; Kolcaba, Tilton,
& Drouin, 2006; Dowd, Kolcaba, Steiner, &
Fashinpaur, 2007), and further refined the the-
ory to include hospital-based outcomes (2001).
She has an extensive series of publications to
document each step in the process, most of
which have been compiled in her book Comfort
Theory and Practice (2003). Many publications
and comfort assessments also are available on
her website at www.TheComfortLine.com.
Katharine Kolcaba
3312_Ch21_381-392 26/12/14 10:41 AM Page 381
Kolcaba taught nursing at UA for 22 years
and is now an associate professor emerita.
Kolcaba still teaches her web-based theory
course once a year, and she represents her own
company, The Comfort Line, as a consultant.
In this capacity, she works with health-care
agencies and hospitals that choose to apply
comfort theory on an institution-wide basis.
She also is founder and member of her local
parish nurse program and is a member of
the American Nurses Association and Sigma
Theta Tau. Kolcaba continues to work with
students at all levels and with nurses who are
conducting comfort studies. She resides in the
Cleveland area with her husband, and near her
two daughters, their children, and her mother.
One other daughter resides in Chicago.
Overview of the Theory
In comfort theory (CT), comfort is a noun or an
adjective and an outcome of intentional,
patient/family focused, quality care. Despite
everyone’s familiarity with the idea of comfort,
it is a complex term that has several meanings
and usages in ordinary language. The use of
comfort as a noun and an outcome is specific
to CT and different from its alternative us-
ages as a verb, adverb (as in comfortably), and
process (Kolcaba, 1995). From the Oxford
English Dictionary, Kolcaba learned that
the original definition of comfort meant “to
strengthen greatly.” Her assumptions were
that (1) the need for comfort is basic, (2) per-
sons experience comfort holistically, (3) self-
comforting measures can be healthy or
unhealthy, and (4) enhanced comfort (when
achieved in healthy ways) leads to greater
productivity.
From the nursing literature, Kolcaba used
three nursing theories to describe three distinct
types of comfort (Kolcaba, 2003). Relief was
synthesized from the work of Orlando
(1961/1990), who stated that nurses relieved
the needs expressed by patients. Ease was syn-
thesized from the work of Henderson (1978),
who described 13 basic functions of humans
that needed to be maintained for homeostasis.
Transcendence was derived from Paterson and
Zderad (1976), who believed that patients
could rise above their difficulties with the help
of nurses. These types of comfort were consis-
tent with usages in nursing textbooks.
The four contexts in which comfort is expe-
rienced by patients are physical, psychospiritual,
sociocultural, and environmental and came
from a further review of literature regarding
holism in nursing (Kolcaba, 1991, 2003). When
these four contexts of experience are juxtaposed
with the three types of comfort, a taxonomic
structure (TS), or grid, is created that covers the
nursing meaning of comfort as a patient out-
come. This TS, with definitions of each type
and context of comfort, provides a map of the
content of comfort so that nurses can use it to
pattern their care for each patient and family
member. Kolcaba’s technical definition of the
outcome of comfort is: The immediate experi-
ence of being strengthened when needs for
relief, ease, and transcendence are addressed
in four contexts of experience. Figure 21-1
contains the TS of comfort with the correspon-
ding definitions of relief, ease, transcendence
and the physical, psychospiritual, environmen-
tal, and sociocultural contexts.
Other uses of the TS of comfort are as
follows: (1) for determining the existence and
extent of unmet comfort needs in patients or
family members; (2) for designing comforting
interventions, which often can be “bundled” in
a single patient interaction; and (3) for creating
measurements of holistic comfort for documen-
tation in practice and research; such measure-
ments would be conducted before and after
comfort interventions and/or interactions.
A place to note the nature and time of the nurs-
ing intervention next to baseline and subsequent
comfort measurements is essential in medical
records. These strategies are discussed further in
a later section of this chapter.
One way to think about the grid is that com-
fort is an umbrella outcome that entails relief
from discomforts such as anxiety, pain, environ-
mental stressors, and/or social isolation. Because
the TS represents a holistic definition of com-
fort, the cells on the grid are interrelated; and
as a whole, comfort interventions directed to
one part of the grid have effects on all parts of
the grid. Total comfort at any one time is also
greater than the sum of its individual parts.
382 SECTION VI • Middle-Range Theories
3312_Ch21_381-392 26/12/14 10:41 AM Page 382
Therefore, comfort interventions to treat anxiety
also may reduce the dosage of analgesia needed
for adequate pain relief. On a comfort contin-
uum, the concept of total comfort (as much as can
be expected given the circumstances) is at one
extreme end, and suffering is at the other end.
Propositions of Comfort Theory
CT contains three intuitive parts that can be
applied or tested separately or as a whole. The
first part states that comforting interventions,
when effective, result in increased comfort for
recipients (patients and families), compared
with a preintervention baseline. Increased
comfort is the immediate desired outcome for
this kind of care. Comfort interventions
address basic human needs, such as rest,
homeostasis, therapeutic communication, and
viewing patients holistically. These comfort
interventions are often nontechnical and
complement delivery of technical care. Care
providers, such as nurses, may also be consid-
ered recipients if the institution makes a com-
mitment to improving comfort in its work
setting (discussed later).
When comfort is not enhanced to the fullest
extent possible, nurses consider intervening
variables for possible explanations as to why
comfort interventions did not work. Abusive
homes, lack of financial resources, devastating
diagnoses, or cognitive/psychological impair-
ments may render ineffective the most appropri-
ate interventions and comforting actions. The
aspect of transcendence, however, guides nurses
to help patients “rise above” or be inspired to
achieve mutually determined goals regardless
of life circumstances. Nurses who practice
CT never give up “being with” and inspiring
their patients. Thus, this focus on comfort is
proactive, energized, intentional, and longed for
by recipients of care in all settings.
The second part of CT states that increased
comfort of recipients results in their being
strengthened for their tasks ahead, which are
called health-seeking behaviors (HSBs). HSBs
are subsequent recipient goals and are negoti-
ated between nurses and the recipients. In the
practice of nursing administration, when the
intended recipients are bedside nurses, HSBs
are negotiated with nursing staff.
The third part of CT states that increased
engagement in HSBs results in increased
institutional integrity (InI). Enhanced InI
strengthens the institution and its ability to
gather evidence for best practices and best
policies. Best practices and policies lead to
quality care, which, in many ways, benefits the
“bottom financial line” of the institution.
Kolcaba believes that nurses already know
how and want to practice comforting care and
that it can be easily incorporated into every
nursing action. Many nurses deliver comforting
care intuitively but do not document its total
effects on patients as enhanced comfort. The
CHAPTER 21 • Katharine Kolcaba’s Comfort Theory 383
Physical
Psychospiritual
Environmental
Sociocultural
Pain
Anxiety
Relief Ease Transendence
Type of comfort:
Relief: the state of having a specific
comfort need met.
Ease: the state of calm or contentment.
Transcendence: the state in which one can rise above
problems or pain.
Context in which comfort occurs:
Physical: pertaining to bodily sensations,
homeostatic mechanisms, immune
function, etc.
Psychospiritual: pertaining to internal awareness of self,
including esteem, identity, sexuality,
meaning in one’s life, and one’s
understood relationship to a higher
order or being.
Environmental: pertaining to the external background
of human experience (temperature,
light, sound, odor, color, furniture,
landscape, etc.)
Sociocultural: pertaining to interpersonal, family, and
societal relationships (finances,
teaching, health care personnel, etc.)
Also to family traditions, rituals, and
religious practices.
Adapted with permission from Kolcaba, K. & Fisher, E.
A holistic perspective on comfort care as an advance directive.
Crit Care Nurs Q,18(4):66-76, (c)1996. Aspen Publishers.
Fig 21 • 1 Taxonomic structure of comfort
(or comfort grid).
3312_Ch21_381-392 26/12/14 10:41 AM Page 383
explicit focus on and documentation of this type
of holistic care is called comfort management
and, as shown in the TS, includes more than
relief of pain or anxiety. Thus, when nurses
adopt CT as a professional practice model, they
are using a simple pattern for individualized
care that is efficient, creative, and satisfying to
themselves and to recipients of their care. When
enhanced comfort is documented, nurses
can also demonstrate their real contributions to
better institutional outcomes such as higher
patient satisfaction, fewer readmissions, or
shorter length of stay. The diagram of CT
shows the relationships between these simple
concepts (Fig. 21-2). Definitions of the con-
cepts follow the diagram.
Theoretical Definitions for
Diagram Concepts
In the context of comfort theory, health-care
needs are defined as needs for comfort, arising
from stressful health-care situations that cannot
be met by recipients’ traditional support systems.
They include physical, psychospiritual, sociocul-
tural, and environmental needs made apparent
through monitoring and verbal or nonverbal
reports, needs related to pathophysiological pa-
rameters, needs for education and support, and
needs for financial counseling and intervention.
Comfort interventions are defined as in-
tentional actions designed to address specific
comfort needs of recipients, including physio-
logical, social, cultural, financial, psychological,
spiritual, environmental, and physical inter-
ventions. Within these contexts of experience,
there are three types of comfort interventions
(described later): technical, coaching, and
comfort food for the soul.
Intervening variables are defined as interact-
ing forces that influence recipients’ perceptions
of total comfort. These consist of variables such
as past experiences, age, attitude, emotional
state, support system, prognosis, finances, edu-
cation, cultural background, and the totality of
elements in recipients’ experience. They are not
easily influenced by nurses.
Comfort was defined technically earlier in this
chapter. It is the state that is experienced imme-
diately by recipients of comfort interventions. It
entails the holistic experience of being strength-
ened through having comfort needs addressed.
The concept of health-seeking behaviors was
developed by Dr. Rozella Schlotfeldt (1975)
and represents the broad category of subsequent
outcomes related to the pursuit of health.
Schlotfeldt stated that HSBs could be internal
or external. She was ahead of her time in think-
ing that a peaceful death could also be an HSB
384 SECTION VI • Middle-Range Theories
Health
care
needs
Health-
seeking
behaviors
Nursing
interventions
Intervening
variables
Enhanced
comfort
Institutional
integrity
Best
practices
Best
policies
External
behaviors
Internal
behaviors
Peaceful
death
+ +
Fig 21 • 2 Conceptual framework for comfort theory.
3312_Ch21_381-392 26/12/14 10:41 AM Page 384
(Schlotfeldt, 1975). Realistic HSBs are deter-
mined by recipients of care in collaboration with
their health-care team.
Institutional integrity is defined as those
corporations, communities, schools, hospitals,
regions, states, and countries that possess
qualities of being complete, whole, sound,
upright, appealing, ethical, and sincere. When
an institution displays this type of integrity,
it can produce valuable evidence for best prac-
tices and best policies. Best practices are
health-care interventions that produce the
best possible patient and family outcomes
based on empirical evidence. Best policies
are institutional or regional policies, ranging
from basic protocols for procedures and
medical conditions to systems for access and
delivery of health care. Best policies are also
determined from empirical evidence.
As stated previously, the diagram and
specific definitions for the concepts in CT
provide a pattern and practical rationale for
practicing comfort management. This kind
of care is individualized, efficient, holistic,
and therapeutic. Importantly, the nurturing
aspect of nursing provides the altruistic mo-
tivation for practicing comfort management.
It is the traditional mission and passion of
nursing (Kolcaba, 2003; Morse, 1992).
But the practical rationale is important at
the institutional level because without
administrative support for optimal staffing
and employment practices, nurses often
cannot give the kind of care that drew them
to the profession.
For teaching and learning purposes, care
plans based on CT are provided on Kolcaba’s
website and in her book (Kolcaba, 2003). One
is for patients, and one is for patients and
family members, as defined by the patient.
(Note: For teaching and learning, it is not
necessary to distinguish among relief, ease,
and transcendence when assessing and inter-
vening for unmet comfort needs.) Institu-
tional outcomes can be included in the care
plans even if these data are not accessible to
students and beginning nurses (Kolcaba,
1995). These care plans can also be applied in
home care and in long-term care.
Application of the Theory
in Practice
As noted earlier, according to CT, there are
three types of comforting interventions: techni-
cal, coaching, and comfort food for the soul.
Technical interventions are those that are speci-
fied by other disciplines or by nursing protocols;
they include medications, treatments, monitor-
ing schedules, insertion of lines, and so forth.
For patients, competency in the administration
and documentation of technical interventions is
the minimum expectation for nurses. Coaching
consists of supportive nursing actions, active
listening, referrals to other members of the
health-care team, advocacy, reassurance, and so
forth. Comfort food for the soul comprises those
extra special, holistic, and more time-consuming
nursing interventions such as back or hand
massage, guided imagery, music or art therapy,
a walk outside, or special arrangements for
family members. The latter two types of inter-
ventions require considerably more expertise and
confidence of nurses and are what patients most
remember. And they are what Benner (1984)
would ascribe to “expert” nurses.
However, most nurses focus on technical in-
terventions first and, when time permits, imple-
ment coaching techniques. Interestingly,
charting usually accounts only for technical
interventions and the effects of analgesia; there
are no places in traditional hospital records to
record the more important healing interven-
tions. But patients rarely remember the techni-
cal interventions; the important interventions to
patients and their families are those that are not
documented, such as coaching and comfort
food for the soul, the most important work of
expert nurses. Thus, there is a perpetual discon-
nect between legal charting and actions that
patients want and need from their nurses and
which we claim to be the essence of nursing. It
is no wonder that, when pressed, nurses cannot
describe the impact they make with patients and
their families—coaching and comfort food
interventions are not valued by administrators
and are not even visible in patient care records.
This can result in the value of nursing being
understated or even invisible.
CHAPTER 21 • Katharine Kolcaba’s Comfort Theory 385
3312_Ch21_381-392 26/12/14 10:41 AM Page 385
CT provides the language and rationale to
once again claim and document essential nurs-
ing activities that are most beneficial to patients
and family members in stressful health-care sit-
uations. It is also important to remember that
the outcome of enhanced comfort is positive
outcome and a true measure of quality care,
rather than a measure of what quality care is not,
such as the currently measured outcomes of
nosocomial infections, falls, decubitus ulcers,
medication errors, and failure to rescue. (Would
you want to go to a hospital that was looking
only at negative outcomes such as medication
errors or “failures to rescue”?)
How to Be a Nurse
CT guides nurses to detect comfort needs of pa-
tients and families that are not being addressed
and to develop interventions to meet those
needs. Their caring actions are intuitive, but in
this theory, caring is a comfort intervention in
and of itself. CT describes how to care and how
to BE a nurse, what is important to patients and
families, and factors that facilitate healing. In
addition, all technical nursing interventions are
delivered in a comforting way.
Nurses and patients want to experience in-
tentional and meaningful moments with each
other and with family members, the kind that
patients might call wow moments. (“Wow! I’ll
always remember that nurse.”) Nurses usually
sense when this happens, and these instances
are sustaining, satisfying, and profound for
them as well as for their patients. But nurses
often fail to understand and share how the mo-
ment intentionally came to be created, especially
if they practice without a theory. These special
instances require appropriate theories to add
both personal and disciplinary structure and
meaning to such experiences (Chinn, 1998).
CT is one such theory and can give structure
to these experiences. CT states that the process
of comforting a patient entails the intention
to comfort, to be present, and to deliver com-
forting interventions based on the patient’s and
loved ones’ unmet comfort needs (Kolcaba,
2003; Kolcaba online at http://www.thecom-
fortline.com/). If the patient needs time to
voice concerns and questions, the nurse listens
attentively and provides culturally appropriate
encouragement and body language (a comfort-
ing intervention). The nurse knows exactly why
and when to do this, because he or she is tuned
into the whole person as patient and because the
nurse wants to provide comfort, to soothe in
times of distress and sorrow. Such an explana-
tion of how to be a nurse is lacking in many
other theories.
Institutional Advocacy
It is not enough for institution administrators to
state that they want nurses and other care
providers to practice comforting care—they
need to implement documentation and rein-
forcement strategies to ensure this is done and
to show that they value this kind of care. If
administrators do not take on this responsibility,
practicing nurses can be self-advocates and begin
to document comforting interventions and their
effects in narrative charting. Whether top-down
and/or from the grassroots, the institutional ideal
is for health-care institutions to provide ways in
which comfort needs of patients and family
members are routinely charted, beginning
with baseline comfort levels. Comforting inter-
ventions are described and implemented, and
comfort levels are reassessed and charted. Mod-
ifications to the interventions are made until
comfort levels are sufficiently increased. Prefer-
ences of patients and families are honored
wherever possible. In appropriate settings, com-
fort contracts (Appendix A) can be instituted
and followed throughout a defined clinical
situation such as surgery, labor and delivery, or
an acute psychiatric episode.
According to CT, technical interventions
should be documented as usual (often on a
checklist including times), but methods of
intentional caring also should be documented—
in the same way that administration of pain
medication is noted in two places. There are
many suggestions for documentation on the
instrument section at Kolcaba’s website, includ-
ing a verbal rating scale, a numeric diagram,
comfort daisies for children, a comfort behaviors
checklist for nonverbal or unresponsive patients,
and several questionnaires about patient comfort
for different research settings. These instruments
386 SECTION VI • Middle-Range Theories
3312_Ch21_381-392 26/12/14 10:41 AM Page 386
can be downloaded from the website and used
in practice and/or research, without permission
because the website is in the public domain.
The address is www.TheComfortLine.com.
In addition to providing methods for doc-
umentation of comfort needs and comforting
measures, there are other ways that institutions
can demonstrate their commitment to comfort
management. These include building comfort
management into orientation, in-service pro-
grams, performance reviews, and methods for
nursing assignments (based in part on comfort
needs of patients and family members).
Institutional Awards
Institutions have adopted CT to enhance
nurses’ work environments, such as in the
quest for national recognition including
Magnet Status, the Baldrich Award, and the
Beacon Award. Many institutions discover
that the application process for these types of
awards is simplified when a professional prac-
tice model is adopted. The main benefit of
doing so is that employees are on the “same
page”—in the case of CT, comforting patients
and family members in their own personalized
styles and capacities. Moreover, and perhaps
most important, administrative commitment
to CT includes sufficient staffing levels in all
departments to support this type of holistic
health care. A large hospital system that
adopted CT to undergird their application for
Magnet Status and was successful in achieving
Magnet Status shortly thereafter is Southern
New Hampshire Medical Center (SNHMC;
Kolcaba, Tilton, & Drouin, 2006).
When SNHMC decided to apply for
Magnet Status, nurses from middle manage-
ment formed a committee and reviewed several
nursing theories. They chose CT because it
most accurately reflected their values and goals.
Kolcaba was contacted to arrange a consultative
visit, which occurred after a sufficient time to
prepare the other departments, including upper
administrative levels, for the visit.
As part of this consultation, Kolcaba and the
chief nursing officer visited all departments.
They requested suggestions from the staff for
ideas that would increase their comfort at work.
The many suggestions that were given came to
be added to comfort “wish lists” on each unit.
Another strategy adopted during this visit con-
sisted of brief instructions about designing and
implementing small “comfort studies” specific to
each unit and to common clinical problems.
The diagram of CT (see Fig. 21-2) defines the
research process when comfort studies are un-
dertaken, often a requirement for national
awards. Any comforting intervention that is im-
plemented by nurses, such as a “Comfort Cart”
or hand massage demonstrate to evaluators how
the practice model (CT) is implemented and
that the nurses are conducting basic research.
Strategies for publicizing the results of these
studies as well as the institutional commitment
to comfort management were also suggested.
The Meaning of Comfort Theory
for Practice
Kolcaba routinely asks nurses and students in her
audiences about their experiences during past
hospitalizations, either as a patient or a family
member. She asks if they remember any of their
nurses, and if so, what do they remember? The
stories that emerge are usually about nurses who
demonstrated small, nontechnical, but very
comforting acts of compassion and understand-
ing. Examples of these interventions include the
following: a brief back massage, helping a child
make a phone call, sitting beside an anxious pa-
tient, making eye contact during an interaction,
gently encouraging ambulation, listening atten-
tively to role-change issues, holding a dying pa-
tient’s hand, washing a patient’s hair, making a
family member comfortable during an overnight
stay, and so forth. Patients remember these types
of interventions for years after a stressful health-
care episode because emotions run high and
kind encounters are precious. Each is an example
of a holistic comfort intervention that has greater
positive effects on the patients’ total comfort
than could be imagined by the caregiver. These
comforting interventions are examples of “wow
moments” for receivers, and the exchange also
renews the givers of such acts. Moreover, such
comforting interventions can be delivered by any
member of the health-care team or department
within the context of their job description.
CHAPTER 21 • Katharine Kolcaba’s Comfort Theory 387
3312_Ch21_381-392 26/12/14 10:41 AM Page 387
How Comfort Theory Lives in Practice
Best Practices
Currently, there is administrative interest in
improving the “patient experience”—a factor
that typically is measured by items on patient
satisfaction instruments, the results of which
are posted on public websites. The quality of
the “patient experience,” as rated by patients
after a hospital stay, determines choices by
insurance companies for future coverage of
their enrollees. Often, these items are nursing
sensitive, meaning that if nurses demonstrate
simple comforting techniques, patients will
respond favorably to those “patient experience”
questions.
One administrative approach to enhancing
the patient experience has been to implement
scripting, in which members of the health-care
team memorize specific prewritten statements
to use during common patient encounters. An
example is a standard script to be delivered on
first introducing oneself to the patient such as,
“Hello, I am Nurse Thomas, and I will be in
charge of your care for today. If you need
anything at all, please let me know.” This
approach may negate individualized care, the
special needs of the patient and family, and the
particular communication skills of the team
member. And most patients can determine
when such statements are prescripted, espe-
cially when they hear the same statements
several times from different caregivers over the
course of a hospital stay.
A different approach is to undergird all pa-
tient interactions with principles of CT, which
caregivers learn in orientation and in-service
programs. Principles of CT that are relevant to
the patient experience are that (1) each interac-
tion entails therapeutic use of self; (2) caregivers
assess for comfort needs of patients and family
members and design their interaction to meet
those needs; (3) caregivers approach each patient
and family member with the intent to comfort
and make a personal, culturally appropriate
connection; and (4) caregivers regularly reassess
comfort of patients and family members and
document comfort levels routinely. Using this
approach facilitates individualized and efficient
care and a more positive patient experience. Two
examples of how CT is being used to enhance
the patient experience are at the Mount Sinai
Hospital in New York City and at Kaiser
Permanente Hospital in San Francisco.
Electronic Database
To support CT in practice, components have
been incorporated into national electronic
databases, such as the National Interventions
Classification and the National Outcomes Clas-
sification systems (the Iowa Taxonomy) as well
as the North American Nursing Diagnosis As-
sociation. Comforting interventions, comfort
outcomes, and comfort diagnoses are included
in these data systems, meaning that individual-
ized comfort needs and the effectiveness of in-
terventions to meet those needs can be charted
electronically and entered into larger databases
by a hospital system, at the local, state, region,
or country level. Although there are at least
13 national databases for nursing, and others
for medicine, when hospital systems select and
contribute data to a mainstream system, docu-
mentation of patient care problems, interven-
tions, and outcomes can be more widely
compared, leading to more consistent and
higher quality patient care practices. In this
regard, an important feature of CT is the uni-
versality of its main concept, comfort. This is a
word that is understood by all health-related
disciplines and is translatable into most lan-
guages, as evident with the number of foreign
language comfort instruments available on
Kolcaba’s website.
Best Policies
An example of how CT is used in practice is the
creation of a policy for Comfort Management
by the American Society of Peri-Anesthesia
Nurses (ASPAN). This national association is
composed of nurses who work in the following
areas: ambulatory surgery, perioperative staging,
operating room, postanesthesia recovery, and
step-down. ASPAN decided collectively to apply
CT in an explicit way throughout patients’ sur-
gical experiences. Kolcaba served as consultant
and facilitator in this process.
First, they achieved national consensus about
the development of Guidelines for Comfort
388 SECTION VI • Middle-Range Theories
3312_Ch21_381-392 26/12/14 10:41 AM Page 388
Management that would complement their
existing Guidelines for Pain Management. The
process proceeded with a survey of its member-
ship about providing comfort to patients, then
with a report of findings, then the conference
about components of Comfort Management,
and finally the composition of the guidelines
(Kolcaba & Wilson, 2002; Wilson & Kolcaba,
2004).
The guidelines contain information about
how to (1) perform a comfort assessment,
(2) create a comfort contract with patients before
surgery, (3) discover the interventions that pa-
tients and families use at home for specific dis-
comforts, (4) use a checklist for comfort
common management strategies, (5) document
changes in comfort, and (6) implement pre- and
post-testing for contact hours in comfort man-
agement. The completed Guidelines for Com-
fort Management are available on ASPAN’s
website (www.ASPAN.org). This is an example
of a grassroots change (within a national associ-
ation of nurses) that was disseminated to all pe-
rianesthesia settings and soon became a practice
expectation. This example could be followed by
any nursing specialty, at the macro level, or any
patient care unit, at the micro level. The impor-
tant point is that the model was initiated by
nurses and is now an expectation that the Joint
Commission reviews on recertification.
CHAPTER 21 • Katharine Kolcaba’s Comfort Theory 389
Practice Exemplar
When I received the night nurse’s report
about a new patient, Susan, I was told she was
55 years old, recovering from abdominal sur-
gery where a large malignant tumor was dis-
covered. This new diagnosis of cancer, and the
subsequent cancer treatments to come, caused
her to be very depressed. She was not eating
and barely talking. I determined that I would
try to get her to start eating and began a series
of “comfort interventions.”
I went into her room and introduced my-
self. Susan was crunched down in her bed, and
her sheets were disheveled. I noticed her
breakfast tray nearby, the cold scrambled eggs
and everything else on the tray untouched. I
asked her if she could eat or drink anything on
the tray and she replied, “No.” Her affect was
flat and depressed, and she did not want to
chat. My informal assessment concluded that
her comfort needs were for improvements in
the following: nutrition, mobility, positioning
(physical needs); spirits and motivation (psy-
chospiritual); social support, listening, under-
standing (sociocultural); and cleanliness of
room, light and noise preferences, clean and
tight linens (environmental).
I began implementing a comfort care plan
automatically, asking Susan if anything at all
might taste good to her? She weakly answered,
“Maybe some cream of wheat.” I told her I
could order that. Then I asked if she could get
into the chair so she could eat more easily. She
agreed, and I helped her sit up. I adjusted the
TV and shades in her room to her specifica-
tions, picked up tissues and trash, and put her
call light at her fingertips. Already her affect
improved a bit. I silenced the beeping IV
pump . . . ahhhhh. “Are you comfortable?”
“Yes, I’m OK.”
“Is there anything else I can do for you
right now?”
“No.” Telling her that I would return with
the cream of wheat, I left the room, told a
team member and the ward clerk that I would
be in Susan’s room, and asked them to try not
to disturb us. I was going to help Susan eat
some breakfast. I turned off my beeper,
retrieved the cream of wheat, entered her
room, and closed the door. We needed some
uninterrupted time!
I sat down in front of her with the tray table
between us, and I asked her if she needed help
with the spoon. She nodded yes. I began
spoon-feeding her the hot cereal with just the
right amount of milk. Slowly, Susan began
taking an interest in the cereal and me, asking
me a few questions about myself as I did her.
As we engaged in small talk, she continued
to let me feed her, until the whole bowl was
finished. “That tasted good,” she said.
Continued
3312_Ch21_381-392 26/12/14 10:41 AM Page 389
390 SECTION VI • Middle-Range Theories
Practice Exemplar cont.
“I’m glad,” I said. “You did very well. Now,
I am going to see to my other patients and I’ll
look in on you again in about 15 minutes,
which I was sure to do.
I had achieved two of the goals for my “plan”
which was to (a) get Susan to start eating and
(b) have her engage in conversation. I also
gained a great deal of satisfaction from the en-
counter. I didn’t realize it was a “Wow Mo-
ment” at the time, but for Susan it was. About
3 weeks later, I received a brief note from Susan
who was now home. It is excerpted below:
It’s your cream of wheat that started me
back to recovery, but more than that, it was
your tender loving care and time that I needed
in my much weakened condition. It was quite
an effort to raise my head to eat so I thank you
and picture you feeding me very often in my
mind. . . .Thank you for being a ‘bedside
nurse’!!
■ Summary
The midrange theory of comfort was first pub-
lished in 1994 and has been tested repeatedly by
nurse scientists since that time. Each test of the
theory has supported the initial propositions,
although many more tests need to be conducted
on the relationships between patient/family
goals and markers for institutional integrity.
Instruments adapted and/or translated from the
original General Comfort Questionnaire, the
newer Comfort Behaviors Checklist, Comfort
Daisies, and Verbal Rating Scale, and the Gen-
eral Comfort Questionnaire has been certified
by AHRQ as a quality measure since 2003.
Comfort theory has also been applied
frequently by health agencies and hospitals for
the purpose of enhancing the work environ-
ment for staff and explicating a unifying
theme for patient and family care. The theory
is popular because it describes what expert
nurses already know: One of the most impor-
tant missions for nursing is still to bring com-
fort to our patients and families, no matter
what their circumstances are. Comfort brings
strength for those difficult health-care tasks
that we must all face.
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Appendix A: Example of a Comfort Contract
Thank you for taking the time to complete the
comfort contract. The purpose of this contract
is to increase your comfort and pain manage-
ment while you are hospitalized. Please rate
your expectation of comfort from 0 to 10 (10 is
highest) for each situation listed. Please use the
comfort scale as directed for all items except
when indicated otherwise and take your time
and complete the following questions.
Developed by the following students at the Uni-
versity of Akron an distributed with their permis-
sion: Robert Bearss, Brent Ferroni, Ryan Hartnett,
Kristy Kuzmiak, Brittney Stover, Spring 2006.
The Comfort Experience
1. I expect a comfort level of:
a._______ when the anesthesia wears off.
b._______ on postoperative day 1
c. _______ on postoperative day 3 (when
ambulating)
d._______ on postoperative day 5 (study
conclusion day)
2. These interventions might assist to increase
my comfort:
Warming blanket (recovery room)
Pet visitation
Family visits (when anesthesia wears off)
Music
Cold washcloth
Pillows—location: ___________
Massage
Other ________________
(Circle All that Apply.)
3. In the past, I have required (small, mod-
erate, large) amounts of pain medication
to keep me comfortable.
4. I have had success with the following
medications during my previous admis-
sions to the hospital ____________
5. The following medications I had taken
have resulted in undesirable outcomes:
_________________________________
The undesirable outcomes have included:
_________________________________
_________________________________
Nursing Interventions
6. I prefer personal hygiene to be performed
during the (morning, afternoon, evening).
7. I prefer my family to be present (all the
time, occasionally, not at all) during my
recovery.
8. I wish to have the following family mem-
ber(s) present:_____________________.
9. I prefer to exclude the following persons
from visiting my room______________.
10.I prefer to have a fan present in my room.
(Yes/No)
11.I prefer updates regarding my status (only
when asked, daily, not at all).
392 SECTION VI • Middle-Range Theories
Extreme
discomfort
1 2 3 4 5 6 7 8 9 10
Extreme
comfort
Comfort
Fig 21 • 3 Comfort scale.
3312_Ch21_381-392 26/12/14 10:41 AM Page 392
Chapter 22Joanne Duffy’s
Quality-Caring Model©
JOANNE R. DUFFY
Introducing the Theorist
Overview of the Theory
Applications of the Model
Practice Exemplar
References
393
Introducing the Theorist
Joanne R. Duffy, PhD, RN, FAAN, has had an
extensive career encompassing clinical, admin-
istrative, and academic roles. Currently, she is
the West Virginia University Hospitals En-
dowed Professor of Research and Evidence-
based Practice and Interim Associate Dean for
Research and PhD Education at the Robert C.
Byrd Health Sciences Center, West Virginia
University, Morgantown, WV, and is an Ad-
junct Professor at the Indiana University School
of Nursing in Indianapolis, IN. She has directed
four graduate nursing programs (critical care,
care management, nursing administration,
and a PhD program) and was a former Division
Director of a school of nursing. She actively
teaches nursing theory, research, and leadership
in PhD, DNP, masters and honors programs,
directs dissertations and scholarly projects, and
interfaces with acute care health professionals
and leaders to advance evidence-based practice.
Dr. Duffy graduated from St. Joseph’s Hospital
School of Nursing in Providence, RI, com-
pleted her BSN at Salve Regina College in
Newport, RI, and her master’s and doctoral
degrees at the Catholic University of America
in Washington, DC.
Dr. Duffy has held clinical positions in
intensive care, coronary care, and emergency
services and is a cardiovascular clinical nurse
specialist. She was an associate director of
nursing at one urban hospital and two large
academic medical centers, developed a Cardio-
vascular Center for Outcomes Analysis, and
administrated a transplant center while simul-
taneously serving in academic appointments.
Her special expertise in outcomes measurement
has led to the focus of her work: maximizing
health outcomes, particularly among older
adults, through caring processes.
Joanne R. Duffy
3312_Ch22_393-410 26/12/14 10:44 AM Page 393
Dr. Duffy was the first to examine the link
between nurse caring behaviors and patient out-
comes and developed the caring assessment tool
(including the newest version, the e-CAT) in
multiple versions. She developed the middle-
range quality-caring model© to guide profes-
sional practice and research, ultimately exposing
the hidden value of nursing work. Dr. Duffy
was the principal investigator on the national
demonstration project, “Relationship-Centered
Caring in Acute Care,” has been the principal
investigator for two caring-based intervention
studies, and served as consultant to several mul-
tidisciplinary studies. Dr. Duffy was a consult-
ant to the American Nurses Association (ANA)
in the development and implementation of the
National Database of Nursing Quality Indica-
tors and the former chair of the National
League for Nursing’s Nursing Educational
Research Advisory Council. Dr. Duffy is a
Commonwealth Fund Executive Nurse Fellow,
a recipient of several nursing awards, a Fellow
in the American Academy of Nursing, a fre-
quent guest speaker, and a former Magnet
Appraiser. The first edition of her book, Quality
Caring in Nursing: Applying Theory to Clinical
Practice, Education, and Research received the
AJN book of the year award in 2009. The
second edition, Quality Caring in Nursing and
Health Systems: Implications for Clinical Practice,
Education, and Leadership (2013), focuses on
caring relationships as the central organizing
principle of health systems.
Overview of the Theory
The quality-caring model© was initially devel-
oped in 2003 to guide practice and research
(Duffy & Hoskins, 2003). The seeds of the
model were sown during discussions concern-
ing nursing interventions, but it was informed
from earlier work on caring (Duffy, 1992).
While examining the outcomes variable of pa-
tient satisfaction in the late 1980s, Dr. Duffy
uncovered that hospitalized patients who were
dissatisfied often expressed, “Nurses just don’t
seem to care.” This concern was corroborated
in the literature and represented a clinical
problem that significantly affected patients’
perceptions of quality. Over time, Dr. Duffy
continued to study human interactions during
illness, developing tools to measure caring
(Duffy, 2002; Duffy, Brewer, & Weaver, 2014;
Duffy, Hoskins, & Seifert, 2007) and studying
the linkage between nurse caring and selected
health-care outcomes (Duffy, 1992, 1993).
In 2002, it became apparent that there were
few nursing theories that could guide the devel-
opment of a caring-based nursing intervention
while simultaneously speaking to the relationship
between nurse caring and quality. As part of a re-
search team, Drs. Duffy and Hoskins developed
and tested the model in a group of heart failure
patients (Duffy, Hoskins, & Dudley-Brown,
2005). Caring relationships were the core concept
in this model and were believed to be integrated,
although often hidden, in the daily work of nurs-
ing. This form of caring was considered different
from the caring that occurs between family and
friends because professional nurse caring requires
specialized knowledge, attitudes, and behaviors
that are specifically directed toward health and
healing. Through this specialized knowledge, re-
cipients feel “cared for,” which was theorized as a
positive emotion necessary for taking risks, feeling
safe, learning new healthy behaviors, or partici-
pating effectively in decision making based on
evidence. This sense of “feeling cared for” was
considered an antecedent necessary to influence
improved intermediate and terminal outcomes,
particularly nursing-sensitive outcomes such as
knowledge (including self-knowledge), safety,
comfort, anxiety, adherence, human dignity,
health, confidence, engagement, and positive ex-
periences of care. Furthermore, the model was
considered supportive to professional nursing be-
cause nurses themselves were theorized to benefit.
Blending societal needs for measurable outcomes
with the unique relationship-centered processes
central to daily nursing practice represented a
practical, postmodern approach.
The major purposes of the quality-caring
model© at that time were to:
• Guide professional practice
• Describe the conceptual–theoretical–
empirical linkages between quality of
care and human caring
• Propose a research agenda that would
provide evidence of the value of nursing
394 SECTION VI • Middle-Range Theories
3312_Ch22_393-410 26/12/14 10:44 AM Page 394
Because of the complexities of modern
society, individuals, the health system, and
the professionals who work in it, the Quality
Caring Model© has evolved from its initiation
in 2003. Since that time, the model has been re-
vised twice (Fig. 22-1) to meet the demands of
the multifaceted, interdependent, and global
health system that “requires a more sophisticated
workforce, one that understands the significance
of systems thinking, whose practice is based on
knowledge, multiple and oftentimes competing
connections, and one that values relationships as
the basis for actions and decision-making”
(Duffy, 2009, p.192). In this revised version, the
link between caring relationships and quality
care is even more explicit, challenging the nurs-
ing profession to use caring relationships as
the basis for daily practice. The revised model
is considered a middle-range theory because
it draws on others’ work, is practical, and can
be tested. It views quality as a dynamic, nonlin-
ear characteristic that is influenced by caring
relationships. “Quality is not an endpoint per se,
but a process of continuous learning and improve-
ment . . . that treats patients as full partners . . .
and is fully integrated into the work of health
professionals” (Duffy, 2013, p. 31).
When caring relationships are the basis of
nursing work, positive human connections are
formed with patients and families that influence
future interactions and positively influence
intermediate health outcomes. Thus, caring is a
process that involves a reciprocal relationship
(characterized by caring factors) between
human persons, whereby the positive emotion,
“feeling cared for,” is attained. It is this feeling
of being “cared for” that matters in terms of en-
abling the conditions for self-advancing systems.
As such, it is an essential performance indicator
of quality nursing care. Caring relationships also
are theorized to enhance interprofessional prac-
tice and benefit nurses themselves by maintain-
ing congruence with professional values and
contributing to meaningful work.
CHAPTER 22 • Joanne Duffy’s Quality-Caring Model© 395
Intermediate
outcomes
SELF-ADVANCINGSYSTEMS
Feel “cared for”
Humans in relationship
Relationship-centered
professional encounters
Communities
Self
Fig 22 • 1 Revised quality-caring model©. (From Duffy, J. [2013a]. Quality caring in nursing and health systems:
Implications for clinicians, educators, and leaders [p. 34]. New York: Springer.)
3312_Ch22_393-410 26/12/14 10:44 AM Page 395
Concepts, Assumptions,
and Propositions
In the latest revision of the quality-caring
model©, there are four main concepts. The first
is humans in relationship. This idea refers to the
notion that humans are multidimensional be-
ings with various characteristics that make
them unique. Recognizing human character-
istics, including how they differ and yet are
the same, provides an understanding that
influences human interactions and conse-
quently, nursing interventions. Humans are
also social beings connected to others through
birth or in work, play, learning, worship,
and local communities. It is through these
connections that humans mature, enhance
their communities, and advance.
Relationship-centered professional encounters
consist of the independent relationship between
the nurse and patient/family and the collabora-
tive relationship that nurses establish with
members of the health-care team. When these
relationships are of a caring nature, the interme-
diate outcome of “feeling cared for” is generated.
Embedded in this concept are the caring factors
that are discussed in the next section. Feeling
cared for is a positive emotion that signifies to
patients and families that they matter. Caring
relationships prompt this feeling, inciting per-
sons’, groups’, and systems’ capabilities to change,
learn and develop, or self-advance. In other
words, “feeling cared for” allows one to relax,
feel secure, and get engaged in his or her health-
care needs. It is an important antecedent to
quality health outcomes, particularly those that
are nursing-sensitive.
Patients and families who experience caring
relationships from health-care providers are
more apt to concentrate on their health, focus
on learning about it, modify lifestyles, adhere to
the recommendations and regimens, and ac-
tively participate in health-care decisions. They
feel understood and more confident in their
abilities. Over time, persons who experience
caring interactions with health professionals
progress or self-advance. Self-advancing systems
is the final concept in this model. It is a phe-
nomenon that emerges gradually over time and
in space reflecting dynamic positive progress
that enhances the systems’ well-being. Self-
advancing systems are stimulated by caring re-
lationships, but the forward movement itself
cannot be controlled directly; rather, it emerges
over time, driven by caring connections. Self-
advancing systems represent quality in the
model because it is a dynamic concept that
enhances an individual’s or system’s well-being.
The overall purposes of the revised quality-
caring model© are to (1) guide professional
practice and (2) provide a foundation for nurs-
ing research. It can also be used in nursing ed-
ucation (to guide curriculum development and
facilitate caring student–teacher relationships)
and in nursing leadership as a basis for human
interactions and decision-making.
Assumptions of the revised quality-caring
model© include the following:
• Humans are multidimensional beings
capable of growth and change.
• Humans exist in relationship to themselves,
others, communities or groups, nature
(or the environment), and the universe.
• Humans evolve over time and in space.
• Humans are inherently worthy.
• Caring consists of processes that are used
individually or in combination and often
concurrently.
• Caring is embedded in the daily work of
nursing.
• Caring is a tangible concept that can be
measured.
• Caring relationships benefit both the carer
and the one being cared for.
• Caring relationships benefit society.
• Caring is done “in relationship.”
• Feeling “cared for” is a positive emotion.
• Professional nursing work is done in the
context of human relationships. (Duffy,
2013, p. 33)
Propositions are those relational statements
that tie model concepts to each other and in
some instances can be the basis for hypothesis
testing. Propositions of the quality-caring
model© include the following:
Human caring capacity can be developed.
Caring relationships are composed of process
or factors that can be observed.
396 SECTION VI • Middle-Range Theories
3312_Ch22_393-410 26/12/14 10:44 AM Page 396
Caring relationships require intent, specialized
knowledge, and time.
Engagement in communities through caring
relationships enhances self-caring.
Independent caring relationships between
patients and health-care providers influence
feeling “cared for.”
Collaborative caring relationships among
nurses and members of the health-care
team influence feeling “cared for.”
Caring relationships facilitate growth and
change.
Feeling “cared for” is an antecedent to
self-advancing systems.
Feeling “cared for” influences the attainment of
intermediate and terminal health outcomes.
Self-advancement is a nonlinear, complex
process that emerges over time and in space.
Self-advancing systems are naturally self-
caring or self-healing.
Relationships characterized as caring con-
tribute to individual, group, and system
self-advancement (Duffy, 2013, p. 38)
Role of the Nurse
The overall role of the professional nurse in
this model is to engage in caring relationships
so that self and others feel “cared for” (Duffy,
2013, p. 33). Such actions positively influence
intermediate and terminal health outcomes
(self-advancement), including those that are
nursing-sensitive.
The revised quality-caring model© specifically
emphasizes the following responsibilities of
professional nurses:
• Attain and continuously advance knowl-
edge and expertise in caring processes.
• Initiate, cultivate, and sustain caring
relationships with patients and families.
• Initiate, cultivate, and sustain caring relation-
ships with other nurses and all members of
the health-care team.
• Maintain an ongoing awareness of the
patient/family point of view.
• Carry on self-caring activities, including
personal and professional development.
• Integrate caring relationships with specific
evidenced-based nursing interventions to
positively influence health outcomes.
• Engage in continuous learning and prac-
tice-based research.
• Use the expertise of caring relationships
embedded in nursing to actively participate
in community groups.
• Contribute to the knowledge of caring and,
ultimately, the profession of nursing using
all forms of knowing.
• Maintain an open, flexible approach.
• Use measures of caring to evaluate nursing
care. (Duffy, 2013, pp. 38–39)
Caring Relationships
There are four caring relationships essential
to quality caring (Fig. 22-2). The first is the
relationship with self. Because humans are
multidimensional (comprising bio–psycho–
social–cultural–spiritual components) that
continuously interact in concert with the uni-
verse, their fundamental nature is integrated
or whole. The many seemingly different parts
relate to and depend on each other, generating
an orientation of the self that represents a
source of understanding often lost in the busi-
ness of life. Individuals, particularly nurses,
tend to go about their day habitually moving
from one task to another without noticing their
internal bodily processes, feelings, or connec-
tions with others. This externally driven focus
separates individuals from those internal forces
CHAPTER 22 • Joanne Duffy’s Quality-Caring Model© 397
Health care
teamPatient/family
CommunitySelf
Relationship-
centered
professional
practice
Fig 22 • 2 Four relationships necessary for quality
caring. (Copyright ©2013 J. Duffy. From Duffy, J.
[2013a]. Quality caring in nursing and health systems:
Implications for clinicians, educators, and leaders [p. 53].
New York: Springer.)
3312_Ch22_393-410 26/12/14 10:44 AM Page 397
that hold a special knowledge of self. In nurs-
ing, professionals care for others and their
families with ease, frequently “forgetting” to
connect with self. Yet allowing oneself to slow
down enough to access his or her own genuine-
ness offers a clarity that is life enhancing. Some
would say such inner awareness is necessary for
authentic interaction and health (Davidson et
al., 2003), whereas others (Siegel, 2007) believe
it is necessary to adequately care for others.
As human beings, professional nurses who are
regularly “in touch” with themselves set up the
conditions for self-caring, a state that offers a
rich supply of energy and renewal.
In nursing, remaining self-aware is a neces-
sary prerequisite for caring relationships because
in knowing the self, it is possible to know others.
Regular mindfulness activities such as prayer,
meditation, quiet time, attention to physical
health through regular exercise and proper nu-
trition, and creative activities, when performed
in a conscious manner, promote insight. Like-
wise in the work environment, short pauses,
consciously remembering to center on the per-
son being cared for, attending to bodily needs
such as nourishment and elimination, and even
short time-outs ensure that the caring focus of
nursing remains the priority. Reflective aware-
ness by actively soliciting feedback about one’s
performance is another method of attaining self-
knowledge that may offer professional nurses a
boost in self-confidence or specific learning
opportunities. Reflective analysis in which
thoughts are actually documented in written or
taped format and then analyzed for their subjec-
tive meanings can be used to inform clinical
practice. Professional nurses need to acknowl-
edge and reflect on the important work they do
to value themselves and nursing, a precondition
for caring relationships (Foster, 2004).
As the primary focus of nursing, patients and
families who are ill are vulnerable and depend-
ent on nurses for caring. Initiating, cultivating,
and sustaining caring relationships with patients
and families is an independent function of
professional nursing that involves intention,
choice, specific knowledge and skills, and time
(Duffy, 2009). Intending to care depends on
one’s attitudes and beliefs; it shapes a nurse’s
choice and resulting behaviors, specifically
whether “to care” for another. Such choice is a
conscious decision that is required for effective
caring relationships. Deep awareness of the self
enhances caring intention and consequential
behaviors become more positively focused
toward the patient/family.
Collaborative relationships with members of
the health-care team are essential to quality health
care (Knaus, Draper, Wagner, & Zimmerman,
1986) and are depicted as an important relation-
ship in the quality-caring model©. Nurses are
already connected to one another by the work
they do and with other members of the health
team by the commonality of simultaneously
providing services to patients and families. But
collaboration connotes mutual respect for the work
of other health professionals and occurs best “in rela-
tionship.” Ongoing interaction is key to collabo-
ration in order to seek the other’s point of view,
validate the work, share responsibilities, and
evaluate the care. The quality-caring model©
maintains that professional nurses have a re-
sponsibility for implementing collegial, caring
interpersonal relationships with each other and
members of the health-care team. Discussing
specific clinical issues pertinent to patients, par-
ticipating in joint rounds, improving quality or
research projects, holding family conferences,
and discharging rounds are all examples of pos-
itive collaboration that benefit not only patients
and families but the health-care team as well.
Affirming each other’s unique contribution to
patient care through genuine collaboration con-
tributes to a healthy work environment that may
increase work satisfaction.
Finally, caring for the communities nurses
live and serve in reflects another caring relation-
ship essential to the revised quality-caring
model.© This relationship is predicated on the
belief that humans interact with groups beyond
the family to connect, share similar history and
customs, and enhance the lives of each other.
Engaging in communities provides professional
nurses opportunities to use caring relationships
as the basis for improving health or decreasing
disease. Such activities contribute to the ongo-
ing vitality of the community and enrich nurses’
personal lives. The four relationships essential
to quality caring, when well developed and
practiced with knowledge of the caring factors,
398 SECTION VI • Middle-Range Theories
3312_Ch22_393-410 26/12/14 10:44 AM Page 398
meets the needs of patients and families for
quality health care.
The Caring Factors
Caring is not just a mindset or simple acts of
kindness; rather, clinical caring requires knowl-
edge (Mayerhoff, 1971) and skills, juxtaposed
on caring values. Many have theorized about
the qualities necessary for therapeutic relation-
ships (Rogers, 1961; Yalom, 1975), but Watson
(1979, 1985) identified 10 carative factors
necessary for human caring in the patient–nurse
relationship. Eight factors, reframed through
research and clinical experience, are currently
used to characterize caring in the quality-caring
model©. These factors are specifically defined,
facilitating the identification of specific cogni-
tive and behavioral abilities necessary for caring
relationships, and are as follows:
• Mutual problem-solving
• Attentive reassurance
• Human respect
• Encouraging manner
• Appreciation of unique meaning
• Healing environment
• Affiliation needs
• Basic human needs (Duffy, Hoskins, &
Seifert, 2007)
The caring factors were initially derived
from Watson’s original work (Watson, 1979,
1985) but also are consistent with the inten-
tions of other nursing theorists (Boykin &
Schoenhofer, 1993; Henderson, 1980; Johnson,
1990; King, 1981; Leininger, 1981; Nightingale,
1992; Orem, 2001; Peplau, 1988; Roach,
1984; Roy, 1980; Swanson, 1991) and empirical
research (Cossette, Cote, Pepin, Ricard, &
D’Aoust, 2006; Boudreaux, Francis, &
Loyacano, 2002; Campbell & Rudisill, 2006;
Mangurten et al., 2006; Paul, Hendry, &
Cabrelli, 2004; Wolf, Zuzelo, Goldberg,
Crothers, & Jacobson, 2006). Mutual problem-
solving refers to assisting patients and families
to learn about, question, and participate in
their health or illness. This is accomplished
reciprocally and requires professional interac-
tion that is informed and engaging. This factor
recognizes that patients and families are the
decision-makers in the health-care process and
facilitating informed alternatives and adoption
of their ideas is paramount.
Attentive reassurance refers to being available
and offering a positive outlook to patients and
families that helps them feel secure. Professional
nurses who use this factor are able to “be with”
their patients long enough to convey possibili-
ties, focus on their unique needs, listen, and
present some cheerful dialogue. Human respect
implies valuing the human person of the other
by acting in such a way that demonstrates that
value. For example, calling a patient by his or
her preferred name, performing tasks in a gentle
manner, and maintaining eye contact show
regard for the other. Using an encouraging man-
ner or a supportive demeanor during interac-
tions conveys confidence and is expressed both
verbally and nonverbally. It is especially impor-
tant to maintain uniformity between messages
expressed and those implied by body language.
Appreciation of unique meanings helps a patient
feel understood because the nurse uses this
factor to acknowledge what is significant to
patients and families. In other words, nurses
aim to see things from the patient’s point of
view and use his or her preferences and their
sociocultural meanings in care. In this way,
nurses tailor interventions to the patient’s frame
of reference. Cultivating a healing environment,
including appealing surroundings, decreasing
stressors (noise, lighting), ensuring patient pri-
vacy and confidentiality, and practicing in a safe
manner are included in this factor. The partic-
ular norms and customs of a department in
which a patient receives care also have an im-
pact. This factor is especially important in acute
care where adverse events remain a major source
of harm, death, and disability for Americans
(Fineberg, 2012). Ensuring that basic human
needs are attended to during an illness (including
the higher order needs; Maslow, 1954) has been
a major role of the professional nurse that today
is often delegated to unlicensed assistive person-
nel. Often this factor is blended with other
nursing activities such as assessments, teaching
and learning, and emotional support. Providing
for basic human needs is an opportunity to
further the development of caring relationships.
Finally, appreciating the significance of affilia-
tion needs refers to making sure that patients
CHAPTER 22 • Joanne Duffy’s Quality-Caring Model© 399
3312_Ch22_393-410 26/12/14 10:44 AM Page 399
are not only allowed access to their families,
but also that families are included in care deci-
sions. Being open and approachable to families
and keeping them informed is important to
patients’ well-being and should be a normal part
of nursing care.
The caring factors are used “in relationship”
with others and comprise the basis for the
“knowledge and skills” required to practice
according to the quality-caring model.© Using
them is dependent on patient needs and the
context of the situation. Not all factors are
necessarily used at once; rather, the professional
nurse uses his or her judgment to decide which
are necessary for certain situations. When ap-
plied with expertise, these factors are theorized
to positively affect recipients such that they feel
“cared for.” In fact, “feeling cared for” is a calm-
ing influence, allowing the patient to concen-
trate on the meaning of illness and the
requirements for health and healing. Feeling
cared for also sets up the conditions for future
interactions with health professionals that sway
eventual outcomes of care. “In other words, the
patient’s ability to progress is mediated some-
what by the feelings generated as a consequence
of caring relationships” (Duffy, 2009, p. 72).
Performing nursing in such a way that valuable
time is spent predominantly in caring relation-
ships with patients and families (i.e., using
the caring factors) ensures that patients and
families feel “cared for” and that health
outcomes are positively impacted.
The caring factors are applicable to the other
three relationships pertinent to the quality-
caring model.© For example, collaborative
relationships founded on the caring factors
enhance teamwork and cooperation. As experts
in caring, professional nurses are in a unique
position to profoundly benefit the health-care
system. Uniting caring knowledge and caring
action(s) in relationships with self, patients
and families, coworkers, and the community
provides opportunities for creative innovations,
improvements in practice, and a source of
energy for future interactions. Furthermore,
some nurses who practice this way describe
richer work experiences that are naturally
renewing (D’Antonio, 2008).
Applications of the Model
Clinical Practice
The quality-caring model© provides individual
clinicians, teams of health professionals, educa-
tors, and leaders with a relationship-centric
approach to health care. In doing so, it honors
the interdependencies necessary for human
advancement. For individual clinicians, it pro-
vides a “way of being with” patients and families
(through the caring factors) that can be used to
guide interventions, practice improvements, and
ongoing learning about the self. For health-care
teams, the model offers a way to relate to and
engage with other health-care providers in care
that is “best for the patient.” The quality-caring
model© offers health educators a caring peda-
gogy that honors caring relationships that are
lived out through the behaviors of faculty mem-
bers. In other words, teaching one “how to care”
is dependent on the “caring milieu” generated
by faculty members themselves who notice and
share “caring moments,” continuously reflect on
the nature of nursing, and who use cognitive,
psychomotor, and affective experiences to help
students acquire the knowledge, skills, and
attitudes of caring professionals. Likewise,
relationship-centered leaders preserve the foun-
dational caring patient–nurse relationship that
gives nursing its identity, ensures ethical
and legal services, and provides the nursing
workforce with meaning.
In Quality Caring in Nursing and Health Sys-
tems: Implications for Clinicians, Educators, and
Leaders, Duffy (2013a) highlights how many
health systems are using the quality-caring
model© to:
• Provide a foundation for patient-
centered care
• Enhance interprofessional practice
• Facilitate staff-directed practice changes
• Redesign professional workflow
• Generate guiding principles for human
resource practices
• Guide nurse residency programs
• Improve collective relational capacity
• Renew the meaning of nursing work
• Extend caring to others FIRST
• Build relationships with community groups
400 SECTION VI • Middle-Range Theories
3312_Ch22_393-410 26/12/14 10:44 AM Page 400
• Create a legacy of caring
• Sustain professionalism
• Revise nursing curricula
• Balance “doing” with “being”
Practice Improvement
Because caring relationships can be measured
and their consequences assessed, the model af-
fords an evaluation design for improvement of
services. The quality-caring model© maintains
that quality nursing care is based on the use of
best evidence and asserts the nursing respon-
sibility to engage in continuous learning, use
measures of caring, and contribute to caring
knowledge and practice-based research. Eval-
uation of nursing practice is an ongoing
process that is tied to nurses’ individual com-
petency as well as the processes used in daily
practice and their subsequent outcomes (both
intermediate and terminal). Using the caring
factors as the basis for competency statements
or performance expectations from which indi-
vidual nurses can complete self-evaluations,
gather peer reviews, or be evaluated by their
supervisors is a first step. A more comprehen-
sive approach using the 360-degree method
(Edwards & Ewen, 1996; London & Smither,
1995) provides assessments from the perspec-
tive of the one being evaluated (nurse self-
evaluation), those being “cared for” (patients
and families), the supervisor, and colleagues
(other nurses, physicians, other members of
the health-care team). This approach provides
the one being evaluated with information
about his/her performance from the perspective
of recipients of his/her care. Thus, patients
(those being “cared for”) and colleagues (those
within the health-care team) offer direct infor-
mation about the nature of caring displayed by
the nurse. Using these perspectives, the one
being evaluated can reflect on this feedback, and
then set personal goals for self-development, ul-
timately improving practice and benefitting
themselves and others (self-advancement). The
360 degree approach to evaluating individual
caring competence is thorough and relation-
ship centered; it takes advantage of multiple
sources and perspectives to provide important
feedback about nursing practice.
Evaluating processes of care requires measur-
ing the quality of caring relationships and using
those data to efficiently revise practice. Although
many performance improvement activities are
conducted in today’s health systems, few focus
on the patient–provider relationship. The lack
of focus on this relationship as a quality indica-
tor, combined with performance reports that
often do not represent the patient’s perspective
(Hudon, Fortin, Haggerty, Lambert, & Poitras,
2011), precludes practice improvement. Fur-
thermore, RNs frequently do not receive per-
formance information for 3 or 4 months or
longer after patients are discharged.
Real-time patient feedback delivered directly
to those providing care enhances performance
improvement (Ayers et al., 2005; Nelson et al.,
2008), and in the case of caring relationships, the
patient’s perspective, particularly at the point of
care is crucial in its evaluation. To rapidly collect
and disseminate patient feedback about caring
relationships with nurses, the use of technology
in the form of a bedside mobile device provides
real-time data for use by RNs to revise their
practice, providing routine evaluation of caring
relationships during the care process. In a pilot
study, Duffy and colleagues (2012) tested this
approach in a sample of 86 hospitalized older
adults using an electronic version of the 27-item
Caring Assessment Tool (e-CAT; Duffy et al.,
2014) and found it feasible and acceptable.
At the microsystems level, assessing nurse
caring on a unit or departmental basis provides
some evidence of how well the quality-caring
model© is integrated into practice and points to
performance improvement recommendations.
Many tools exist that are available to assist this
process (Watson, 2002). However, they vary in
terms of how they define caring, the approach,
how they are administered and scored, whose
view they are obtaining (e.g., patients, nurses, or
others), and validity and reliability. Only a few
directly gather information from patients. This
is an important component of assessment be-
cause the one being “cared for” is the direct
source of knowledge and others’ opinions may
not be consistent. The revised Caring Assessment
Tool© (CAT; Duffy, Hoskins et al., 2007,
2012), a 27-item instrument designed to capture
CHAPTER 22 • Joanne Duffy’s Quality-Caring Model© 401
3312_Ch22_393-410 26/12/14 10:44 AM Page 401
patients’ perceptions of nurse caring, has been
used with success in several health-care institu-
tions (Duffy, 2013). This tool has established
validity and reliability and is available in English,
Spanish, and Japanese. Using this tool provides
an evaluation of nurse caring behaviors as
perceived by patients that can be used for per-
formance improvement and practice revisions.
Another instrument that was adapted
from the CAT© is the Caring Assessment
Tool for Administration (CAT-admin;
Duffy, 2002). This tool is a 39-item ques-
tionnaire that assesses how nurses perceive
nurse manager caring behaviors and has be-
come important in the assessment of caring
practice environments. Many other instru-
ments exist to measure caring; however, en-
suring that the conceptual base, population
and setting, and perspective of the respondent
are consistent with individual and organiza-
tional values is vital to successful evaluation.
Specific nursing-sensitive outcomes are likely
to be influenced through use of the quality-
caring model©, so knowledge about these is nec-
essary to improve and accelerate its translation
into practice. To extend the understanding and
strengthen the evidence pertaining to caring
relationships (specifically nurse caring) as a
significant process indicator, tying it to outcomes
indicators may better reflect the value of nursing.
For example, hospitalized older adults frequently
leave the hospital with poorer physical function
than when admitted. This is a national problem
with significant cost and clinical burden (Good-
win, Howrey, Zhang, & Kuo, 2011), not to
mention the personal burden it places on pa-
tients and families. Measuring and reporting dif-
ferences in functional status from admission to
discharge for older adults on Quality-Caring
units would add to the evidence base. Those with
chronic illnesses, such as heart failure, cancer,
and chronic obstructive pulmonary disease often
are readmitted within 30 days of discharge,
financially draining the US health system (Jackson,
Trygstad, DeWalt, & DuBard, 2013). This bur-
den may be lessened if nurses worked, through
caring relationships, to engage and activate
patients in their care before discharge. Patient
engagement is a measurable intermediate out-
comes indicator (Hibbard, Stockard, Mahoney,
& Tusler, 2004) that has been associated with
decreased readmissions (Coulter, 2012) and
reflects the relational aspect of nursing care,
potentially raising positive regard for nursing’s
value.
Other nursing-sensitive intermediate out-
comes indicators such as comfort, knowledge,
dignity, optimistic mood, recovery time, adher-
ence, contentment (versus anxiety), continence,
cognition, empowerment, health-seeking be-
haviors, mobility, symptom control, and skin
integrity are examples of affirming intermediate
outcomes that could be used to demonstrate
the effects of caring relationships. Many of
these indicators have well-documented instru-
ments that would easily translate to the clinical
environment, rendering measurement and re-
porting feasible. Routinely using such existing
tools may validate the effects of nurse caring on
important intermediate outcomes and provide
a basis for improvement.
Researching Caring Relationships
Effectively appraising research informs nursing
practice by providing evidence that can guide
nursing interventions. Unit-based journal
clubs, nursing rounds, or even routine dialog
can provide forums for such appraisal. With
special attention to those studies that investi-
gate aspects of caring relationships, nurses
can help translate findings into practice and/or
extend the research itself.
Because the quality-caring model© pro-
vides a set of concepts, assumptions, and
propositions, questions generated from these
theoretical ideas can provide the basis for
research. For example, the proposition, “feel-
ing ‘cared for’ influences the attainment of
intermediate and terminal health outcomes”
(Duffy, 2013a, p. 38) could be tested by link-
ing the results of an instrument measuring
caring with a set of specific patient outcomes.
In fact, nurse researchers have investigated
this and found some evidence that caring
is linked to patient satisfaction, postoperative
recovery, and decreased anxiety (Burt, 2007;
Swan, 1998; Wolf, Zuzelo, Goldberg,
Crothers, & Jacobson, 1998). Or consider
the proposition, “relationships characterized
as caring contribute to individual, group, and
402 SECTION VI • Middle-Range Theories
3312_Ch22_393-410 26/12/14 10:44 AM Page 402
system self-advancement” (Duffy, 2013a,
p. 38) might be tested by examining the rela-
tionship between adoption of a caring profes-
sional practice model and staff nurses’
satisfaction with work.
Others have developed caring nursing in-
terventions and used them to study effects on
specific patient outcomes (Duffy et al., 2005;
Erci et al., 2003). An example geared to opti-
mizing patient-centered care for hospitalized
older adults uses flexible education, rapid-cycle
performance improvement, and facilitated
group reflection to support busy RNs to use
the caring factors in a complex environment
(Duffy, 2013b). Such research adds to the
knowledge base and offers implications for
the improvement of nursing practice. Schools
of nursing have used the caring factors to
develop and test caring competencies of
baccalaureate students longitudinally; and
students themselves, particularly those in Doc-
tor of Nursing Practice (DNP) programs,
often use the quality-caring model© to guide
their scholarly inquiries. Finally, nursing lead-
ers study caring behaviors of nurse managers
(using the CAT-adm) and evaluate implemen-
tation of the model organizationally using
comparative designs of patient outcomes on
implementation and control units.
Studying caring relationships is important to
provide evidence of nursing’s contribution to
health-care and to advance the profession. Such
evidence provides policymakers with documen-
tation of nursing’s value that may affect impor-
tant decisions such as funding, job descriptions,
promotion and advancement, and staffing. To
that end, the quality-caring model© provides a
foundation for continued research and model
testing. Ensuring that results are disseminated
quickly to the nursing community through pub-
lications and presentations is a nursing respon-
sibility that can advance caring science.
Up until now, weaknesses in caring evalua-
tion and research including the lag time behind
new caring theories, the vagueness between
findings and components of theory, measure-
ment issues, and poorly designed studies with
small and/or nonprobability samples have cre-
ated gaps in caring knowledge. Linking caring
to nursing-sensitive patient outcomes, improv-
ing existing caring instruments, designing car-
ing-based interventions, educational caring, and
cost–benefit analyses are urgently needed to
provide evidence of nursing’s value. Using rig-
orous methods, research that builds on the work
of others and includes multiple patient popula-
tions and settings demonstrates the validity of
caring theories and advances nursing practice.
CHAPTER 22 • Joanne Duffy’s Quality-Caring Model© 403
Practice Exemplar
Mr. S is an 86-year-old man with chronic ob-
structive pulmonary disease (COPD) who
lives with his daughter, her husband, and their
three children. He has been living with the
disease for 15 years and is mostly homebound.
Mr. S has home oxygen, a wheelchair, and his
own room on the second floor of the home
equipped with a TV, DVD player, and books.
He interacts with his grandchildren, who are
teenagers, and relies on his daughter for activ-
ities of daily living. Mr. S lost his wife several
years earlier to cancer and was a computer pro-
grammer before retirement. He was a two
pack per day smoker who rarely exercised and
had been in good health before his diagnosis.
He communicates well verbally and uses an
intercom set up by his son-in-law when neces-
sary. His breathing has been gradually getting
worse (despite medications), and he produces
quite a bit of sputum daily. He is easily fatigued
and occasionally experiences wheezing. He
takes both a short- and a long-acting bron-
chodilator and is on steroid therapy.
Mr. S has been noticing increasing insom-
nia lately with some nocturnal dyspnea and a
cough. His pulmonary function studies have
not changed, but his pulmonologist suggested
that he consider elective lung volume reduc-
tion surgery (LVRS) to help him breathe
better and avert an emergency. Mr. S subse-
quently entered a large teaching Magnet hos-
pital at 7:30 a.m. one day to have this surgery
Continued
3312_Ch22_393-410 26/12/14 10:44 AM Page 403
404 SECTION VI • Middle-Range Theories
Practice Exemplar cont.
performed. He arrived in his wheelchair ac-
companied by his daughter. He was nervous
about the procedure—not only because of the
surgery itself but also because he knew he
would most likely be in the intensive care unit
afterward. That place scared him! The admit-
ting office was busy, so the technician took his
time gathering insurance information and
then wheeled Mr. S down to the preop area.
He sat in the wheelchair for 45 minutes until
a nurse, who was busy on the phone, arrived.
She introduced herself and stated that he
should undress and get in bed so that she
could begin her assessment. Mr. S’s daughter
assisted him, as she always does at home, and
then placed him safely in the hospital bed. The
nurse returned with a clipboard and began her
assessment, collecting pertinent history. Then
she began a physical assessment. Her resultant
problem list consisted of two problems: short-
ness of breath due to COPD and sleep pattern
disturbance. She told Mr. S a little about the
upcoming surgery and asked his daughter to
sign the consent papers. The anesthesiologist
arrived to start the anesthesia, so Mr. S’s
daughter kissed him, and he was wheeled into
the OR. Three hours later, he was in the re-
covery area, and when Mr. S’s daughter saw
her father, he was on a ventilator, with multi-
ple IVs, and extremely agitated. He was able
to take his own breaths but was obviously
frightened. Because he was “tied down” to the
bed rails, his daughter, who understood his
anxiety, sat by his side and softly talked to him.
He used his hands to show her he felt like
he couldn’t breathe. The daughter, in turn, re-
layed this to the nurse, who asked her to tell
him that this was a normal feeling after this
surgery. Mr. S continued to experience anxi-
ety, often coughing, and was eventually placed
in the farthest bed so as to not disturb the
other patients. Unfortunately, his daughter
could not allay his concerns, and he continued
to feel anxious and distressed.
It was 5:00 p.m., and Mr. S was doing well
according to the nurses in the postanesthesia
care unit (PACU); they began his discharge by
searching for an intensive care unit (ICU) bed,
but there were no available beds in this busy
teaching hospital. Unfortunately, Mr. S had to
stay in the PACU overnight until an ICU bed
became available. Two other patients were also
staying overnight. The PACU nurses were un-
happy with this arrangement because it meant
two of them would have to stay on call to staff
the unit. They were overheard talking to each
other, saying, “If I had wanted to work on a sur-
gical floor, I wouldn’t have applied to the
PACU.” Mr. S continued to display anxiety,
often gagging and looking fearful with his eyes.
His daughter could not help him because she
didn’t know enough about the procedure he had
had to answer his questions. She thought maybe
he was in pain, but he denied this. He continued
to remain lying in the bed with his frightened
look. The daughter asked the PACU nurses for
help in figuring out what was wrong, but they
saw that his vital signs, blood gases, and dressing
were normal. One nurse decided to suction him,
but there were few secretions. Her technique
was rather rough; Mr. S grimaced with pain,
and his daughter asked if it would always be this
way. The nurse said it would get better with time
and went over to talk to the other nurse. Mr. S
remained anxious throughout the night while
his daughter sat by his side. Neither of them
slept. He was taken to the intermediate respira-
tory care unit at 8:30 a.m.
On this unit, Mr. S was cared for by a
young nurse named Megan who had graduated
2 years earlier. Megan stopped briefly to focus
herself and readjust her thoughts toward Mr. S
before she entered his room. Taking a couple
of slow deep breaths, Megan entered the room
and quickly scanned the environment and the
patient to notice anything significant. She
introduced herself by name and then looked
Mr. S in the eyes, smiled, and squeezed his
hand lightly (human respect). Then she asked
what he would like to be called while he stayed
with them and wrote that name on a board
on the wall opposite his bed. Since he couldn’t
talk, Megan asked Mr. S’s daughter to explain
how she had been communicating with him;
then Megan tried it with Mr. S to better un-
derstand his needs. Turns out, the daughter
3312_Ch22_393-410 26/12/14 10:44 AM Page 404
CHAPTER 22 • Joanne Duffy’s Quality-Caring Model© 405
Practice Exemplar cont.
was spelling words that were eventually incor-
porated into sentences.
Using the Quality Caring Model© as a
frame of reference, Megan completed a physical
assessment that included physiological, emo-
tional, sociocultural, and spiritual components.
Her goal was to use this opportunity to initiate
a caring relationship with Mr. S and his family
that could grow and be sustained throughout
the hospitalization experience. Through this
process, Megan came to know Mr. S as a re-
tired software engineer who is widowed and
lives with his married adult daughter and
3 grandchildren, is an avid reader of history,
who was anxious and tired. She also learned he
received his diagnosis of COPD 15 years earlier
and had progressively become weaker, more
breathless, and eventually homebound. Mr. S
was taking multiple medications as well as O2
therapy at home. His vital signs were good. Al-
though he was slightly tachycardic with a heart
rate of 112, his dressing was dry, and his back
showed evidence of a beginning pressure ulcer
at the coccyx region. Mr. S’s daughter relayed
her difficulty in caring for Mr. S while also
working part time, raising three children, and
maintaining a home. This family had not been
on a vacation in several years. This physical as-
sessment time provided Megan with the oppor-
tunity to understand the unique human being
(Mr. S) in relationship to his family, his friends,
and life role (appreciation of unique meanings) and
to begin a relationship-centered professional en-
counter that was based on these findings.
She documented the results of the assess-
ment in the computer, looking frequently at
Mr. S so he could see her. The problem list
Megan came up with included issues such as
airway maintenance, anxiety, impaired com-
munication, altered family processes, potential
skin breakdown, inadequate knowledge, and
inadequate coping. Then she sat down, and,
using the caring factor mutual problem-solving,
explained to Mr. S and his daughter what
would happen on this unit, including how long
they might stay, and how and when to contact
her. She engaged them in the dialogue by
inviting questions and asked them for guidance
regarding Mr. S’s normal routines. She relayed
that she would be there all day and gave them
her telephone number. Then she asked them
what they knew about recovering from lung
volume reduction surgery and listened atten-
tively to their responses. She sat a little toward
the patient and looked at him as he “talked.”
This took longer than usual because he was
using letters to spell out words (encouraging
manner). She explained a little about living
with COPD, but together they decided to wait
until after they had some sleep to review care
of the incision and other issues related to
COPD. Megan assured Mr. S that he had the
capacity to live well with this chronic disease,
using examples of what she had already ob-
served about the family (attentive reassurance).
Megan then asked the daughter if she wanted
something to drink and made sure Mr. S was
comfortable (pain free) as well. Then she of-
fered him mouth care and turned him slightly
to the side with a pillow behind his back.
Megan closed the blinds and offered Mr. S’s
daughter a pillow and a reclining chair and let
them sleep for 2 hours, as they had been up all
night (healing environment). She put a sign on
the door reminding others that the patient was
sleeping (basic human needs and affiliation
needs). For the first time in more than 24 hours,
Mr. S was able to relax and shut his eyes,
showing evidence of feeling “cared for.”
Megan’s professional encounter with this
family was relaxed, genuine, and distinguished
by the caring factors. With only 2 years’ expe-
rience, she was competent in their use. Megan’s
focus and knowledge of herself provided the
strength to meet this family’s needs. During the
time they were resting, Megan checked on
them quietly and frequently (healing environ-
ment). At one of these opportunities, Mr. S’s
daughter sought out Megan to relay her anxi-
eties about taking Mr. S home. Megan listened
and encouraged the daughter to adjust first to
this new environment while she (Megan)
would come back later to help them understand
how to live with COPD (affiliation needs).
During the next 2 days, Megan took care of
Mr. S and spent time collaborating with Mr. S’s
Continued
3312_Ch22_393-410 26/12/14 10:44 AM Page 405
406 SECTION VI • Middle-Range Theories
Practice Exemplar cont.
pulmonologist and surgeon on his care plan. She
listed his problems, and when they came for
rounds, Megan accompanied them, and they
conversed about Mr. S’s vital signs, his breathing
(he had been extubated after 24 hours), incision,
and secretions while also discussing some inter-
ventions Megan suggested based on her knowl-
edge of his family situation, the patient’s own
routines, and their joint interactions. Including
Mr. S in the discussions, they asked how he was
feeling, and he communicated with Megan’s
help. During a conversation at the nurses’ sta-
tion, Megan and both physicians agreed that
Mr. S could go home the next day with support.
The surgeon relied on Megan’s judgment about
Mr. S’s readiness for discharge because he had
come to know her these last 2 years as a compe-
tent and caring nurse. Megan trusted her own
recommendations; their encounter was collab-
orative and friendly.
Later that day, Megan returned with a writ-
ten set of instructions about caring for chest
incisions. She reviewed the instructions with
both Mr. S and his daughter, answering ques-
tions, allowing the daughter and Mr. S to
“practice.” She used a positive approach, reas-
suring the daughter that she could do this and
that she would be there in a couple of hours to
review the procedure again (attentive reassurance
and encouraging manner). Megan then called the
social worker and the home care team to get
things rolling for discharge. Megan also took
the daughter aside to discuss living and caring
for an elderly man with COPD. She provided
the daughter with referrals for a support group
and a lung association program.
During report, Megan reviewed Mr. S’s
problem list and her recommended interven-
tions to the oncoming nurse using the caring
factors as a basis for the interaction. She felt
good that Mr. S and his family were learning
about his needs and pleased that she had re-
lieved some of their anxiety. She said good-
bye to all her patients and went to her weekly
yoga class to unwind. The next morning,
Megan had the same assignment and worked
with Mr. S and his daughter to ensure their
self-caring needs were met.
Although this “case” is typical in many acute
care facilities, Mr. S is a unique individual who
experienced two different nursing encounters.
In the first instance, one might say that his
physical needs were met, yet he was not af-
firmed as the one being treated (the nurses
talked to his daughter about him), he was not
adequately assessed by the preop nurse, he
remained anxious for many hours postop, was
isolated from others, didn’t sleep, overheard
professional nurses talking about not wanting
to be there, was treated roughly, and was not
turned for 12 hours despite the fact that he was
immediately postop. On the intermediate care
unit, the nurse used the caring factors to initi-
ate and cultivate a caring relationship with him
from admission. She used this relationship as
the basis for care that included attention to his
basic needs for sleep, comfort, and nutrition.
Megan helped Mr. S understand his new situ-
ation and included his daughter, who was his
caretaker. She was collaborative with the physi-
cians and other nursing staff and positive in her
demeanor. She referred to the patient as Mr. S
and used her time appropriately to ensure that
his transition to home would occur safely. In
essence, this nurse saw the patient as a whole
person, not a physical body after surgery, and
used her caring knowledge and skills to build a
relationship that generated trust and security.
Through ongoing interaction, a connection
developed between the nurse and patient that
provided the insight necessary for effectively
following the nursing process including specific
interventions and evaluation. Although the
tasks she performed were routine in nature, this
nurse balanced doing with being caring. The
caring relationship she established created a
higher quality nursing care that benefited both
the patient and the nurse.
Acknowledging the unique caring nature of
nursing and demonstrating a professional
commitment to it offers a way for nursing to
help patients make sense of their illnesses. It
also provides an opportunity for nursing to
claim a unique place in the health-care system
by generating evidence of the value of caring
through high quality outcomes.
3312_Ch22_393-410 26/12/14 10:44 AM Page 406
CHAPTER 22 • Joanne Duffy’s Quality-Caring Model© 407
■ Summary
Practice-based knowledge is a hallmark of a
profession; therefore, a strong alignment be-
tween a theory and the practice of it enhances
its significance to society. Caring and quality in
health care are implicitly tied together. Because
humans exist in relation to others, caring rela-
tionships facilitate human advancement and
the future interactions so necessary for excellent
health care. Independent and collaborative car-
ing relationships in health care contribute to
patients’ welfare in that they promote comfort,
safety, consistent communication, and learning.
Professional nurses who regularly relate to
themselves and their communities are more
equipped to engage in genuine independent
and collaborative caring relationships with
patients and families as well as advance their
own self-caring. Spending time “in relation-
ship” focuses attention on the patient versus the
disease or task and generates a meaningful
practice that is the basis for joy. In essence, the
model benefits both patients and nurses as well
as the profession and the health-care system.
Theory-guided, evidence-based professional
practice that is holistic and meaningful can
make a profound impact on patient outcomes.
Implications of the revised quality-caring
model© exist for educators to help students
learn how to care. Transforming the learning
environment with meaningful learning activi-
ties, clinical experiences, and frequent reflec-
tion on the salience of caring relationships
helps students share meanings, elicit relevant
data, listen, notice cues, establish rapport, and
develop mutually caring interactions. Using
evaluation techniques and frequent caring stu-
dent–teacher interactions, nurse educators can
greatly enhance learning outcomes. Clinical
courses in which caring behaviors are valued
and role-modeled by faculty are essential. Sim-
ilarly, it is crucial that those nurses in leader-
ship positions create caring–healing–protective
environments for staff and patients in a cost-
effective manner. Redesigning professional
workflow so that its primary function is rela-
tionship centered and making decisions in a
participatory manner are paramount to quality
caring. Finally, showing evidence of nursing’s
foremost professional purpose (caring) through
ordinary everyday caring actions blended with
a culture of continuous inquiry creates novel
possibilities for advancing the profession.
Example Institutions Using the Quality–Caring Model©
for Professional Practice
Children’s Mercy Hospital and Clinics,
Kansas City, MO
Forsyth Medical Center, Winston-Salem, NC
Hannibal Medical Center, Hannibal, MO
Holy Cross Hospital, Silver Spring, MD
Johns Hopkins, Bayview, Baltimore, MD
Lakeland Regional Medical Center,
Lakeland, FL
Lowell General Hospital, Lowell, MA
McLaren, Northern Michigan Medical
Center, Petoskey, MI
M.D. Anderson Medical Center, Houston, TX
Methodist Hospital, Henderson, KY
Presbyterian Hospital, Charlotte, NC
Prince William Hospital, Manassas, VA
St. Joseph’s Medical Center, Towson, MD
Swedish American Hospital, Rockford, IL
Texas Health Resources, Arlington, TX
Torrance Memorial Hospital, Torrance, CA
West Virginia University Hospitals, Mor-
gantown, WV
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Chapter 23Pamela Reed’s Theory of
Self-Transcendence
PAMELA G. REED
Introducing the Theorist
Overview of the Theory
Applications of the Theory
Practice Exemplar
Summary
References
411
Introducing the Theorist
Pamela G. Reed is professor at the University
of Arizona College of Nursing in Tucson. She
received her academic degrees from Wayne
State University in Detroit, Michigan: a BSN
and an MSN with a double major in child &
adolescent psychiatric–mental health nursing
and nursing education, which prepared her
both as a clinical nurse specialist and a nurse
educator. In 1982, Dr. Reed received her PhD
from Wayne State University, majoring in
nursing research and theory with a minor in
life span development and aging.
She promoted the study of spirituality as an
area of scientific inquiry in nursing. Her research
in spirituality, mental health and well-being,
aging, and end-of-life was strongly influenced
by the theoretical ideas of Martha Rogers and
the life span developmentalists. Dr. Reed’s the-
ory of self-transcendence is based in part on her
research and on her developmental perspective
of well-being. The theory has been widely pub-
lished and is used by many nurses in practice and
research. In addition, Dr. Reed developed two
widely used research instruments, the Spiritual
Perspective Scale and the Self-Transcendence Scale.
Dr. Reed is a fellow in the American Acad-
emy of Nursing and is a member of a number of
professional organizations including Sigma
Theta Tau International, the American Nurses
Association, and the Society of Rogerian Schol-
ars. She serves on editorial review boards of
numerous journals and as a contributing editor
for Applied Nursing Research and Nursing Science
Quarterly. Dr. Reed is coeditor of a nursing
theory text, Perspectives on Nursing Theory, now
in its 6th edition, and author, along with Nelma
Shearer, of Nursing Knowledge and Theory
Innovation: Advancing the Science of Practice.
Pamela Reed
3312_Ch23_411-420 26/12/14 10:44 AM Page 411
Since January 1983, Dr. Reed has been on
the University of Arizona faculty, where she
teaches, writes, conducts research, and served
as Associate Dean for Academic Affairs for
7 years. She has received many teaching
awards from faculty and students. In addition
to writing for research publications, she fre-
quently writes about the philosophical and
theoretical dimensions of nursing with a focus
on practice-based knowledge development.
She lives with her husband in the Sonoran
desert of Tucson, Arizona, where her two
daughters also reside.
Overview of the Theory
The focus of the theory is on facilitating the
process of self-transcendence for the purpose of
enhancing or supporting well-being. Theories
from other sciences, such as psychology, also
address self-transcendence. However, what dis-
tinguishes this particular theory as a nursing the-
ory is its focus on well-being in the context of
difficult health experiences. The theory proposes
that people’s capacity for self-transcendence is
activated when they face life-threatening illness
or undergo health-related changes that intensify
awareness of vulnerability or mortality. This
increase in self-transcendence is evident in
expansion of self-boundaries in ways that foster
well-being. Individuals have the capacity to
expand their boundaries in healthy ways, but in
serious illness or other health-related life crises,
nurses and other professionals can be helpful in
facilitating this process of self-transcendence.
The scope of the theory has been extended
beyond its original focus on later adulthood to
address self-transcendence as a resource for
well-being across the life span from adolescence
to adulthood, with potential applications to
childhood.
Foundations of the Theory
All theories are built on assumptions generally
considered to be true as derived from widely ac-
cepted theory or empirical findings or as self-
evident. Assumptions are not tested in research
but instead serve as foundational ideas for the
theory. Two major frameworks that originated
in the mid-20th century and continue to be
relevant today motivated the theory of self-
transcendence: Martha Rogers’s (1970, 1980,
1990) conceptual system about the human–
environment process and the life-span devel-
opmental science perspective articulated by
Richard Lerner (e.g., 2002; Lerner, Lamb, &
Freund, 2010), both of which are related to
complexity science (e.g., Kauffman, 1995).
One philosophical assumption of self-
transcendence theory is that humans undergo
change that is developmental in nature (char-
acterized by increasing complexity and organ-
ization) and as part of this innovative process,
humans also possess inherent potential for
healing, emotional growth, and well-being
throughout the lifespan. This potential for
well-being has been described by Reed (1997)
most fundamentally as a nursing process, anal-
ogous to basic chemical processes of chem-
istry or the social processes of interest to
sociologists. Self-transcendence is an example
of a nursing process.
A second philosophical assumption is that
humans, as open systems, impose conceptual
boundaries on their “openness” to define their
reality and provide a sense of identity and se-
curity. This assumption is based on ideas
from life-span developmental psychology
about the formation and differentiation of self
across development. For example, theorists
have identified the diffuse boundary between
infant and parent, the increased sense of
identity and self-consciousness in children
and adolescents as they clarify their boundary
between self and others, the increased differ-
entiation of self and more secure sense of
identity in middle adulthood, and the complex
and expanded forms of connections to others
and spirituality in later adulthood and end of
life. This assumption was also influenced by
Rogers’s (1970, 1980) nursing science about
perceived self-boundaries that may fluctuate
during health-related life events. She pro-
posed that humans are energy fields infinite
in space and time, extending beyond the “dis-
cernible mass” we identify as the human
body, and without boundaries.
Rogers (1994) used the term pandimension-
ality (revised from her former terms of four-
dimensionality and multidimensionality) to
412 SECTION VI • Middle-Range Theories
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describe the unbounded connections in the
human–environment process and to challenge
conventional distinctions between, for exam-
ple, person and environment, living and
dying. Her principle of integrality proposed a
fundamental connectedness instead of these
perceived boundaries. Her concept of relative
present challenged conventional distinctions
among past, present, and future to acknowl-
edge both the individual’s temporal perspec-
tives and the discoveries in physics about
space-time. So self-transcendence involves
expanding and redefining self-boundaries dur-
ing health events and is evident in connections
to our inner life, to others, to natural and
technological environments, and to imagined
worlds. The theory is based on a pluralistic
view of reality that accounts for the human
capacity—as latent as it may be today—to
expand self-boundaries in innovative ways.
The Theory: Concepts
and Relationships
The theory of self-transcendence, like theories
in general, is a compressed description of a
phenomenon or process and does not catalog
every instance of self-transcendence. A theory
provides a coherent description of key concepts
and their relationships, which researchers and
practitioners can further specify for application
to their unique situations. There are three major
concepts in the theory: self-transcendence,
vulnerability, and well-being.
Self-Transcendence
The core concept of the theory is self-
transcendence. It refers to the capacity to ex-
pand self-boundaries in various ways that en-
hance well-being. For example, self-boundaries
can expand intrapersonally (toward greater
awareness of one’s beliefs, values, and dreams),
interpersonally (to connect with others, nature,
and surrounding environment), transpersonally
(to relate to dimensions beyond the ordinary,
observable world), and temporally (to integrate
one’s past and future in a way that expands and
gives meaning to the present). Other ways of
expanding self-boundaries are possible. For
example, in our increasingly technological world,
expansion of self-boundaries may also involve
connectedness of self with nonliving entities
such as symbolic objects, memories, machines,
and prosthetics that influence well-being in
profound ways.
One caveat in understanding the theory is
that the term self-transcendence may evoke
ideas about the mystical, supernatural, or
other experiences that disconnect self from
others or from the present. However, spiritual
meanings associated with this theory refer
more to terrestrial, everyday practices of spir-
ituality that alter self-boundaries in meaning-
ful ways to connect rather than separate a
person from self, others, nature, and other as-
pects of our environment. Nevertheless, it may
be important to acknowledge the unseen or
the mystery in life.
With regard to assessment, the 15-item
Self-Transcendence Scale (STS) was developed
by Dr. Reed to measure self-transcendence
in individuals who are either well or have
health problems or other limitations due to ill-
ness or disability. The STS is used widely in
research and may also be used by practicing
nurses to better understand areas for assessing
patients. The STS has been translated into sev-
eral languages, including Spanish, Mandarin,
and Korean.
Vulnerability
Vulnerability is a contextual concept in the
theory and refers to an increased awareness of
personal mortality. A wide variety of human
experiences can increase this awareness, but of
particular note are health-related events that
are life threatening or that involve loss.
Chronic and serious illness, disability, aging,
bereavement, traumatic events, and facing end
of life all are contexts of vulnerability and
increased awareness of mortality.
For assessment, a variety of measures or
questions can be used to assess a person’s sense
of vulnerability. Examples of areas to assess
include perceived risk for illness, concerns
about potential loss, and perspectives on living
with a life-threatening illness.
Well-Being
Well-being is the third major concept in
the theory. Well-being is defined broadly as a
CHAPTER 23 • Pamela Reed’s Theory of Self-Transcendence 413
3312_Ch23_411-420 26/12/14 10:44 AM Page 413
subjective feeling of health or wholeness as
based on the person’s own criteria at a given
point in time. It involves an existential judg-
ment by the individual and is influenced by
one’s history, culture, values, family and
other significant relationships, and biophys-
ical factors.
There are many measures for the assessment
of well-being in nursing and other health and
social sciences. This reveals the diversity of
values about health and wellness. Examples of
indicators of well-being that have been found
to be significantly related to self-transcendence
include life satisfaction, happiness, high morale
in aging, self-care agency in chronic illness,
sense of meaning in life, and specific indicators
of mental health such as absence of depression,
decreased anxiety, subjective well-being, and
happiness.
Relationships Among the Concepts
Self-transcendence, as a nursing process,
is linked logically with positive, health-
promoting experiences. Self-transcendence
can be a correlate if not a predictor of well-
being. In addition, accumulated research
findings support self-transcendence as a me-
diator of well-being during significant life
events that increase sense of vulnerability.
The model in Figure 23-1 depicts the three
concepts and their relationships.
From the Rogerian-based assumption that
human beings have potential for innovative
expansion of self-boundaries, it was theorized
that vulnerability is related to increased self-
transcendence. In other words, increased
awareness of one’s vulnerability or mortality
can trigger positive, inner strengths—in this
case self-transcendence, an idea long sup-
ported by experts on development at end of
life (e.g., Becker, 1973; Corless, Germino, &
Pittman, 1994; Erikson, 1986; Frankl, 1963;
Marshall, 1996). Self-transcendence in turn
may directly influence increased well-being.
Self-transcendence may also function as a re-
source for well-being during increased vulner-
ability by mediating the relationship between
increased vulnerability and well-being to help
the person transform loss into a growth or
healing experience of well-being.
Additional concepts in the theory are per-
sonal and contextual factors that can influ-
ence the relationships among vulnerability,
self-transcendence, and well-being. Potential
factors include age, gender, ethnicity, years
of education, illness intensity, life history,
social or spiritual support, and other factors
concerning the person’s social, cultural, and
physical environment.
Applications of the Theory
Self-transcendence theory has applications in
both research and practice. In research, the
theory is used as a broad framework for ex-
ploring ideas about self-transcendence in
qualitative studies and as a theoretical frame-
work for examining specific relationships
using quantitative measures. The theory has
been studied for its practice applications with
patients as well as among nurses, family care-
givers, and other health-care providers, and
healthy populations.
Research results support the significance of
self-transcendence as a correlate or predictor
of well-being across a variety of populations,
particularly those experiencing serious illness
or other challenging life situations.
Research
Examples of research applications include the
following studies: clinical depression in older
adults (Haugan & Innstrand, 2012; Reed, 1991;
414 SECTION VI • Middle-Range Theories
Personal and
contextual factors
Self-transendence
Vulnerability Well-being
Fig 23 • 1 Model of Reed’s self-transcendence
nursing theory. (Copyright ©2012 by Pamela G. Reed.)
3312_Ch23_411-420 26/12/14 10:44 AM Page 414
Stinson & Kirk, 2006); bereavement (Chan, &
Chan, 2011; Kausch & Amer, 2007); people
diagnosed with HIV/AIDS (Coward, 1995;
McCormick, Holder, Wetsel, & Cawthon,
2001; Ramer, Johnson, Chan, & Barrett, 2006;
Sperry, 2011); chronic illness and loss in later life
(Bickerstaff, Grasser, & McCabe, 2003; Gusick,
2008; Nygren et al., 2005); women with breast
cancer (Coward, 2003; Farren, 2010; Matthews
& Cook, 2009; Thomas, Burton, Quinn Griffin,
& Fitzpatrick, 2010); liver and stem cell and
transplant recipients (Bean & Wagner, 2006;
Burns, Robb, & Haase, 2009; Williams, 2012);
older adults both in the community and in
nursing home (Haugan et al., 2012; McCarthy,
2011); and persons with dementia and other
progressive or intractable diseases (Chen &
Walsh, 2009; Iwamoto, Yamawaki, & Sato,
2011). Other research supports the significance
of self-transcendence among caregivers of family
members with dementia or other debilitating
illness and at end-of-life (Acton, 2002; Guo,
Phillips, & Reed, 2010; Kidd, Zauszniewski,
& Morris, 2011; Kim, Reed, Hayward, Kang,
& Koenig, 2011; Reed & Rousseau, 2007)
and among nurses dealing with difficult caregiv-
ing situations (Hunnibell, Reed, Griffin, &
Fitzpatrick, 2008; Palmer, Griffin, Reed, &
Fitzpatrick, 2010). A literature search of the
term self-transcendence using databases from
nursing and other sciences (for example,
CINAHL, BioMed Central, PsycInfo) will
easily generate an up-to-date list of studies and
clinically based articles on self-transcendence1.
Also, see Reed (2013) for an extended list of
references on self-transcendence.
Practice
Practice applications summarized from this
and other research indicate various self-
transcendence strategies that expand self-
boundaries. These approaches may be organ-
ized in terms of intrapersonal, interpersonal,
and transpersonal approaches to boundary
expansion. There may be overlap across these
categories. Many of these activities also ex-
pand temporal boundaries by helping the
person focus on the present.
Intrapersonal approaches help the person
look inward to expand boundaries and inte-
grate loss through self-knowledge and finding
meaning or purpose in one’s life. Examples of
strategies that nurses may suggest for patients
are meditation, self-reflection, and prayer;
guided reminiscence and life review; self-talk,
emotion or stress management, and relaxation
strategies; artistic and other creative activities
of self-expression, reading and writing poetry,
music therapy, and journaling; and exercise
and other physical activities.
Interpersonal activities that facilitate self-
transcendence connect individuals to others
through formal or informal means, including
support groups, faith-based groups, or group
psychotherapy; telephone or Internet-based
interactions; volunteer work and other altruistic
activities including those that allow one to be
of help to others and to share one’s wisdom. Of
course, relationships with family and friends are
central to the interpersonal dimension.
Transpersonal approaches for self-transcendence
are designed to help the person connect with
a power or purpose greater than self. The
nurse’s role in this process is often one of cre-
ating an environment or providing guidance
that fosters approaches such as religious par-
ticipation, spiritual exploration and expression,
involvement in altruistic activities, and work
on creative projects.
CHAPTER 23 • Pamela Reed’s Theory of Self-Transcendence 415
1For additional practice exemplars please go to bonus
chapter content available at FA Davis http://davisplus
.fadavis.com
3312_Ch23_411-420 26/12/14 10:44 AM Page 415
416 SECTION VI • Middle-Range Theories
Practice Exemplar
This practice exemplar focuses on how to facilitate
well-being outcomes through various strategies that
support self-transcendence. The idea behind the in-
terventions is that facilitating self-transcendence
promotes positive mental health outcomes either
by diminishing the negative effect that vulnera-
bility has on well-being or more directly by en-
hancing those perspectives on life that increase
emotional well-being.
Several years ago, Rose was diagnosed with
emphysema. In her youth and through young
adulthood, Rose had been a professional
dancer on Broadway. But she now found that
what were once the strongest parts of her
body—her legs—were no longer able to carry
her around with grace and ease. Her illness
had advanced to the point that she required
supplemental oxygen and a walker at home.
This made it difficult for her to get out of the
house as often as she desired. She lived alone,
but her daughter, her family caregiver, visited
her several times a week. Recently, Rose expe-
rienced a worsening of her physical symptoms
and more difficulty breathing; so, with her
daughter’s encouragement, she moved closer
to her daughter. Even though Rose’s new
apartment was more modern than her old
house and her daughter could visit more often,
Rose wasn’t as happy in her new surroundings,
and her daughter was concerned about her
depressed mood during her frequent visits.
Their nurse worked together with Rose and
her daughter to design a plan of care that not
only tended to Rose’s declining physical health
needs and any other underlying problems but
also focused on complex needs regarding her
mental health and her emotional and social
well-being. Self-transcendence theory provided
a framework for practice to address these latter
needs. The nurse acknowledged that Rose’s
worsening illness might be contributing to a
heightened sense of vulnerability not only be-
cause it was life-threatening but also because it
diminished the quality of certain areas of her
life. The nurse operated from the basic assump-
tion that nursing care could help activate Rose’s
inner strengths and potential to transcend
some of the boundaries she was facing to attain
a sense of well-being in the midst of vulnera-
bility. And because the theory is a guide and
not an exact recipe for intervention, using the
theory increased the likelihood that the nurse,
Rose, and her daughter together would dis-
cover important areas of self-transcendence
unique to Rose’s situation.
Intrapersonal
The nurse helped expand Rose’s boundaries
on an interpersonal level through a variety of
interactions. Rose explained that she was a pri-
vate person and didn’t like to depend on others.
The nurse’s openness and empathy supported
her in expressing her beliefs about quality of
life, spiritual values, goals for herself, and
dreams for her daughter’s future. These insights
were useful in making health-care and other
decisions. Their discussions also helped Rose
acknowledge and integrate difficult feelings
into her life. Whether she resolved all of her
concerns was not as important as acknowledg-
ing and accepting them for the time being. The
nurse acknowledged Rose and her daughter’s
fears and losses along the way and supported
their hope and faith that they could cope with,
and maybe even grow from, the experience.
Interpersonal
Besides the fact that these objects confronted
her with her mortality, Rose found it embarrass-
ing that she had to use a walker and supplemen-
tal oxygen wherever she went. She perceived
these items as foreign and undignified objects
that announced her aging and disability to the
world. Rose also missed her friends from her
former home and especially missed her “mailbox
neighbor” who also carried an oxygen tank. The
nurse suggested that Rose participate in a pul-
monary rehabilitation program, particularly a
program-sponsored support group where she
might gain friends among people who not only
had similar illness experiences but who also, as
Rose said, “looked like [her] too!” As Rose was
able to expand her self-boundary to integrate
assistive devices into her life, she became more
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CHAPTER 23 • Pamela Reed’s Theory of Self-Transcendence 417
Practice Exemplar cont.
accepting of her illness and herself overall.
Attending the support group also provided her
opportunities to use her own experiences to help
others. Sharing her wisdom with others was very
gratifying to Rose and enhanced her well-being.
The nurse also worked to ensure that Rose and
her daughter would lead the health-care decisions
and fully participate in health-care activities.
She helped connect Rose and her daughter
with resources to navigate the health-care sys-
tem and address financial concerns. Information
about the illness and self-care strategies helped
demystify the health experience and regimen.
Transpersonal
Rose admitted that she was not particularly re-
ligious but found herself praying each morning
and evening. The nurse was aware that religious
beliefs held in youth can become important at
the end of life, even if they had been eschewed
during adulthood. The nurse acknowledged
that Rose, like others, might find value in spir-
itual perspectives that connected her to some
thing or some purpose larger than the individ-
ual. Even though she had difficulty believing in
a life after death, the possibility offered some
comfort and helped Rose integrate awareness
about her own mortality and being separated
from her family and friends. The nurse also
guided Rose through a spiritual history of her
life to uncover other sources of strength and
perhaps make new discoveries about herself that
she could draw from as time progressed.
Temporal
The illness initiated and intensified Rose’s con-
cerns about the future and fears about pain and
mortality. The nurse explored these concerns
with Rose in a realistic yet empathetic manner.
A life review in which Rose reflected on her
past, discussed anticipating the unknown, and
then connected these insights to her present
concerns provided a sense of meaning that
she found emotionally satisfying. The nurse
also facilitated Rose’s fuller enjoyment in the
present by encouraging positive experiences
such as planning enjoyable activities, holding
small celebrations, and taking pictures of im-
portant or memorable events. These activities
generated a legacy and a gift that connected
Rose’s present to her family’s future. Expand-
ing her self-boundary to incorporate other
temporalities gave Rose access to meaningful
experiences that often sustained her across the
trajectory of her illness. Also, simply reminding
Rose to try to engage in positive self-talk
was sometimes helpful in getting her through
a difficult moment.
Rose’s Self-Transcendence
Rose did not expect the nurse or her daughter
to create self-transcendent experiences for
her. But their support and guidance but-
tressed her own inner potential for healing
through the illness experience. Transcending
self-boundaries may require the support of
others, even though there is the assumption
that self-transcendence is a natural human
capacity. Rose’s openness to accepting help
and guidance from the nurse was a first step in
expanding her self-boundaries. By nurturing
connections to her beliefs and values, her God,
her support group friends, and to her daughter
and nurse, Rose was able to expand her self-
boundaries in ways that enhanced her well-
being within the context of her incurable illness.
■ Summary
The theory of self-transcendence was built on
the assumption that people may perceive self-
boundaries but that they also have the capacity
to expand or adjust these boundaries in positive
ways, whether by bringing in new perspectives,
revising old beliefs, reaching out to others, or
connecting to something greater than oneself.
The theory of self-transcendence acknowledges
the tendency to construct a self-boundary as
well as the capacity to transcend limiting views
3312_Ch23_411-420 26/12/14 10:44 AM Page 417
418 SECTION VI • Middle-Range Theories
of self and the world in ways that reflect the
pandimensional nature of living systems. The
theory provides an approach to facilitating
well-being in nursing practice by helping indi-
viduals expand their personal boundaries within
their developmental and situational contexts.
The theory of self-transcendence comprises
three key concepts: self-transcendence, well-
being, and vulnerability. The theory’s concepts
were designed to be clear and measurable yet
to be broad enough in scope to allow nurses
the flexibility in using the theory across a vari-
ety of research and practice situations. Practi-
tioners and researchers who use the theory can
define the general concepts of vulnerability and
well-being using more specific, measurable
terms to make the theory applicable to their
specific group of patients or clinical practice
setting.
In a general sense, the theory of self-tran-
scendence is a well-being theory (Reed, 2008).
The theory proposes that self-transcendence
arises in contexts of vulnerability and facili-
tates well-being, either in directly increasing
well-being or acting as a mediator in the
relationship between vulnerability and well-
being. Evidence to date indicates that self-
transcendence interventions may diminish
risks of vulnerability and increase sense of
well-being during difficult health-related
situations. Both practitioners and researchers
can use the theory to build knowledge about
facilitating human well-being across a variety
of health experiences.
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Chapter 24Patricia Liehr and Mary Jane
Smith’s Story Theory
PATRICIA LIEHR AND MARY JANE SMITH
Introducing the Theorists
Overview of the Theory
Applications of the Theory
Practice Exemplar
Summary
References
421
Introducing the Theorists
Patricia R. Liehr, PhD, RN, graduated from
Ohio Valley Hospital School of Nursing in
Pittsburgh, Pennsylvania. She completed her
baccalaureate degree in nursing at Villa Maria
College, her master’s in family health nursing
at Duquesne University, and her doctorate at
the University of Maryland–Baltimore School
of Nursing, with an emphasis on psychophys-
iology. She completed postdoctoral studies at
the University of Pennsylvania as a Robert
Wood Johnson Scholar. Dr. Liehr is currently
a Professor of Nursing at the Christine E.
Lynn College of Nursing at Florida Atlantic
University. She has taught nursing theory to
master’s and doctoral students for nearly two
decades.
Mary Jane Smith, PhD, RN, earned her
bachelor’s and master’s degrees from the
University of Pittsburgh and her doctorate
from New York University. She has held
faculty positions at the following nursing
schools: University of Pittsburgh, Duquesne
University, Cornell University-New York
Hospital, and Ohio State University; and she
is currently a Professor at West Virginia
University School of Nursing. She has been
teaching theory to nursing students for nearly
three decades.
Overview of the Theory
Story theory evolved as the cocreators talked
about their practice-research experience with
pregnant teens and people recovering from a
cardiac event (Smith & Liehr, 2014b). It was
clear to the creators that health-promoting
change was fostered when one’s story of preg-
nancy or living through a cardiac event was
Patricia Liehr Mary Jane Smith
3312_Ch24_421-434 26/12/14 10:43 AM Page 421
embraced. It was as though acceptance of these
health circumstances energized new directions
for healing and health. Story theory was first
published in 1999 (Smith & Liehr, 1999), and
it has continued to be used, tested, and shaped
for more than a decade (Smith & Liehr, 2014a).
Stories are integral to nursing practice. Prac-
tice decisions are informed both by physiological
bodily responses and by the stories that infuse
bodily responses with unique personal meaning.
To focus on one without attention to the other
contributes to less than optimal nursing care.
There are times when either the physiological
bodily responses or the story is foreground
and the other is background; this foreground–
background interplay dynamically emerges over
the course of each nurse–person caring interac-
tion. For instance, when a person comes into the
emergency room with crushing chest pain and
then suddenly becomes unconsciousness, num-
bers related to physiology are in the foreground.
Heart rate, blood pressure, and respiratory rate
guide critical immediate action. Within a short
time, the nurse will want to begin to gather the
story, including dimensions such as what the
person was doing when the chest pain began,
whether this has ever happened before, and
what other life and health circumstances could
have contributed to the chest pain. Stories are
essential to even the most technology-driven
nursing practice, and in some ways, the more
technology-driven the practice, the more impor-
tant the place of relevant health stories.
Our linear-thinking culture often places
greater value on physiological bodily responses
than stories. In fact, precious stories shared
during nursing practice may be heard and
disregarded or heard and acted on without
another thought about the practice evidence
generated. Practice stories are seldom chroni-
cled, unfortunately lost to becoming part of the
foundation of nursing practice evidence. The
overall intent of this chapter is to describe
story theory as a framework informing story-
gathering and story analysis, thereby position-
ing story as a major thread of nursing practice
evidence, contributing to substantive nursing
knowledge.
This chapter first addresses the emergence
of story, or narrative, as a topic of interest for
health-care providers, including nurses. Then
story theory is summarized, including the es-
sential theory concepts (intentional dialogue,
connecting with self-in-relation, creating ease)
and discussion of ways that the theory comes
alive in practice. Bringing the theory to life is
described in the context of the theory method
dimensions (complicating health challenge,
developing story plot, movement toward
resolving) aligned respectively with each theory
concept. We discuss a seven-phase inquiry
process for using the evidence from practice
stories to grow the substantive knowledge
of the discipline. Finally, an exemplar is used
to highlight the potential of the theory for
guiding practice through application of the
seven-phase inquiry process.
Emergence of Story as a Topic
of Interest
Story is not new to nursing. Nurse theorists
(Boykin & Schoenhofer, 1991, 2001; Newman,
1999; Parse, 1981; Peplau, 1991; Watson, 1997)
have called attention to the importance of listen-
ing to what matters since the time of Florence
Nightingale, who implored nurses to stop
chattering and begin listening (Nightingale,
1969). Others (Benner, 1984; Chinn & Kramer,
1999; Ford & Turner, 2001) have used the sto-
ries of practicing nurses to understand both the
challenge and the essence of nursing practice. In
a discussion of the importance of story for
research with minority populations, Banks-
Wallace (2002) discussed the therapeutic value
of storytelling. Story sharing has also had a
prominent place in research with elders (Heliker,
2007; Sierpina & Cole, 2004). It is often used
by nurse researchers focused on the art of caring
for people who have dementia (Crichton &
Koch, 2007; Holm, Lepp, & Ringsberg, 2005;
Keady, Williams, & Hughes-Roberts, 2007).
Recently, physicians have emphasized nar-
rative medicine as both a way of learning
clinical practice essentials and a way of ap-
proaching patients (Charon, 2006, 2012;
Charon & Montello, 2002; Mehl-Medrona,
2007). Diamond, a psychotherapist, addressed
the long history of using narrative, in forms
such as personal testimony and letter writing,
to treat alcoholism and addiction. In his book
422 SECTION VI • Middle-Range Theories
3312_Ch24_421-434 26/12/14 10:43 AM Page 422
titled Narrative Means to Sober Ends (Diamond,
2000), he describes the spirit of narrative ther-
apy: “Stories, not atoms, are the stuff that hold
our lives and our world together” (p. 5). This
view of stories resonates with the foundational
assumptions of story theory and with a valuing
of the important place of stories for health
promotion. In Narrative Medicine: The Use of
History and Story in the Healing Process, Mehl-
Madrona (2007) approached the topic of nar-
rative from a Native American perspective,
distinguishing narrative medicine from conven-
tional medicine and proceeding to share Native
American stories that he described as maps for
healing. The outside-the-discipline focus “con-
firms our beliefs about the significance of story
and reminds us that this core dimension of
nursing practice is now being recognized by
other disciplines” (Smith & Liehr, 2014b,
p. 229). Although we, the authors, do not
equate story with narrative, we accept the place
of narrative within the context of story. Story
moves beyond narrative, intricately weaving re-
membered events, personal interpretations of
the moment and hopes and dreams to create the
“now” moment, guiding choices in the moment.
Story theory is one way to conceptualize an
idea that has a long history in nursing and
recently escalated attention from other disci-
plines. The authors believe that the structure of
story theory creates possibilities for application
and evaluation that are critical to the endeavor
of building substantive disciplinary knowledge.
Foundations of the Theory
Story theory proposes that story is a narrative
happening wherein a person connects with self-
in-relation through nurse–person intentional
dialogue to create ease (Smith & Liehr, 2014b).
Ease emerges in the midst of accepting the
whole story as one’s own—a process of attentive
embracing the complexity of one’s situation. All
nursing encounters occur within the context of
story. The stories of the nurse, patient, family,
and other health-care providers are woven to-
gether to create the tapestry of the moment—
this is the whole story in the moment. Each
time a nurse engages a patient about what
matters most regarding a health challenge, story
theory is applicable. By abandoning preexisting
assumptions, respecting the storyteller as the ex-
pert, and querying vague story directions, the
nurse intentionally engages the other, enabling
connecting with self-in-relation to create ease.
The theory is based on three assumptions
that underpin the framework. The assumptions
are that people (1) change as they interrelate
with their world in a vast array of flowing con-
nected dimensions, (2) live in an expanded pres-
ent moment where past and future events are
transformed in the here and now, and (3) expe-
rience meaning as a resonating awareness in the
creative unfolding of human potential (Smith &
Liehr, 2014b). These assumptions are consistent
with a unitary–transformative “view of the
world,” an inherently complex view (Newman,
Sime, & Corcoran-Perry, 1991), establishing a
value structure that creates a foundation for the
theory concepts.
The three concepts of the theory are inten-
tional dialogue, connecting with self-in-relation,
and creating ease (Fig. 24-1). The related
method dimensions are complicating health
challenge, developing story plot, and movement
toward resolving. The nurse engages a person
through intentional dialogue about a complicat-
ing health challenge, where connecting with
self-in-relation ensues as the developing story
plot surfaces through story sharing. As the
storyteller makes explicit what may have been
tacit (Polanyi, 1958), moments of ease accom-
pany movement toward resolving the health
challenge. Figure 24-1 depicts the theory model,
indicating relationships among the theory
concepts and related method dimensions.
CHAPTER 24 • Patricia Liehr and Mary Jane Smith’s Story Theory 423
Connecting with
self-in-relation
Developing story-plot
Intentional dialogue
Complicating health challenge
Nurse Person
Creating ease
Movement toward resolving
Fig 24 • 1 Story theory with method. (Reprinted
with permission of M. J. Smith and P. Liehr (2014). Story
theory. Middle Range Theory for Nursing. New York:
Springer, p. 234.)
3312_Ch24_421-434 26/12/14 10:43 AM Page 423
The current theory model spreads a “wave”
across all concepts in the theory, expressive of
the energy essential to story-sharing through
intentional dialogue. The heavy dotted ellipse
between nurse and person highlights nurse–
person intentional dialogue, the core activity
enabling connecting with self-in-relation and
creating ease. There are three ellipses in the
design of the model, mapping a vortex of a con-
tinually evolving process, encompassing all the
theory concepts and associated method dimen-
sions. The links between the essential elements
of the model map the theory phenomenon as an
energy-laden integrated whole.
Intentional Dialogue About
a Complicating Health Challenge
Intentional dialogue is the central activity
between nurse and person that brings story to
life; it is querying emergence of a health chal-
lenge story in true presence (Smith & Liehr,
1999). True presence is a fully immersed way of
being with another, where authenticity and
mindfulness prevail. This purposeful engage-
ment with another creates potential for embrac-
ing the whole story in the moment as the nurse
summons the storyteller’s narrative focusing on
what matters most about a complicating health
challenge (Smith & Liehr, 2014b). The com-
plicating health challenge is a life circumstance
in which life change generates uneasiness.
Understanding the uneasiness refines the health
challenge to enable meaningful nurse–person
interaction. For instance, getting married could
be both a joyful and an uneasy transition. In this
case, the complicating health challenge may
be articulated as the transition from being single
to being married. What matters most to the
anticipatory bride may be the uncertainty she
is feeling in the midst of excited planning.
This joyful–uneasy paradox will become the
focus for the nurse using story theory to guide
practice; the nurse will listen to the bride’s
complaint of stomach pain within the context
of joy–uneasiness emerging in the transition to
married life.
In another example, for a woman facing the
complicating health challenge of a breast cancer
diagnosis, it is possible that the thought of
losing her breast matters most. However, what
matters most could be the threat of a shortened
life imposed by the cancer, the response of her
husband to her changing body, or concern
about who will care for her puppy while she is
in the hospital. There is an endless list of possi-
bilities known only to the person who is living
the health challenge. The nurse can never
assume to know what matters most about a
health challenge regardless of the extent of
experience in a particular practice environment.
The nurse knows how to proceed only by query-
ing what matters most about a complicating
health challenge.
Connecting With Self-in-Relation
Through Developing Story Plot
Connecting with self-in-relation occurs as
reflective awareness on personal history
(Smith & Liehr, 1999). It is an active process
of recognizing self as related with others in a
developing story-plot uncovered through
intentional dialogue (Smith & Liehr, 2014b).
To connect with self-in-relation, people see
themselves not as isolated individuals but as
existing and growing in a context, which in-
cludes awareness of other people and times,
sensitivity to bodily expression, and a sense of
history and future in the present moment.
One way to gain insight into the story plot is
to gather a health challenge story using a
story-path approach. Story path begins with
a focus on a present health challenge; then,
moves to the past calling attention to the
relationship between the past and the present
challenge. The final phase of story-gathering,
when using the story path approach, happens
when the nurse asks about hopes and dreams
related to the current health challenge. Some-
times this story path approach is visually
depicted as the nurse and the story-sharer
cocreate a picture of past-present-future
along a horizontal line. When using story
path, “the nurse encourages reckoning with a
personal history by traveling to the past to
arrive at the story beginning, moving through
the middle, and into the future all in the pres-
ent, thus going into the depths of the story
to find unique meanings that often lie hidden
in the ambiguity of puzzling dilemmas”
(Smith & Liehr, 2014b, p. 231).
424 SECTION VI • Middle-Range Theories
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The story path is an expression of a develop-
ing story plot with high points, low points,
and turning points. High points are times
when things are going well by the storyteller’s
evaluation; low points are times when they are
not going so well; and turning points are times
when the story twists, sometimes subtly, some-
times dramatically, creating a shift in the
forward view. Often, we and our colleagues
have used a story-path approach to gather
stories for research (Hain, 2007, 2008; Liehr,
Nishimura, Ito, Wands, & Takahashi, 2011;
Ramsey, 2012; Wands, 2013; Williams, 2007).
The story path links present, past, and future
(Liehr & Smith, 2000), beginning with the
question, “What matters most to you right now
about (the health challenge you are facing)?”
This question is followed by one that queries the
past, asking how it contributes to the present.
Finally, hopes and dreams are elicited.
Figure 24-2 depicts a story path for Mary, a
29-year-old woman who has come to see the
nurse practitioner for hypertension. Her blood
pressure was recorded as 180/110 mm Hg on
the primary care visit. The nurse has drawn a
line on a sheet of paper and asked Mary to tell
her where she is in her life path by marking the
“present” on the line. Then she asks Mary what
matters most in this present moment. Mary
talks about her discomfort with her elevated
blood pressure at her young age. She adds
detail about her job as a project director for a
research study while having just finished full-
time study for her master’s degree and now
beginning work on her doctoral degree in psy-
chology. Mary’s home situation is “stabilized”
by her husband John, whom she describes as
mellow and the strongest supporter for “con-
sidering lifestyle changes to lower her high
blood pressure.” She tells the nurse that the
only time her blood pressure is normal is
on weekends, when she is away from work.
She provides great detail about her work situa-
tion on this visit, describing work as an “out-
of-control stress” environment aggravated by
people who “seem to enjoy her stressful frenzy.”
Mary believes that work-related stress is the
strongest contributor to her hypertension. The
nurse clarifies with Mary, “So . . . are you saying
that stress-induced high blood pressure is your
pressing concern right now?” Mary says, “Yes.”
What matters most to Mary about the health
challenge of hypertension on this visit is her
stressful work life, which she feels unable to
control. The nurse then moves to the past and
asks Mary to identify situations and events on
her story path that contributed to her current
health challenge of stress-induced high blood
pressure, and then to the future, asking her to
note hopes and dreams related to the health
challenge. Mary notes story-path events related
to her father and identifies her desire to have
a baby within the next 5 years. Each of these
markings along the story path is discussed
CHAPTER 24 • Patricia Liehr and Mary Jane Smith’s Story Theory 425
4 years old–
Dad always
“dissatisfied”
with her
College–
First experienced
DBP
Present:
Stress-induced
BP
Married John
Mary’s Story Path
Master’s work–
paid for by self,
father gave credit
Normal BP through
lifestyle change
Somewhere in here–
wants to have child
5 years
“down the
road”
Fig 24 • 2 Mary’s story path.
3312_Ch24_421-434 26/12/14 10:43 AM Page 425
with the storyteller leading the way. The nurse
makes notes on the story path so that both
participants are engaged in the process, infus-
ing the physiological indicator, a blood pressure
of 180/110 mm Hg, with Mary’s unique
personal story.
Before ending any visit where story has been
pulled into the foreground, it is important that
the nurse ask if there is “anything else” about the
health challenge that the storyteller wants to
share to enhance understanding. What matters
most about a health challenge may change from
visit to visit, and any single visit may encompass
more than one issue that matters the most.
Detailed story paths include bits of evidence
gleaned from what the storyteller emphasized.
This evidence has the potential to guide nursing
practice, including the next steps the nurse will
take during this and upcoming visits.
Story path is just one approach to gathering
the story in a practice setting. We have suggested
others such as photographs, family trees, and
pain diaries (Smith & Liehr, 2014b). There
seems to be value in eliciting a story through a
collaborative creation that enhances the telling
and takes the story to a structure such as story
path. The possible approaches for story gathering
are limitless. The creative nurse will identify
other unique approaches for querying what
matters most about a health challenge. Coming
to grips with what matters most about the health
challenge one is facing is a process of embracing
story, where paradoxically, embracing releases
a person from story confines, engendering a
sense of ease.
Creating Ease While Moving Toward
Resolving
In the context of story theory, creating ease is
defined as remembering disjointed story
moments to experience flow in the midst of
anchoring (Smith & Liehr, 1999) to an under-
standing of the whole story, even for only one
“aha” moment. As a person anchors for a mo-
ment, embracing the comprehensible whole,
flow ensues as easiness-with-self situated in a
complex context. Ease is neither assured nor
pervasive during story sharing. Sometimes it is
elusive; sometimes it is experienced as only a
moment in time. When story moments come
together in a meaningful way for the person
sharing a story, there is often some movement
toward resolving the health challenge. Move-
ment may be minuscule, or it may be a leap;
it enables a shift in one’s perspective usually
accompanied by action to address what matters
most about the health challenge.
Application of the Theory
to Research
Story theory has been used to guide a story-
centered intervention in a study of people
with Stage 1 hypertension (Liehr et al.,
2006). It has been used to guide structured
data collection in qualitative studies with
cancer patients (Williams, 2007), hemodial-
ysis patients (Hain, 2008) and women suf-
fering from migraine headaches (Ramsey,
2012). The story inquiry research method
has also been used for story gathering and
data analysis (Hain, Wands, & Liehr, 2011;
Kelley & Lowe, 2012; Liehr et al., 2011;
Wands, 2013). Details of the use of story
theory for research can be found in the text-
book Middle Range Theory for Nursing (Smith
& Liehr, 2014a).
Application of the Theory
Application of the theory to nursing practice
has occurred throughout discussion of the
theory concepts, providing real-life examples
that enable a move from conceptual to em-
pirical. In the next section, we describe a
seven-phase process that chronicles the de-
velopment of nursing knowledge from evi-
dence collected during nursing practice.
Application to practice will surface as the
exemplar of “transitioning to a nursing home”
is described.
426 SECTION VI • Middle-Range Theories
3312_Ch24_421-434 26/12/14 10:43 AM Page 426
CHAPTER 24 • Patricia Liehr and Mary Jane Smith’s Story Theory 427
Practice Exemplar
Advancing Practice Scholarship
Through Story Theory
We have proposed seven phases of inquiry
for practicing nurses who want to develop
practice evidence as a base for knowledge
development (Smith & Liehr, 2005). The
phases are as follows: (1) gather a story about
what matters most about a health challenge;
(2) compose a reconstructed story; (3) connect
existing literature to the health challenge;
(4) refine the name of the health challenge;
(5) describe the developing story plot with
high points, low points, and turning points;
(6) identify movement toward resolving; and
(7) collect additional stories about the health
challenge (Smith & Liehr, 2014b). For the
purposes of this chapter, we address all phases
of the inquiry process except the last, which
takes the nurse back to the practice environ-
ment to substantiate what emerged while
completing the first six phases.
Phase one asks the practicing nurse to gather
a story of what matters most about a health
challenge. Querying what matters most about
the health challenge is coming to know the
unique perspective of the person sharing the
story. To gather the story, the nurse could use
a structured approach such as the story path, or
story gathering could occur over time through
attentive presence recognizing circumstance
and life changes that are continually shaping
one’s story. Irrespective of how the nurse gath-
ers the story, coming to know the other in true
presence with mindful attention to what mat-
ters most culminates in a reconstructed story.
The nurse in the following story queried the
health challenge of transitioning to a nursing
home environment for elders who had been
living independently.
Phase two requires that the nurse compose
a reconstructed story. A reconstructed story is
a narrative creation with a beginning, a mid-
dle, and an end that weaves together the
nurse’s and the storyteller’s perspective of the
health challenge. The reconstructed story nat-
urally incorporates what matters most about
the health challenge. The reconstructed story
shared in this chapter was written by a nurse
who cared for Elizabeth during the last
months of her life in a nursing home. The
nurse had practiced in this nursing home for
10 years, often witnessing the health challenge
of transitioning from independent to nursing
home living. The story gathering occurred over
time, and story moments are synthesized as a
reconstructed story to serve as an evidence base
for understanding the independent living to
nursing home living transition.
Elizabeth was an 88-year-old woman who
enjoyed independent living in her bungalow
with her husband of 65 years. She and her
husband resided in the independent living
component of a continuing care community.
Elizabeth had a long history of atrial fibrilla-
tion, chronic heart failure, and diabetes; but
she managed to remain independent, using a
walker to get around. She attributed her inde-
pendence to the devotion of her husband, who
watched over her medication routine, diet, and
the balance between her activity/rest patterns.
At the end of January, Elizabeth began having
difficulty moving her left leg, especially when
she awoke in the morning. It seemed to her
that her leg had fallen asleep due to position-
ing during the night. Then, one February
morning, Elizabeth’s lower leg was painful,
cool to touch, and slightly discolored. Her
husband called the community nurse, who
immediately sent Elizabeth to the hospital,
where a popliteal clot was found to be occlud-
ing the artery. Amputation was considered but
rejected due to the complexity of Elizabeth’s
health situation. Clot-buster was dripped
directly into Elizabeth’s clot for 7 hours while
she lay on her back and the clot dissolved.
Elizabeth was relieved because she had always
feared losing her leg after witnessing her
grandmother’s double amputation as a result
of long-standing diabetes.
After 10 days in the hospital, Elizabeth
returned to the nursing home component of
her continuing care community, planning to
Continued
3312_Ch24_421-434 26/12/14 10:43 AM Page 427
428 SECTION VI • Middle-Range Theories
Practice Exemplar cont.
begin rehabilitation. Shortly after admission,
she was diagnosed with the flu, delaying the
start of rehabilitation. Once she began, the
physical therapists referred to her as their
“energizer bunny” because of her spirited
approach to therapy. Throughout this time, it
was very hard for Elizabeth to lift her left leg.
No matter how hard she tried, she couldn’t
move it like she could move her right leg. Still,
she was anticipating return to the bungalow to
get on with everyday living with her husband.
While Elizabeth was in the nursing home, her
husband visited every day at mealtimes and
when she was ready to go to sleep. She referred
to these visits as the “best times of her day.”
As part of the discharge plan, the physical
therapists took Elizabeth to her bungalow to
try out everyday activities. The difficulty mov-
ing her leg was magnified when she was in her
usual environment, and the therapists began
to think that she might not be able to return
home. About the same time, Elizabeth began
to have dramatic blood sugar swings that were
accompanied by confusion and twitching that
engaged all parts of her body. Her husband
was anxious and looking for answers while she
was consistently questioning: “What’s going
to happen to me now?” Her health challenge
at this time was an arduous struggle to resume
normal “independent” living in her bungalow
with her husband, and what mattered most at
this point was the unfamiliar, uncontrollable
bodily experience and the uncertainty that
ensued from unfamiliarity. The question
“What’s going to happen to me now?” was one
the nurse had heard repeatedly over her years
of nursing home practice as residents began
to understand that they might not return
home. She had begun to view the question as
a marker of transition that demanded her
concentrated attention to what mattered most
for the resident.
Elizabeth didn’t understand why her leg
wouldn’t move even though she worked so
hard in therapy; she tried to hide the twitch-
ing, which she had never experienced before.
The twitching and her attempts to move
her leg took a lot of energy, and she often said
that she was tired. She never stopped saying
that she wanted to “go home,” but at some
point the nurse suspected that the meaning
of “going home” had changed for Elizabeth.
The nurse asked her “Where is home?” and
Elizabeth responded that she wasn’t sure.
Shortly thereafter, Elizabeth stopped asking
to go to the bungalow, and she expressed
wishes for a peaceful death.
It became clear that Elizabeth was not get-
ting better as her heart failure became more
debilitating and blood sugar swings continued
despite precise insulin dosing and measured
carbohydrate intake. At this time, the doctor
suggested hospice. Elizabeth and her husband
listened to the description of hospice services,
and she signed the hospice papers. While
under hospice care, she stopped troubling over
her failed effort to move her left leg, continued
to have blood sugar swings, and never stopped
trying to hide the twitching.
Appearances mattered to Elizabeth, and
she continued to care about how she looked.
One time she told the nurse that she wore her
pink shirt as often as she could because her
husband liked it. She asked to have her roots
done, and the nurse took her to the beauty
shop one floor away. When she returned, her
husband took her picture. She was wearing her
pink shirt, and her husband later included the
picture in a memorial collage that was created
when she died. The long loving relationship
between Elizabeth and her husband was most
important to both of them in her last days. She
giggled with him while recalling fun times
they had over the years, and she asked for
hugs, an uncharacteristic request that became
increasingly familiar to her husband during
this time.
Elizabeth and her roommate told each
other stories, shared chocolates, and looked out
for each other as well as they could. Her room-
mate called her “sweet pea.” On the day Eliz-
abeth died, the roommate asked Elizabeth’s
husband and the nurse if she could pray
with them.
Elizabeth had been in the nursing home
about 3 months before she died. The course of
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CHAPTER 24 • Patricia Liehr and Mary Jane Smith’s Story Theory 429
Practice Exemplar cont.
her story shifted from one of expectation for
familiar normalcy in her bungalow with her
husband to one of peaceful going home. The
nurse in this situation of caring for Elizabeth
was attentively present to the shifting story,
following Elizabeth’s lead to pursue meaning
during the last months of her life.
Phase three of the story inquiry process re-
quires that the nurse become familiar with the
existing literature about the complicating
health challenge—in this case, transitioning
from independent to nursing home living.
For the purposes of this chapter, only the
beginnings of a literature review are reported.
However, the practicing nurse interested in a
particular health challenge will stay abreast of
related literature and eventually develop a
broad literature base informing ongoing inter-
pretation of stories and physiological bodily
responses. To begin this literature search, the
phrases nursing home transition and elder were
searched together.
Brandburg (2007) conducted an integrated
literature review intended to synthesize the
state of the science regarding transition to a
nursing home for older adults. The 13 articles
that met the inclusion criteria led to the
creation of a “transition process framework”
with the foundational concepts of initial reac-
tion, transitional influences, adjustment, and
acceptance. Brandburg (2007) reported that
the initial reaction and adjustment phases of
the process require approximately 6 months.
During that time, people move from disorgan-
ization to reorganization and relationship
building. They also move from a sense of
homelessness to recognition of a new home
where new relationships are developed and old
ones are cultivated. She describes the “final” or
acceptance phase as one in which “reflecting
on the transition experience in light of per-
sonal values helped many older adults accept
their new home because they could find mean-
ing in their present situation” (p. 55).
The theme of home that was noted by
Brandburg (2007) was strongly described by
Heliker and Scholler-Jaquish (2006) in a study
of 10 newly admitted nursing home residents
who were interviewed multiple times over
their first 3 months of residency. Residents
responded to the directive: “Tell me a story
about what it is like for you to come here
and live.” Data from 32 interviews lasting
from 15 to 60 minutes were analyzed using a
hermeneutical phenomenological approach.
Three themes emerged: becoming homeless,
getting settled, learning the ropes, and creating
a place. The first theme, becoming homeless,
contributed to the researchers’ conclusion that
“one cannot separate home, memories, and
friends from one’s very identity. Each contin-
uously shapes and is shaped by the other”
(p. 41). Getting settled and learning the ropes
was a theme characterized by residents’ shift
from unknown to known, invisible to
visible. Creating a place was a theme related
to creating meaning in this new life situation.
In their conclusion, the authors note the im-
portant place of story: “The challenge for nurs-
ing home staff is to create situations, a clearing
for sharing stories . . . that facilitate the cocre-
ation of new meanings. . . . A staff that listens
to what matters to residents can interpret a
plan of care that is meaningful” (p. 41).
Listening was the major theme in a brief by
Maynes (2004). She shared the story of a
patient she met on a short hospitalization, dur-
ing which his cancer diagnosis was confirmed
and he was evaluated as having a “poor prog-
nosis.” The nurse listened to the quiet man and
honored his wish to return “home” to the farm
country where he was raised. On the day he was
to be transferred, the nurse went to his bedside
to say good-bye, thankful that he would be
returning to the place he loved. When she
approached the bed, she realized that he had
died. “I sat next to him, put his hand in mine,
and whispered ‘good-bye’” (p. 32).
Elizabeth’s short nursing home stay fits most
clearly with the initial reaction phase described
by Brandburg (2007) and the becoming homeless
theme described by Heliker and Scholler-Jaquish
(2006), both of whom call attention to the mean-
ing of home. The idea of “home” emerges
strongly from the literature and story sources.
Both Elizabeth and the man in Maynes’s (2004)
Continued
3312_Ch24_421-434 26/12/14 10:43 AM Page 429
430 SECTION VI • Middle-Range Theories
Practice Exemplar cont.
brief feel the pull of “home” as they approach
death. Merging Elizabeth’s story with the rele-
vant literature prepared the stage for the next step
of the story inquiry process: refining the name of
the health challenge.
Phase four suggests that the nurse refine the
name of the health challenge, if necessary.
There may be some times when the original
name is confirmed as adequately expressive of
the challenge, and there are other times when
the convergence of the reconstructed story
with the existing literature demands that the
health challenge name be refined. We believe
that “naming” is most important for the con-
tinuing work, and we advocate that the health
challenge name be neither too high nor too
low in level of abstraction. Names that are too
high may be difficult to apply to practice situ-
ations, and names that are too low may be
meaningful for only a few people. Considering
Elizabeth’s story and the existing literature,
the name of the complicating health challenge
was changed to “struggling to go home.” This
health challenge name is consistent with the
original name of transitioning from independ-
ent to nursing home living, but it captures
more clearly what matters most about the
transition. It is neither so high that it cannot
be applied in practice nor so low that it applies
to only a narrow subset of people. Because
it is in the middle, it may also have applicabil-
ity to other populations, such as people who
have been evacuated from their homes due to
natural disasters or families of premature new-
borns who demand extended hospital stays.
Phase five of the story inquiry process focuses
on the developing story plot through identifi-
cation of high points, low points, and turning
points. Turning points are shifts in what is hap-
pening to create a revision in the storyteller’s
forward view. These are situations or events that
move the story along. High and low points note
times when things are going well or not so well.
Table 24-1 records the turning points, high
Story Event TP HP LP
Difficulty moving leg beginning in January
Change in leg pain, temperature, and color—leading to
hospitalization
Decision not to amputate
Clot was dissolved
Return to nursing home for rehabilitation
Diagnosed with flu
Couldn’t move leg though she tried
Husband’s four-times-daily visits
Inability to perform usual activities with physical therapist
in bungalow—aware she may not return
Blood sugar swings, confusion, and twitching
“What’s going to happen to me now?”
Stopped asking about going to bungalow and began talking
about peaceful death
Signed hospice papers
Getting roots done, giggling with husband, sharing chocolate
with roommate
Table 24 • 1 Turning Points, High Points, and Low Points in Elizabeth’s Story
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
TP = turning point; HP = high point; LP = low point.
3312_Ch24_421-434 26/12/14 10:43 AM Page 430
CHAPTER 24 • Patricia Liehr and Mary Jane Smith’s Story Theory 431
Practice Exemplar cont.
points, and low points in Elizabeth’s recon-
structed story. Turning points may also be high
points or low points, but this is not always the
case. Sometimes turning points exist with no
particular value assigned by the person living
the story. In Elizabeth’s story, turning points
can be summarized as: (1) diagnosed health
issues, (2) treatment milestones, and (3) the
hospice decision. High points are (1) “favor-
able” (according to Elizabeth) treatment mile-
stones and (2) relationship-centered moments
of joy. Low points are (1) limitations in physical
movement, (2) unfamiliar bodily experiences
with and without diagnoses, and (3) uncer-
tainty. As the practicing nurse collected more
stories of this nature, comparison, contrast, and
synthesis of turning points, high points, and
low points would be possible, and the evidence
from stories could contribute to the knowledge
base guiding practice with people who are tran-
sitioning into a nursing home. One last phase
of analysis considers the evidence from stories
to identify how people get through the health
challenge.
Phase six asks that the practicing nurse
identify how an individual moved toward
resolving the health challenge. This phase of
practice inquiry may be most instructive for
the nurse’s continuing work with a particular
population because it taps the inherent
wisdom of people living the challenge to un-
derstand how they got by. The question facing
the nurse analyzing Elizabeth’s reconstructed
story is: How does Elizabeth move toward
resolving the complicating health challenge
of struggling to go home? Elizabeth put all her
effort into her recovery so that her therapists
called her their “energizer bunny.” When her
efforts failed and her bodily experience indi-
cated that she was on a different path, she
signed the hospice papers. Finally, Elizabeth
enjoyed moments with her husband and her
roommate and chose to do things that kept
her appearance as she liked. Movement to-
ward resolving recounted in the reconstructed
story included the approaches of (1) devoting
energy to recovery, (2) accepting hospice,
(3) experiencing the joy of relationship, and
(4) attending to self through personal appear-
ance. The range of ways Elizabeth moved
toward resolving reflects the dynamic and
complex nature of story. What is characterized
as movement toward resolving emerges as the
story unfolds. At a higher level of abstraction,
these approaches used by Elizabeth, may be
conceptualized as (1) focusing energy to heal,
(2) accepting the inevitable, (3) appreciating
relationship, and (4) attending to self. At this
higher level of abstraction, the four approaches
extracted from the reconstructed story have
implications for people who are struggling
to go home, regardless of the context of their
situation. The story describes how one person
created ease and offers an invitation to con-
sider how others in similar situations may
create ease as they move toward resolving a
health challenge of struggling to go home.
Once again, there is guidance for nursing
practice in the wisdom of people living health
challenges. The nurse could use what is learned
from this story analysis to guide current
practice and frame further inquiry.
■ Summary
This chapter has introduced the reader to
story as an essential element of evidence
guiding nursing practice. The authors hope
that practicing nurses can use the story in-
quiry process to access story evidence for the
precious contribution it can make to nursing
knowledge. Each nurse at the bedside, in the
clinic, or in the office is uniquely positioned
to gather and analyze practice stories. The
middle-range story theory is proposed as a
framework for structuring story-gathering
and analysis.
3312_Ch24_421-434 26/12/14 10:43 AM Page 431
432 SECTION VI • Middle-Range Theories
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Chapter 25The Community Nursing
Practice Model
MARILYN E. PARKER,
CHARLOTTE D. BARRY,
AND BETH M. KING
Introducing the Theorists
Overview of the Model
Application of the Model
Practice Exemplar
Summary
References
435
Introducing the Theorists
Marilyn E. Parker is professor emerita at the
Christine E. Lynn College of Nursing at Florida
Atlantic University and recently retired professor
from the University of Kansas School of Nurs-
ing. She earned degrees from Incarnate Word
College (BSN), the Catholic University of
America (MSN), and Kansas State University
(PhD). Her overall career mission is to enhance
nursing practice, scholarship, and education
through nursing theory, using both innovative
and traditional means to improve care and
advance the discipline.
As principal investigator for a program of
grants to create and use a new community nurs-
ing practice model, Dr. Parker has provided
leadership to develop transdisciplinary school-
based wellness centers devoted to health and
social services for children and families from un-
derserved multicultural communities, to teach
university students from several disciplines,
and to develop research and policy to promote
community well-being.
Dr. Parker’s active participation in nursing
education and health care in several countries
led to her 2001 Fulbright Scholar Award to
Thailand, where she continues collaboration
with Thai colleagues. Her commitment to
caring for underserved populations and to
health policy evaluation led to being named a
National Public Health Leadership Institute
Fellow and to being elected a distinguished
practitioner in the National Academies of
Practice in Nursing. Dr. Parker is a fellow in
the American Academy of Nursing.
Charlotte D. Barry is a professor and master
teacher at the Florida Atlantic University Chris-
tine E. Lynn College of Nursing. Dr. Barry
Charlotte D. BarryMarilyn E. Parker
3312_Ch25_435-448 26/12/14 10:43 AM Page 435
graduated from Brooklyn College, New York,
with an associate’s degree in nursing; holds a
bachelor’s degree in health administration, a
master’s degree in nursing from Florida Atlantic
University, and a PhD from the University of
Miami, Florida. She is nationally certified in
school nursing and in 2013 was recognized as
one of the best 25 Nursing Professors in Florida.
Dr. Barry is a fellow in the American Academy
of Nursing.
The focus of Dr. Barry’s scholarship has been
caring for persons in schools and communities.
As a coprincipal investigator with Dr. Parker,
Dr. Barry cocreated the community nursing
practice model from the transdisciplinary prac-
tice unfolded at several school-based wellness
centers. Her current research includes the
usefulness of the community nursing practice
model to guide practice in global communities
including the United States, Uganda, and Haiti.
Building on the school-based wellness center in
Uganda, a replica program is being developed
in a rural community in Haiti.
Dr. Barry provides leadership in many
community and professional organizations in-
cluding Sigma Theta Tau, Iota XI Chapter, the
International Association for Human Caring,
the National Association of School Nursing,
and the Florida Association of School Nurses.
She also serves on the Board of the South
Florida Haiti Project and the Broward County
School Health Advisory Committee.
Overview of the Model
The community nursing practice model (CNPM)
began with and continues to be a blend of the
ideal and the practical. The ideal was the com-
mitment to develop and use nursing concepts to
guide nursing practice, education, and scholar-
ship and a desire to develop a nursing practice as
an essential component of a college of nursing.
The practical was the effort to bring this CNPM
to life within the context and structures of an ex-
isting community health care system. The model
reflects the mission of the Christine E. Lynn
College of Nursing at Florida Atlantic Univer-
sity and the concept of nursing held by its fac-
ulty: Nursing is nurturing the wholeness of persons
and environments in caring (Florida Atlantic
University College of Nursing Philosophy and
Mission [FAU], 1994/2012).
The concepts and relationships of the
model are the guiding forces for community
practice. Through various participatory-action
approaches, including ongoing shared reflec-
tion, intuitive insights, and discoveries, the
CNPM has evolved and continues to develop.
The education of university students and the
conduct of student and faculty research have
been integrated with nursing and social work
practice. Throughout the early development
and ongoing refinement of the model, there
has been nurturing of collaborative commu-
nity partnerships, evaluation and development
of school and community health policy, and
development of enriched community.
Foundations of the Model
Essential values that form the basis of the model
are (1) persons are respected; (2) persons are car-
ing, and caring is understood as the essence of
nursing; and (3) persons are whole and always
connected with one another in families and
communities. These essential, or transcendent,
values are always present in nursing situations,
while other actualizing values guide practice in
certain situations.
The principles of primary health care from
the World Health Organization (WHO; 1978)
are the actualizing values. These additional con-
cepts of the model are (1) access, (2) essentiality,
(3) community participation, (4) empower-
ment, and (5) intersectoral collaboration. Con-
cepts of nursing practice that have emerged
include transitional care and enhancing care.
The CNPM illuminates these values and each
of the concepts in four interrelated themes:
nursing, person, community, and environment,
along with a structure of interconnecting serv-
ices, activities, and community partnerships
(Parker & Barry, 1999). An inquiry group
method has been designed and is the primary
means of ongoing assessment and evaluation
(Barry, Lange, & King, 2011; Campbell et al.,
2001; Clark et al., 2003; Parker, Barry, & King,
2000; Ryan, Hawkins, Parker, & Hawkins,
2004; Sadler, Newlin, & Jenkins, 2011).
436 SECTION VI • Middle-Range Theories
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Nursing
The unique focus of nursing is nurturing the
wholeness of persons and environments in
caring (FAU, 1994/2012). Nursing practice,
education, and scholarship require creative
integration of multiple ways of knowing and
understanding through knowledge synthesis
within a context of value and meaning. Nurs-
ing knowledge is embedded in the nursing
situation, the lived experience of caring be-
tween the nurse and the one receiving care.
The nurse is authentically present for the
other, to hear calls for caring and to create
dynamic nursing responses. The school-based
wellness centers in the community become
places for persons and families to access nurs-
ing and social services where they are: in
homes, work camps, schools, or under trees
in a community gathering spot. Nursing is
dynamic and portable; there is no predeter-
mined nursing and often no predetermined
access place (Dyess & Chase, 2012; Parker,
1997; Parker & Barry, 1999).
Nursing practice is further described within
the context of transitional care and enhancing
care. Transitional care is that in which clients
and families are provided essential health care
while being referred to a more permanent
source of health care in the community. Tran-
sitional care, an ideal for nursing and social
work practice, is sometimes not possible owing
to immigration status, a complex and con-
founding health-care system, or other issues of
the family.
Enhancing care describes nursing and social
work that is intended to assist the client and
family who need care in addition to that pro-
vided by a local health-care provider.
Person
Respect for person is present in all aspects of
nursing, with clients, community members,
and colleagues. Respect includes a stance of
humility that the nurse does not know all that
can be known about a person and a situation,
acknowledging that the person is the expert in
his or her own care and knowing his or her
experience. Respect carries with it an openness
to learn and grow. Values and beliefs of various
cultures are reflected in expressions of caring.
The person as whole and connected with oth-
ers, not the disease or problem, is the focus of
nursing.
Persons are empowered by understanding
choices, how to choose, and how to live daily
with choices made. The person defines what is
necessary to well-being and what priorities
exist in daily life of the family. Nursing and
social work practice based on practical, sound,
culturally acceptable, and cost-effective meth-
ods are necessary for well-being and wholeness
of persons, families, and communities.
Early on, Swadener and Lubeck’s (1995)
work on deconstructing the discourse of risk
was a major influence on practice. At risk con-
notes a deficiency that needs fixing; a doing to,
rather than collaborating with. Thinking about
children and families “at promise” instead of
“at risk” inspires an approach to knowing the
other as whole and filled with potential.
Respect and caring in nursing require full
participation of persons, families, and commu-
nities in assessment, design, and evaluation of
services. Based on this concept, an inquiry group
method is used for ongoing appraisal of services.
This method is defined as a “route of knowing”
and “a route to other questions.” Each person is
a coparticipant, an expert knower in his or her
experience; the facilitator is the expert knower
of the process. The facilitator’s role is to encour-
age expressions of knowing so that calls for nurs-
ing and guidance for nursing responses can be
heard. In this way, the essential care for persons
and families can be known, and care can be de-
signed, offered, and evaluated (Barry, 1998;
Barry, Lange, & King, 2011; Gordon, Barry,
Dunn, & King, 2011; Parker et al., 2000).
Community
Community, as understood within the model,
was formed from the classical definition offered
by Smith and Maurer (1995) and from Peck’s
(1987) existential, relational view. According
to Smith and Maurer, a community is defined
by its members and is characterized by shared
values. This expanded notion of community
moves away from a locale as a defining charac-
teristic and includes self-defined groups who
CHAPTER 25 • The Community Nursing Practice Model 437
3312_Ch25_435-448 26/12/14 10:43 AM Page 437
share common interests and concerns and who
interact with one another.
Community, offered by Peck (1987), is
a safe place for members and ensures the
security of being included and honored. His
work focuses on building community
through a web of relationships grounded in
acceptance of individual and cultural differ-
ences among faculty and staff and acceptance
of others in the widening circles, including
colleagues within the practice and discipline,
other health-care colleagues from varied
disciplines, grant funders, and other collab-
orators. The notion of transdisciplinary care
is an exemplar of this approach to commu-
nity. Another defining characteristic of com-
munity, according to Peck, is willingness
to risk and tolerate a certain lack of structure.
The practice guided by the model reflects
this in fostering a creative approach to pro-
gram development, implementation, evalua-
tion, and research.
Practice within the model, whether un-
folding in a clinic or under a tree where per-
sons have gathered, provides a welcoming
and safe place for sharing stories of caring.
The intention to know others as experts in
their self-care while listening to their hopes
and dreams for well-being creates a com-
munion between the client and provider that
guides the development of a nurturing rela-
tionship. Knowing the other in relationship
to their communities, such as family, school,
work, worship, or play, honors the complex-
ity of the context of persons’ lives and offers
the opportunity to understand and partici-
pate with them.
Environment
The notion of environment within the CNPM
provides the context for understanding the
wholeness of interconnected lives. The envi-
ronment, one of the oldest concepts in nursing
described by Nightingale (1859/1992), is not
only the immediate effects of air, odors, noise,
and warmth on the reparative powers of the
patient but also indicates the social settings
that contribute to health and illness such as
those identified as the social determinants of
health (WHO, 2007, 2012). Another nursing
visionary, Lillian Wald, witnessed the hard-
ships of poverty and disenfranchisement on
the residents of the lower Manhattan immi-
grant communities. She developed the Henry
Street Settlement House to provide a broad
range of care that included direct physical care
up to and including finding jobs, housing, and
influencing the creation of child labor laws
(Zaiger, 2013).
Chooporian (1986) reinspired nurses to
expand the notion of environment not only to
include the immediate context of patients’ lives
but also to think of the relationship between
health and social issues that “influence human
beings and hence create conditions for heath
and illness” (p. 53). Reflecting on earth caring,
Schuster (1990) urged another look at the
environment, inviting nurses to consider a
broader view that included nonhuman species
and the nonhuman world. Acknowledging the
interrelatedness of all living things energizes
caring from this broader perspective into a
wider circle. Kleffel (1996) described this
as “an ecocentric approach grounded in the
cosmos. The whole environment, including
inanimate elements such as rocks and minerals,
along with animate animals and plants, is
assigned an intrinsic value” (p. 4). This per-
spective directs thinking about the intercon-
nectedness of all elements, both animate and
inanimate. Teaching, practice, and scholarship
require a caring context that respects, explores,
nurtures, and celebrates the interconnected-
ness of all living things and inanimate objects
throughout the global environment.
Structure of Services and Activities
The CNPM is envisioned as three concentric
circles around a core. Envisioning the CNPM
as a watercolor representation, one can appre-
ciate the vibrancy of practice within the
CNPM, the amorphous interconnectedness
of the core and the circles, and the “certain
lack of structure” draws attention to the
beauty in creating responses to unique calls
for nursing. The CNPM calls into the circles
others to create programs and environments
that nurture well-being (Fig. 25-1).
438 SECTION VI • Middle-Range Theories
3312_Ch25_435-448 26/12/14 10:43 AM Page 438
Core Services
Core services, created from the results of
inquiry group methodology (Barry, Gordon,
& Lange, 2007; Barry et al., 2011; Parker et
al., 2002), are provided to nurture the whole-
ness of persons and environments through
caring. The unique experiences of staff and
faculty with the hopes and dreams for well-
being of those receiving care create the sub-
stance of the core: respecting self-care practice;
honoring lay and indigenous care; inviting
participation and listening to clients’ stories of
health and well-being; providing care that is
essential for the other; supporting caring for
self, family, and community; providing care
that is culturally competent; and collaborating
with others for care. These services, provided
to children, students, school staff, and families
from the community, occur in the following
(and frequently overlapping) categories of care:
1. Design and coordinate care: examples include
referrals, navigation to other health services,
home visits, and concepts of transitional
and enhancing care are illuminated here
through the development of collaborative
relationships
2. Primary prevention and health education:
examples include assessment of child-
development milestones, pre- and
postnatal wellness, breast health,
testicular health, and stress reduction
3. Secondary prevention/health screening/early
intervention: examples include screenings
for hearing and vision, height/weight/
BMI, cholesterol, blood sugar, blood
pressure, clinical breast examinations,
lead levels, assessment, administration
of immunizations, and early management
of health issues
4. Tertiary prevention/primary care: assessment,
diagnosis, treatment, and care management
for chronic health issues, crisis intervention,
and behavioral support
First Circle
The first circle of the CNPM depicts a widen-
ing circle of concern and support for the well-
being of persons and communities. This circle
includes persons and groups in each school and
community who share concern for the well-
being of persons served at the centers. This in-
cludes participants in inquiry groups, parents/
guardians, school faculty, and noninstructional
staff, after-school groups, parent/teacher or-
ganizations, and school advisory councils. The
services provided within this circle might
include the following:
1. Consultation and collaboration: building
relationships and community, answering
inquiries on matters of health and well-
being, providing in-service and health
education, serving on school committees,
reviewing policies and procedures
2. Appraisal and evaluation: conducting
community assessments, appraising care
provided, evaluating outcomes, and
promoting programs that enhance well-
being for individuals and communities
Second Circle
The second circle draws attention to the wider
context of concern and influence for well-
being and includes structured and organized
groups whose members also share concern for
CHAPTER 25 • The Community Nursing Practice Model 439
Nursing
Situation
Or
ga
niz
atio
ns with wider jurisdictions
S
tr
uc
tu
re
d
an
d o
rgan
ized individuals and groups
Sc
ho
ol
a
nd
c
om
mu
nity individuals and groups
The Community Nursing Practice Model:
Concentric Circles of Empathetic Concern
Fig 25 • 1 The community nursing practice model:
Concentric circles of empathic concern. ©Florida
Atlantic University.
3312_Ch25_435-448 26/12/14 10:43 AM Page 439
the education and well-being of the persons
served at the centers but within a wider range
or jurisdiction such as a district or county. Ex-
amples of these policy-making or advising
groups include the school district and county
public health department, voluntary organiza-
tions such as the Red Cross, and funders who
offer support for school and community car-
ing. The services provided in this circle include
the following:
1. Consultation and collaboration: building
relationships and community with
members of these groups; contributing
to policy appraisal, development, and
evaluation; leading and serving on
teams and committees responsible for
overseeing the care of students and
families; providing school nurse education
2. Research and evaluation: assessing school
health services, describing research find-
ings for best practices related to school and
community health, and designing research
projects focused on school/community
health issues, and/or school/community
nursing practice.
Third Circle
The third circle includes state, regional, national,
and international organizations with whom we
are related in various ways. Services within this
circle are focused on:
1. Consultation and collaboration: building
relationships and community with mem-
bers and collaborating about scholarship,
policy, outcomes, practice, research,
educational needs of school nurses
and advanced practice nurses; sustain-
ability through ongoing and additional
funding
2. Appraisal and evaluation: school nursing
and advanced practice faculty organiza-
tions offer a milieu for discussion and
appraisal of the services provided at the
centers (Organizations in this circle
may include national and international
organizations such as universities,
religious organizations, the Centers
for Disease Control and Prevention,
Department of Health and Human
Services, Ministry of Health, World
Health Organization, national profes-
sional organizations and boards, licensing
agencies, and various non-governmental
organizations [NGOs], such as Partners
in Health and Doctors Without
Borders.)
Connection of Core to Concentric
Circles
Connections of the core to the concentric
circles of services illuminate the complexity
of the practice within the CNPM. The core
service of consultation and collaboration is a pri-
mary focus of practice, beginning with nursing
and social work colleagues and extending to
participating clients, families, policymakers,
funders, and legislators. This value-laden
service has been essential to the viability and
sustainability of this CNPM. It promotes the
stance of humility that guides the respectful
question throughout the circles: How can
we be helpful to you? The answer directs the
creation of respectful, individualized care and
program development. Essential health-care
services are created within the core and extend
into the first circle.
Connections to the second circle unfold
from the collaborating relationships with
colleagues in the health department, school
district, and other groups taking the lead with
school and community health. Committees
of center administrators and staff meet regu-
larly to discuss school and community health
issues and to seek consensus on possible so-
lutions. Health-care providers are consultants
for medical questions and referrals, and
school nurse education may also be provided
for nurses to prepare them for community
nursing practice.
Like the other circles, the third circle de-
picts the breadth of relationships developed
at meetings and through publications and
presentations at local, regional, national, and
international conferences. Administration
and faculty have been widely recognized for
the contribution made to the health and
well-being of children and families.
440 SECTION VI • Middle-Range Theories
3312_Ch25_435-448 26/12/14 10:43 AM Page 440
Application of the Model
The model has been used as the framework
for research, education, and practice across
disciplines and with diverse foci. Some exam-
ples include the study of nursing language in
electronic records; a framework for curricu-
lum development for a master’s program in
advanced community nursing at Naresuan
University, Phitsanulok, Thailand; and the
use of the model by faculty of nursing at
Mbarara University of Science and Technol-
ogy, Mbarara, Uganda, to develop study of
advanced community nursing and to design
and operate the first school-based community
nursing wellness center in Uganda.
The CNPM guides a diverse, complex,
and transdisciplinary practice of nursing and
social work in school-based community well-
ness centers serving children and families
from diverse multicultural communities. The
collaborative approach of the CNPM fosters
relationships and acceptance by local commu-
nities and providers as essential component
to the health-care system. The CNPM was
featured in a major community nursing text
(Clark, 2003) and a school nursing practice
text (Gordon & Barry, 2006).
The CNPM has been the guiding frame-
work for a wide range of theses and disserta-
tions and in software development. In the
field of computer science engineering, the
CNPM has been used to give voice to nursing
through the development of a web-based
classification system, which quantifies the
qualitative language of nursing, specifically
the concepts of caring, knowing, connection,
and respect. The researchers analyzed nursing
situations based on the CNPM to develop an
electronic record that quantified the transcen-
dent values of the CNPM (Chinchanikar,
2009; Dass, 2011; Parker, Pandya, Hsu,
Noel, & Newlin, 2008; Tripathi, 2010). A
first patent application has been published
by the US Patent Office (U.S. Patent No.
2013/0311203A1; Parker, Pandya, Hsu, &
Huang, 2013). The research includes use of
caring theory and nursing language research
based on the community caring practice
model as a framework for patient human–
robot interaction (Huang, Tanioka, Locsin,
Parker, & Masory, 2011)
Sternberg (2009) identified the CNPM
as the theoretical perspective grounding her
research exploring the experience and meaning
of transnational motherhood. Her findings
illuminated the themes of sacrifice, suffering,
and hoping for a better life for their children
as the essence of their mothering from a dis-
tance. The author affirms the usefulness of the
CNPM in guiding this research to understand
the experience of these women living as whole
caring individuals.
Similarly the findings of Conrad’s (2010)
dissertation research identified the usefulness
of the CNPM as a framework to provide care
to culturally diverse populations. The inten-
tion to respect each individual and to respect
his or her health-care beliefs and practices can
be the grounding for the creation of nursing
responses that nurture the other’s hopes and
dreams for well-being. Pope’s (2011) histor-
ical research was grounded in the core beliefs
of the CNPM, and her findings identified
the need for interconnectedness to facilitate
community partnership and enhancement of
relationships.
Application in Nursing Education
Barry, Blum, Eggenberger, Palmer-Hickman,
and Mosley (2010) focused on the transcendent
values of respect, caring, and wholeness of per-
sons in the nursing situation through the use of
simulation to enhance nursing education.
Through simulation, the students were guided
to come to know the human face of homeless-
ness, to understand the whole context of the
person’s life, and, through compassion, to come
to see their faces reflected back. The specific
goals of the simulation were to understand the
fullness of the lived experience of homelessness
and to understand the full experience of caring
for Mildred, the simulated woman who was
homeless.
Ladd, Grimley, Hickman, and Touhy
(2013) built on the simulation model grounded
in the CNPM to develop a teaching–learning
nursing situation related to end-of-life care.
CHAPTER 25 • The Community Nursing Practice Model 441
3312_Ch25_435-448 26/12/14 10:43 AM Page 441
Focusing on coming to know the individual
and family, students studied ways of nurturing
wholeness. Reflective analysis was incorporated
to promote the student’s self-awareness of their
own values and beliefs and the relation of these
to nursing care.
Barry, Blum, and Purnell (2007) used the
CNPM to assist nursing’s students under-
standing of the lived experience of victims of
Hurricane Katrina. The students went door to
door asking individuals how they could be
helpful and listening to calls for nursing. Many
times the call was to listen to an individual’s
story of survival and displacement; for others,
it was facilitating getting a child enrolled in
school. The students reached out into the com-
munity for resources and brought them back
to the individuals. Through this immersion ex-
perience, the students were able to live and feel
the connectedness to others and community
and to experience the meaning of nurturing
the wholeness of the other through caring.
Application in Practice
The transcendent values of respect and caring
provide the underpinnings of the inquiry group
method used by the CNPM to identify health
concerns and community strengths and assets.
Several studies have identified the usefulness
of the inquiry group method as a valuable tool
not only to gather perspectives from commu-
nity residents and partners to understand and
identify health needs and services but also
to resolve problems (Clark, 2003; Kasle,
Wilhelm, & Reed, 2002; Plonczynski et al.,
2007; Sadler et al., 2011). This method has
also been linked to increasing the likelihood of
acceptance of change by communities (Camp-
bell et al., 2001). The value of including
community partners and stakeholders in deci-
sion making was supported by the research of
Dyess and Chase (2012).
The actualizing values of access, essentiality,
community participation, empowerment, and
intersectoral collaboration guide nursing practice
in the CNPM. An example of these values in
action can be found in the study by Barry et al.
(2011). They used the CNPM as the framework
to develop a breast health promotion outreach
for underserved women. The inquiry group
method was used to establish the participant
as the expert of her own care with dialogue and
inclusiveness grounded in the values of respect,
caring, and wholeness of persons. The value of
community voice to enhance the care of the
underserved is highlighted in the research of
Sternberg and Lee (2013). Their research com-
pared the frequency of depressive symptoms of
premenopausal Latinas born in the United
States to Latina immigrants and found that
immigrant Latinas rated themselves slightly
higher on the Centers for Epidemiologic Studies
Depression Scale.
Tables 25-1 and 25-2 highlight the re-
search and studies focusing on the transcen-
dent and actualizing values of the CNPM.
442 SECTION VI • Middle-Range Theories
Value Category Description References
Transcendent Values: Present
in all nursing situations
Respect
Caring
Table 25 • 1 Illumination of the Transcendent and Actualizing Values of the
Community Nursing Practice Model
Refers to honoring the inher-
ent dignity and uniqueness of
each individual
Understand that to be human
is to be caring and also that
caring is the essence of nursing
Barry, Gordon, & Lange
(2007); Barry, Lange, &
King (2011); Chinchanikar
(2009); Dass (2011);
Tripathi (2010)
Barry, Gordon, & Lange
(2007); Barry, Lange, &
King (2011); Chinchanikar
(2009); Dass (2011);
Huang, Tanioka, Locsin,
3312_Ch25_435-448 26/12/14 10:43 AM Page 442
Wholeness
Actualizing Values: Guides
practice in specific nursing
situations
Access
Essentiality
Community participation
Empowerment
Intersectoral collaboration
CHAPTER 25 • The Community Nursing Practice Model 443
Value Category Description References
Table 25 • 1 Illumination of the Transcendent and Actualizing Values of the
Community Nursing Practice Model—cont’d
Views persons as whole in the
moment and always connected
with others in families and
communities
Views as ongoing and con-
stant availability of health
care that is competent, cultur-
ally acceptable, respectful
and cost-effective
Described from the client’s
view as what is necessary for
well-being
Described as the active
engagement with members
of a community fostered by
openness to listen to calls for
nursing and to create nursing
responses
Understood as the client’s
awareness of making individ-
ual choices that influence
health and well-being
Refers to the openness to seek
and honor the expertise of
providers and agencies to
potentiate the outcomes
of services essential to
well-being
Parker, & Masory (2011);
Parker, Pandya, Hsu,
Noell, & Newlin (2008);
Tripathi (2010)
Barry, Gordon, & Lange
(2007); Barry, Lange, &
King (2011); Chinchanikar
(2009); Dass (2011);
Tripathi (2010)
Barry, Blum, Eggenberger,
Palmer-Hickman, &
Mosley (2010); Barry,
Gordon, & Lange (2007);
Sternberg (2009);
Sternberg & Lee (2013);
Larson, Sandelowski, &
McQuiston, (2012)
Barry, Blum, Eggenberger,
Palmer-Hickman, & Mosley
(2010); Barry, Blum, &
Purnell, M. (2007); Ladd,
Grimley, Hickman, &
Touhy (2013)
Barry, Lange, & King
(2011); Plonczynski et al.,
(2007)
Barry, Gordon, & Lange
(2007); Barry, Lange, &
King (2011)
Barry, Gordon, & Lange
(2007); Barry, Lange, &
King (2011); Pope, B.
(2011)
3312_Ch25_435-448 26/12/14 10:43 AM Page 443
444 SECTION VI • Middle-Range Theories
Application to Research
Authors Application of Model Study Design/Focus/ Hypothesis
Chinchanikar (2009,
master’s thesis/engineering)
Tripathi, S. (2010, master’s
thesis/engineering)
Dass (2011, master’s
thesis/engineering)
Huang, Tanioka, Locsin,
Parker, & Masory (2011).
Sternberg (2009, doctoral
dissertation/nursing)
Conrad (2010, doctoral
dissertation)
Pope (2011, doctoral
dissertation)
Application to Education
Authors Application of Model Study Design /Focus/ Hypothesis
Barry, Blum, Eggenberger,
Palmer-Hickman, & Mosley
(2010)
Ladd, Grimley, Hickman,
& Touhy, (2013).
Barry, Blum, & Purnell (2007)
Application to Practice
Authors Application of Model Study Design/ Focus/Hypothesis
Barry, Lange, & King (2011)
Table 25 • 2 Overview of publications
Framework for study
Framework for study
Framework for study
Framework for study
Part of the framework
for study
Identified as faculty
practice model
Drew grounding con-
cepts from the model of
interconnectedness to
facilitate partnerships
and enhancement
of relationships
Document indexing framework
for automating classification of
nursing knowledge and language
Development of a knowledge
based decision making and
analyzing system for the nurses
to capture and manage the
nursing practice
Development of a nursing knowl-
edge management system
Development of a patient
human–robot interaction.
Qualitative research that ex-
plored the experiences of Latinas
living transnational motherhood
Evidence-based project that
compared faculty practice
models through comprehensive
literature review of evidence
based documents
Social history research study that
explored the eugenic policies of
the Progressive Era and the Social
Security Act of 1935, specifically
the maternal and child health
services as it relates to nursing
Development of a simulation to
guide students in understand the
“face” of homeless individuals
and families
Simulation development related
to nursing situations at the end
of life
Immersion experience with
victims of Hurricane Katrina
Qualitative descriptive study
which developed a community
outreach program for breast
health promotion for underserved
women
Used transcendent
values of respect,
caring, and wholeness
of person in a nursing
situation
Used model to further
develop nursing
simulation/situation
Used model to help
students understand
the lived experience
of Hurricane Katrina
Framework for study
3312_Ch25_435-448 26/12/14 10:43 AM Page 444
Parker, Pandya, Hsu,
Noell, & Newlin (2008)
Plonczynski et al. (2007)
Sadler, Newlin,
Johnson-Spruill, & (2011)
Gordon, Barry,
Dunne, & King (2011)
Sternberg & Lee (2013)
CHAPTER 25 • The Community Nursing Practice Model 445
Application to Research
Authors Application of Model Study Design/Focus/ Hypothesis
Table 25 • 2 Overview of publications—cont’d
Framework for collabo-
rative project with com-
puter science engineers.
Identified use of inquiry
group method and cor-
related to participatory
action
Used inquiry group
method
Framework for study
Further research based
on original dissertation
Used the model concepts to
illuminate nursing’s voice in
an electronic record
Discussed use of inquiry group
method to be used by groups to
define and resolve problems
Longitudinal study examining the
faith community values, disease
threats, and barriers to self-care
Described the process of bringing
community partners in a school
health program together to clarify
a vision of health literacy
Secondary analysis of longitudinal
study which compared frequency
of depressive symptoms of pre-
menopausal Latinas women born
in the United States compared
with Latina immigrants
PRACTICE EXEMPLAR
The following is an exemplar of the useful-
ness of using the inquiry group method as a
“route to knowing.” As part of a community
assessment, the inquiry group methodology
was used to determine the hopes and dreams
for well-being of community members in
rural Haiti. Community members were gath-
ered together at a primary school, and intro-
ductions were made using a language
facilitator. Then the assertions were discussed
that the three facilitators were experts in
the method and in nursing but that each
participant was expert in his or her self-care
and care of the family and community. The
following question was asked: “How can we
be helpful to you?” One man responded with
a story of caring for his wife who was in a
prolonged labor. He described how he carried
her down from the mountain, her back
against his back, and hired a motorbike to
take her to the closest hospital 45 minutes
away. His call for nursing was heard loud and
clear. We need a hospital so that our families
don’t have to suffer so much.
Another teacher told a story of his concern
for his baby, Grace, 8 months old. He said she
had a temperature and cough and that he and
his wife were worried about her. He asked if we
would examine her when the meeting was over.
We agreed and were brought to his home on the
school campus. We were invited inside and met
his wife and baby. At first glance, the baby
looked very well nourished; she was alert, smil-
ing in response to interactions, and laughing
when we babbled to her. The mother told us she
was nursing her and that Grace had been able
to nurse as usual. With a stethoscope, we
listened to her chest and took her temperature
the old-fashioned way—with the back of our
hands. Her chest was clear, by our estimation
she did not have a fever, and her skin showed
no sign of dehydration. We instructed the
parents to watch for signs of deterioration and
to seek medical help. They said they had neither
local access to a doctor nor transportation to
seek help elsewhere. And another call was
heard—to develop a school-based wellness
center for health promotion and primary care.
3312_Ch25_435-448 26/12/14 10:43 AM Page 445
446 SECTION VI • Middle-Range Theories
■ Summary
The fundamental beliefs and commitment to
the discipline and unique practice of nursing
provided for both creating and sustaining the
CNPM. This CNPM provides the environ-
ment in which nursing and social work is prac-
ticed from the core beliefs of respect, caring,
and wholeness. Nurses and social workers are
encouraged to reach out through the concentric
circles, strengthening and widening the web
of relationships with colleagues, clients, and
community members. Through use of this
CNPM, the ideals of the discipline are brought
into the reality of care for wholeness and well-
being of persons and families in multicultural
communities.
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Chapter 26Rozzano Locsin’s
Technological Competency as
Caring in Nursing
Knowing as Process and Technological
Knowing as Practice
ROZZANO C. LOCSIN
Introducing the Theorist
Overview of the Theory
Application of the Theory
Practice Exemplar
Summary
References
449
Introducing the Theorist
Rozzano C. Locsin is Professor Emeritus
of Nursing at Florida Atlantic University’s
Christine E. Lynn College of Nursing, and in-
augural International Nursing Professor at the
Institute of Health Biosciences, University of
Tokushima, in Tokushima, Japan. His pro-
gram of research focuses on life transitions in
the health–illness experience. He holds bac-
calaureate and master’s degrees in nursing from
Silliman University in the Philippines and a
Doctor of Philosophy degree from the Univer-
sity of the Philippines. Dr. Locsin was a Ful-
bright Scholar in Uganda in 2000, a recipient
of the 2004 to 2006 Fulbright Alumni Initia-
tive Award to Uganda and the Fulbright Senior
Specialist in Global and Public Health and
International Development Award. He was
inducted as a Fellow of the American Academy
of Nursing in 2006, and received the presti-
gious Edith Moore Copeland Excellence in
Creativity Award from Sigma Theta Tau In-
ternational Honor Society of Nursing and two
lifetime achievement awards from premier
schools of nursing in the Philippines. In addi-
tion, Locsin received the first University Re-
searcher of the Year Award in 2006 in the
Scholarly/Creative Works category as Professor
at Florida Atlantic University. Published in
2001, his edited book Advancing Technology,
Caring, and Nursing introduced the germinal
work of relating technology with caring in
nursing. His middle-range nursing theory,
Technological Competency as Caring in Nursing:
A Model for Practice, was published by Sigma
Rozzano C. Locsin
3312_Ch26_449-460 26/12/14 3:23 PM Page 449
Theta Tau International Press in 2005. In
2007, his coedited book Technology and Nurs-
ing: Practice, Process and Issues illustrated the im-
portance of technology in nursing practice. A
fourth book, A Contemporary Process of Nursing:
The (Unbearable) Weight of Knowing in Nursing,
was published in 2009. This book provides
essential chapters defining and describing the
concept of “knowing persons.” Dr. Locsin’s
interest in global nursing and care initiatives
enhances his appreciation of the dynamic nature
of humans and of nursing as the practice of con-
tinuously knowing persons through emerging
technologies within a caring framework.
Overview of the Theory
There is a great demand for a practice of nursing
based on an authentic intention to know human
beings fully as persons and as participants in
their care rather than as objects of our care.
Nurses want to use creative, imaginative, and
innovative ways of affirming, appreciating,
and celebrating humans as whole persons. In
present-day health and human care, advancing
technologies claim a stronghold. Often the best
way to realize intended nursing care outcomes is
the excellent and competent use of nursing tech-
nologies (Locsin, 1998). Frequently perceived
as the practice of using machines in nursing
(Locsin, 1995), technological competency as
caring in nursing is the process of knowing per-
sons as whole (Locsin, 2001), while frequently
engaging technological advancements.
Contemporary definitions of technology in-
clude (1) a means to an end, (2) an instrument,
(3) a tool, or (4) a human activity that increases
or enhances efficiency (Heidegger, 1977). Con-
ceptualizing caring and technology within
nursing practice is challenging. However, view-
ing them in harmonious coexistence is crucial
so that mutual caring occurs, fostering the un-
derstanding of technological competency as an
expression of caring in nursing (Locsin, 2005).
The purpose of this chapter is to explain
“knowing persons through technological com-
petency as a process of nursing,” a framework
of nursing that guides its practice, grounded in
the theoretical construct of technological compe-
tency as caring in nursing (Locsin, 2005). This
model of practice illuminates the harmonious
relationship between technological competency
and caring in nursing. In this model, the
emphasis of nursing is on the person, a human
being whose hopes, dreams, and aspirations are
focused on living life fully as a caring person
(Boykin & Schoenhofer, 2001).
As a model of practice, technological compe-
tency as caring in nursing (Locsin, 2005) is as
valuable today as it has been in the past and
will continue to be in the future. Technological
advances in health care demand expertise with
technology. Often, such expertise is perceived as
the antithesis of caring, particularly in situations
in which the focus of attention is on the tech-
nology rather than on the person. Nonetheless,
it is the premise of this chapter that being tech-
nologically competent is being caring.
Technological competency as caring in nursing is
a middle-range theory illustrated in the practice
of nursing and grounded in the harmonious co-
existence between technology and caring in
nursing. The assumptions of the theory are
informed by Boykin and Schoenhofer’s (2001)
work and include the following:
• Persons are caring by virtue of their
humanness.
• Persons are whole or complete in the
moment.
• Knowing persons is a process of nursing
that allows for continuous appreciation of
persons moment to moment.
• Technology is used to know wholeness of
persons moment to moment.
• Nursing is a discipline and a professional
practice.
The ultimate purpose of technological com-
petency in nursing is to acknowledge that the
person is the focus of nursing and that various
technologies can and should be used in the
service of knowing the person.
This acknowledgment of persons brings
together the relatively abstract concept of
wholeness-of-person with the more concrete
concept of technology. Such acknowledgment
compels the redesigning of nursing processes—
ways of expressing, celebrating, and appreciat-
ing the practice of nursing as continuously
knowing persons as whole moment to moment.
450 SECTION VI • Middle-Range Theories
3312_Ch26_449-460 26/12/14 3:23 PM Page 450
In this practice of nursing, technology is used
not to know the person as object to be con-
trolled and manipulated but rather to know
who the person is as an experiencing subject in
her or his wholeness. Appropriately, knowing
person as object alludes to an expectation of
knowing empirical aspects and facts about the
composite person, whereas knowing person
as subject requires the understanding of an
unpredictable, irreducible person who is more
than and different from the sum of his or her
empirical parts. In this way, technology is
used to understand the uniqueness and individ-
uality of persons as humans who continuously
unfold and who, therefore, require continuous
knowing (Locsin, 2005).
Persons as Whole and Complete in the
Moment
One of the earlier definitions of the word person
appeared in Hudson’s 1988 publication claiming
that the “emphasis on inclusive rather than sexist
language has brought into prominence the use of
the word ‘person’” (p. 12). The origin of the word
person is from the Greek word prosopon, which
means the actor’s mask of Greek tragedy; of
Roman origin, persona indicated the role played
by the individual in social or legal relationships.
Hudson (1988) also declares that “an individual
in isolation is contrary to an understanding of
‘person’” (p. 15). A necessary appreciation of per-
sons requires the view that humans are whole or
complete in the moment. As such, there is no
need to fix them or to make them complete again
(Boykin & Schoenhofer, 2001). There is nothing
missing that requires nurses’ intervening to make
persons “whole or complete” again, or for nurses
to assist in this completion. Persons are complete
in the moment. Their varying situations of care
call for creativity, innovation, and imagination
from nurses so that they may come to know the
nursed as a “whole” person. The uniqueness of
the person emerges in the response to being
called forth in particular situations.
Inherent in humans as unpredictable, dy-
namic, and living beings is the regard for self-
as-person. This appreciation is like the human
concern for security, safety, self-esteem, and
self-actualization popularized by Maslow
(1943) in his quintessential theoretical model
on the hierarchy of needs. More important,
however, is the understanding that being
human is being a person, regardless of bio-
physical parts or technological enhancements.
Because the future may require relative
appreciation of persons, if the ultimate crite-
rion of being human today is being wholly
natural, organic, and functional, then being
human may not be so easy to determine or
appreciate. The purely natural human being may
be rare. The understanding that technology-
supported life is artificial, and therefore is not
natural, stimulates discussions among practi-
tioners of nursing (Locsin & Campling,
2005), particularly when the subject of
concern is technology-dependent care and
technological competency as an expression of
caring in nursing. Hudson (1988) suggests
that “false comfort may be offered whenever
it is implied that this life and this body are
significantly less important than the ‘spiritual
body’ and the ‘next life’. . . the time has come
to enhance an awareness of the post human
or spiritual future” (p. 13). What structural
requirements will the next-generation human
possess? Today, some humans have anatomic
and/or physiological components that are
already electronic and/or mechanical, such
as mechanical cardiac valves, self-injecting
insulin pumps, cardiac pacemakers, or artifi-
cial limbs, all appearing as excellent facsimiles
of the real. Yet the idea of a “whole person”
and being natural continues to persist as a re-
quirement of what a human being should be.
How Are Persons Known?
Often, questioning in order to know the person
is limited to inquiry about his or her body parts.
For example, “How are your knees?” instead of
“How are you doing with your knees?” Of what
purpose is the question? Is it to know the person
or to know the condition of the specific com-
ponent part? Perhaps inadvertently, uncon-
sciously, or both, one inquires about the body
part because of a culturally founded reason or
because the customary focus on another’s bodily
features defines that person.
How are persons known as human beings?
Historically, humans were depicted through
drawings and paintings. Colorful artworks
CHAPTER 26 • Rozzano Locsin’s Technological Competency as Caring in Nursing 451
3312_Ch26_449-460 26/12/14 3:23 PM Page 451
represented the human being in imaginative
ways as conceptualized by painters and illus-
trators. Artists and their works became com-
modities, and Leonardo da Vinci may top this
list as, perhaps, the most prized of illustrators
and painters. Studying the human being as an
object allowed Leonardo to illustrate the com-
posite of the human being through dissected
remains. Illustrations such as these may have
influenced Michelangelo in his creation of
masterful artworks such as David and Moses.
The clarity, definition, and fidelity of these
representations reveal the utmost appreciation
of the human being. Yet the question
remains: Does the human being become a
person, or is he always a person? Is the com-
position of the human being the ultimate
descriptor, characteristic, and quality of a
whole and complete person? What happens
when the human being has no limbs, or has
limbs that are not functional? Is this human
being a person?
Consider the case of a baby born without
limbs but otherwise alive and well. When the
baby became ill, he was rushed to a hospital. To
the chagrin of the nurses and physicians, they
were at first unable to care for the baby. Their
main question was “How can we initiate IV
when there are no extremities?” They may also
have wondered, “On growing up, will this baby
be concerned about what it is like to have no
limbs, or will he wish he had limbs so he could
‘go’ places like others?” (Barnard & Locsin,
2007, p. 17).
Consider also the “Girl With Eight Limbs”
(PBS) from a province in India, who was
subjected to intense surgical intervention to
remove the other “nonfunctional” limbs that
were putting her life in a precarious situation.
What does this girl think now? “Am I complete
or incomplete? Am I normal or abnormal, just
because I am like everyone else—with two
upper limbs and two lower limbs?” (PBS).
In an episode of the television series The
Twilight Zone, a woman perceived herself as
so hideous that she thought she was unworthy
to be seen; she had to hide her face behind a
veil. She was shunned by her family. It was an
unbearable life for her and for her family as
well. In the end, the moral of the story focused
on the adage “beauty is in the eye of the
beholder” (Serling, 1960). The people who
shunned the woman had faces like those
of pigs, while she had more “human-like”
features. In fact, she was a beautiful human
woman whom everyone found to be ugly,
embarrassing, pitiful, and a misfit and was ad-
vised to move to a distant colony with a small
population of people like her. This particular
story addresses the impact of prejudice in con-
sidering what a person ought to be. In essence,
it marginalizes those who are not like others
and in doing so prevents the understanding of
nursing as the process of knowing persons as
whole and complete in the moment.
In a recent Associated Press news article,
“The Androgynous Pharaoh? Akhenaten Had
Feminine Physique” (USA Today, May 2, 2008),
writer Alex Dominguez presented Dr. Irwin
Braverman’s findings on the controversial “fem-
inine” features of the pharaoh Akhenaten.
Dominguez wrote, “Akhenaten wasn’t the most
manly pharaoh, even though he fathered at least
a half-dozen children. In fact, his form was quite
feminine, which has puzzled experts for years.
And he was a bit of an egghead.” The pharaoh
had “an androgynous appearance. He had a
female physique with wide hips and breasts, but
he was male and he was fertile and he had six
daughters,” Braverman is quoted as saying. “But
nevertheless, he looked like he had a female
physique.” Apparently, what constitutes “know-
ing” whether a human being is a man or a
woman is the physical appearance. This makes
Braverman’s study of the Pharaoh Akhenaten
most meaningful.
An example of person as object, known as
a composite of physical elements, is the leg-
endary Frankenstein monster, an entity assem-
bled from various human parts. The monster
was created and made human in the sense of
being a composite of parts but also in the sense
of his essence of being energy (electricity).
The Process of Knowing Persons
Persons possess the prerogative and the choice
of whether to allow nurses to know them fully.
Entering the world of the other is a critical req-
uisite to knowing as a process of nursing. Estab-
lishing rapport, trust, confidence, commitment,
452 SECTION VI • Middle-Range Theories
3312_Ch26_449-460 26/12/14 3:23 PM Page 452
and the compassion to know others fully as
persons is integral to this crucial positioning.
Wholeness is the idealized condition or
situation of the one who is nursed. This ideal-
ization is held within the nurse’s understanding
of persons as complete human beings “in the
moment.” Expressions of this completeness vary
from moment to moment. These expressions are
human illustrations of living and growing. Using
technology alone and focusing on the received
technological data rather than on continually
“knowing” the other fully as person can lead to
the nurse thinking of the person as an object
who needs to be completed and made whole
again. Paradoxically, because of the idea that hu-
mans are unpredictable, it is not entirely possible
for the nurse to fully know another human
being—except in the moment and only if the
person allows the nurse to know him or her by
entering into the other’s world.
In this perspective, the condition in which
the nurse and the other allow knowing each
other exists as the nursing situation, the shared
lived experience between the nurse and nursed
(Boykin & Schoenhofer, 2001).
In this relationship, trust is established that
the nurse will know the other fully as person;
the trust that the nurse will not judge the per-
son or categorize the person as just another
human being or experience but rather as a
unique person who has hopes and aspirations
that are singularly his or her own.
It is the nurse’s responsibility to know the
person’s hopes and aspirations. Technological
competency as caring allows for this under-
standing. In doing so, the nurse also sanctions
the other (the nursed) to know him or her as
person. The expectation is that the nurse is to
use multiple ways of knowing competently in
using technologies to know the other fully as
person.
The nurse’s responsibility is immeasurable
in creating conditions that demand technolog-
ical competency and care. In creating a nursing
situation of care, there is a requisite compe-
tency to know persons fully, to understand,
and to appreciate the important nuances of the
person’s dreams and desires.
There are many ways of interpreting the
concept of “person as whole.” We will look at
three interpretations that shape the popular
understanding of the concept. One of these
interpretations is the mind–body dualism
ascribed to Descartes, which describes the
connection between mind and body. In nursing,
the mind–body–spirit connection is popular-
ized by Jean Watson (1985) in her theory
of transpersonal caring. Another version of
the mind–body connection, the simultaneity
paradigm (Parse, 1998), categorizes the
human–environment mutual connection as the
relationship that best serves the nursing per-
spective and grounds theoretical frameworks
and models of practice, including many of
those in caring science. These contemporary
and popular elucidations regard humans as the
focus of nursing and knowing persons in their
wholeness as the practice of nursing.
Knowing persons as the process of nursing
is a dynamic encounter between the nurse and
nursed in which nursing situations unfold to-
ward an encompassing practice of knowledge-
based nursing. The meaning of the process is
characterized by listening, knowing, being
with, enabling, and maintaining belief as
described by Swanson (1991). The following
descriptions exemplify the process of knowing
persons as nursing within the theory of tech-
nological competency as caring in nursing:
• Knowing: The process of knowing a person is
guided by technological knowing in which
persons are appreciated as participants in
their care rather than as objects of care. The
nurse enters the world of the other. In this
process, technology is used to magnify the
aspect of the person that requires revealing—
a representation of the real person. The
person’s state may change moment to
moment—the person is dynamic and alive,
and his or her actions cannot be predicted.
This provides the opportunity for nurses to
continuously know the person as whole.
• Designing: Both the nurse and the one
nursed (patient) plan a mutual care process
from which the nurse can organize a
rewarding nursing practice that is respon-
sive to the patient’s desire for care.
• Participative engaging: This encounter pro-
vides a simultaneous practice of conjoined
CHAPTER 26 • Rozzano Locsin’s Technological Competency as Caring in Nursing 453
3312_Ch26_449-460 26/12/14 3:23 PM Page 453
activities that are crucial to knowing
persons. This stage of the process is charac-
terized by alternating rhythms of imple-
mentation and evaluation. The evidence of
continuous knowing, implementation, and
participation is reflective of the cyclical but
recursive process of knowing persons.
• Furthering knowing: The continuous, circular
and recursive process of knowing persons
demonstrates the ever-changing, and dynamic
nature of fundamental ways of knowing in
nursing. Knowledge about the person that is
derived from knowing, designing, and partici-
pative engagement further informs the caring
practice of the nurse, thereby acknowledging
the recursive process of knowing persons.
Figure 26-1 describes the process of knowing
persons.
Notice in the model of practice shown in the
figure that knowing is the primary process.
“Knowing nursing means knowing in the
realms of personal, ethical, empirical, and
aesthetic—all at once” (Boykin & Schoenhofer,
2001, p. 6). Knowledge about the person that is
derived from knowing, designing, participative
engaging and furthering knowing additionally
informs the nurse in appreciating the patient.
In knowing persons, one comes to understand
that more knowing about the person and about
his or her being allows the nurse to affirm, sup-
port, and celebrate his or her dreams and aspi-
rations in the moment. Supporting this process
of knowing is the understanding that persons
are unpredictable, that they simultaneously con-
ceal and reveal themselves as persons from one
moment to the next (Parse, 1998).
The nurse can know the person fully only in
the moment. This knowing occurs only when
the person allows the nurse to enter his or her
world. When this happens, the nurse and
nursed become vulnerable as they move toward
further continuous knowing.
454 SECTION VI • Middle-Range Theories
Knowing Persons: Framework for Nursing
Calls for
nursing
(supporting,
affirming,
celebrating)
Responses to
calls for nursing
Multiple patterns of
knowing in nursing
Empirics, aesthetics, ethic,
personal (Carper 1978)
Knowing persons
Who is person?
What is person?
Nursing as caring
(Boykin and
Schoenhofer, 2001)
Loscin, R. (2005).Technological Compentency as Caring in Nursing: A Model for Practice. Sigma Theta Tau International Press, Indianapolis, IN
Fig 26 • 1 Nursing as knowing persons. (From Locsin, R. (2005). Technological Competency as Caring in Nursing:
A Model for Practice. Indianapolis, IN: Sigma Theta Tau International Press.)
3312_Ch26_449-460 26/12/14 3:23 PM Page 454
Vulnerability allows participation so that
the nurse and nursed continue knowing each
other moment to moment. Daniels (1998)
explained that in such situations, the “nurse’s
work is to ameliorate vulnerability” (p. 191).
Demonstrating vulnerability in caring situa-
tions enables others to recognize it, participate
in mutual vulnerability, and share in the
humanness of being vulnerable. Further,
Daniels declared that “vulnerable individuals
seek nursing care, and nurses seek those who
are vulnerable” (p. 192). By entering the world
of the one nursed, the nurse shares “power
with” rather than having “power over” the
patient through a created hierarchy (Daniels,
1998). The nurse does not know more about
the person than the person knows about him-
or herself. No one knows the lived experience
of the patient better than the patient.
Nonetheless, there is the possibility that the
nurse will be able to predict and prescribe for
the one nursed. When this occurs, these situa-
tions forcibly lead the nurse to appreciate
persons more as object than as person. Such a
situation can occur only when the nurse is
assumed to “have known” the one nursed.
Although it can be assumed that with the
process of “knowing persons as whole,” oppor-
tunities to continuously know the other become
limitless, there is also a much greater likelihood
that having “already known” the one nursed,
the nurse will predict and prescribe activities for
the one nursed, ultimately causing objectifica-
tion of the person (see Fig. 26-2).
To Know and Knowing
The verb know has common definitions. Of
these definitions, some are appropriate
descriptions that explain the intended use of
the word in nursing, thereby facilitating its
understanding for the purpose and process of
competently using technologies in nursing.
These definitions are as follows:
• To perceive directly with the senses or mind
• To be certain of, regard, or accept as true
beyond doubt
• To be capable of, have the skills to
• To have thorough or practical understanding
of, as through experience of
• To be subjected to or limited by
• To recognize the character or quality of
• To be able to distinguish, recognize
• To be acquainted or familiar with
• To see, hear, or experience
While the verb know sustains the notion
that nursing is concerned with activity and that
the one who acts is knowledgeable (in the
sense of understanding the rationales behind
the activities), the word knowing is a key
concept that alludes to the focus of an action
from a cognitive perspective requiring descrip-
tion. Knowing perfectly describes the ways of
nursing—transpiring continuously as expli-
cated from the framework of knowing persons.
It is the use of the word knowing in which the
process of nursing as knowing persons is lived.
The framework for practice clearly shows the
circuitous and continuous process of knowing
persons as a practice of nursing.
We hope that nurses practice nursing from
a theoretical perspective rather than from
tradition or from blind obedience to instruc-
tions and directions. Nevertheless, processes of
nursing that are derived from extant theories
of nursing continue to dictate and prescribe
how a nurse should nurse. Contrary to this
popular conception, knowing persons as a
model of practice using technologies of nurs-
ing achieves for the nurse an appreciation of
expertise and the knowledge of persons in the
moment. Technologies allow nurses to know
about the person only as much as the person
permits the nurse to know. It can be true that
technologies detect the anatomical, physiolog-
ical, chemical, and/or biological conditions
of a person. This identifies the person as a
living human being. However, with knowing
persons, the nurse is allowed to understand
and anticipate the ever-changing person from
moment to moment.
The purpose of knowing the person is
derived from the nurse’s intention to nurse
(Purnell & Locsin, 2000)—a continuing
appreciation of the person as ever-changing
and never static: one who is a dynamic human
being. The information derived from knowing
the person is only relevant for the moment, for
the person’s “state” can change moment to
CHAPTER 26 • Rozzano Locsin’s Technological Competency as Caring in Nursing 455
3312_Ch26_449-460 26/12/14 3:23 PM Page 455
moment. Importantly, knowing the “who or
what” of persons helps nurses realize that a
person is more than simply the physiochemical
and anatomical being. Knowing persons allows
the nurse to know “who and what” is the
person. “Who” is the subjective knowing of
the person as whole and “what” is objective
knowing of the person as parts.
Knowing When Using Technology
From such a view, it may seem that the process
of knowing is possible only when using
technologies in nursing. This perception,
which is not necessarily true, is supported by
the idea that nursing is technology when tech-
nology is appreciated as anything that creates
efficiency, whether this is an instrument or a
tool, such as machines, or the activity of nurses
when nursing. Sandelowski (1993) has argued
about the metaphorical depiction of nursing
as technology, or with technology as nursing,
and the semiotic relationship of these con-
cepts. Locsin and Purnell (2007) have declared
that accompanying the nurse’s rapture with
technologies in nursing is the consequent
suffering or the price of advancing dependency
on technologies that critically influence con-
temporary human lives. With increased use
of technologies and ensuing technological
dependency experienced by recipients of care,
the imperative is to provide technological com-
petency as caring in nursing (Locsin, 2005).
Regardless, the idea of knowing persons
guiding nursing practice is novel in the sense
that there is no ideal prescription; rather there
is the wholesome appreciation of an informed
practice that allows the use of multiple ways of
knowing such as described by Phenix (1964)
and expanded by Carper (1978). These ways
of knowing involve the empirical, ethical,
personal, and aesthetic. Aesthetic expressions
document, communicate, and perpetuate the
appreciation of nursing as transpiring moment
to moment. Popular aesthetic expressions
include storytelling; poetry; visual expressions
as in drawings, illustrations, and paintings; and
aural renditions such as music. Encountering
aesthetic expressions again allows the nurse
and the nursed to relive the occasion anew.
Reflecting on these experiences using the
fundamental patterns of knowing (Carper,
1978) enhances learning, motivates the fur-
therance of knowledgeable practice, and in-
creases the valuing of nursing as a professional
practice grounded in a legitimate theoretical
perspective of nursing.
The use of technologies in nursing is con-
sequent to the contemporary demands for
nursing actions requiring technological know-
ing (Locsin, 2009). Technological knowing is
demanded for the ultimate purpose of know-
ing the real person. Technological knowing is
defined as the practice of using technologies of
care to know the one nursed. Important along
with technology use in nursing is the condition
that the one nursed allows himself or herself
to be known as a person.
Technological competency in nursing fos-
ters the recognition of persons as participants
in their care rather than as objects of care. The
idea of participation in their care stems from
active engagement, in which the nurse enters
the world of the one nursed through available
appropriate technologies, attempting to know
the nursed more fully in the moment. In this
practice, the assumption is understood that the
one nursed allows the nurse to enter his or her
world so that together they may mutually
support, affirm, and celebrate each other’s
being. In this relationship of the knower and
the one known, technology provides the effi-
ciency and the valuing that marks their mutual
and momentary reality (Locsin, 2009).
Technology currently encompasses the bulk
of functional activities that nurses are expected
to perform, particularly when the practice is in
a clinical setting. Clinical nursing is firmly
rooted in the clinical health model (Smith,
1983) in which the organismic and mechanistic
views of humans as persons convincingly dictate
the practice of nursing. Nevertheless, the
process of knowing persons will prevail, for the
model of technological competency as caring in
nursing provides the nurse the fitting stimula-
tion and motivation (and the prospective auton-
omy to judge critically) a mode of action that
desires an appreciation of persons as whole.
The model articulates continuous knowing.
Continuing to know persons deters objectifi-
cation, a process that ultimately regards human
456 SECTION VI • Middle-Range Theories
3312_Ch26_449-460 26/12/14 3:23 PM Page 456
beings as “stuff” to care about, rather than as
knowledgeable participants in their care.
Participating in his or her care frees the per-
son from having to be “assigned” care that he
or she may not want or need. This relationship
signifies responsiveness of the cared for by the
person who is caring for (Hudson, 1988).
Continuous knowing results when findings
obtained through consequent knowing further
increase the desire to know “who” and “what”
the person is. Continuous knowing overpow-
ers the motivation to prescribe and direct the
person’s life. Rather, it affirms, supports, and
celebrates his or her hopes, dreams, and aspi-
rations as a participating human being.
Technological Knowing
Technological knowing in nursing illustrates the
shared practice of using technologies to know
persons as whole and using technologies of care
for the purpose of understanding persons more
fully. The circuitous and recursive engagement
that occurs in technological knowing includes:
• Appreciating the person’s humanness
• Engaging in mutual knowing—between the
nurse and nursed
• Participating in dynamic relating within
caring nursing relationships
• Furthering knowing of persons
Through technological knowing, further
knowing of persons is achieved. Because it
is a circuitous and recursive process, conse-
quently, the practice of technological know-
ing begins anew. The following model
(Fig. 26-2) illustrates the way of technolog-
ical knowing in nursing.
Calls and Responses for Nursing
Calls for nursing are illuminations of the per-
sons’ hopes, dreams, and aspirations. Calls
for nursing are individual expressions by per-
sons who seek ways toward affirmation, sup-
port, and celebration as person. The nurse
appreciates the uniqueness of persons in his
or her nursing. In doing so, the nurse sus-
tains and enhances the wholeness of the
human being, while facilitating the realiza-
tion of the persons’ completeness through
“acting for or with” the person. This is a way
of affirming, supporting, and celebrating the
person’s wholeness.
CHAPTER 26 • Rozzano Locsin’s Technological Competency as Caring in Nursing 457
Calls and responses
between the nurse and
person being nursed
Technological Knowing
is Nursing
Appreciating
humaness
of persons
Engaging in
mutual
knowing
Participating in
dynamic relationships
within caring
nursing situations
Further
knowing
of persons
Fig 26 • 2 Technological knowing in nursing.
3312_Ch26_449-460 26/12/14 3:23 PM Page 457
The nurse relies on the person for calls for
nursing. These calls are specific mechanisms that
the persons use, allowing the nurse to respond
with authentic intentions to know them fully as
persons in the moment. Calls for nursing may
be expressed in various ways, often as hopes and
dreams, such as the hope to be with friends
while recuperating in the hospital, the desire to
play the piano when the fingers are well enough
to function effectively, or simply the ultimate de-
sire to go home or to die peacefully. As uniquely
as these calls for nursing are expressed, the nurse
knows the person continuously moment to
moment. Nursing responses to these calls may
to monitor patterns of information, such as those
derived from an electrocardiogram to know the
physiological status of the person in the moment
or to administer lifesaving medications, to insti-
tute transfer plans, or to refer patients for services
to other health-care professionals.
The entirety of nursing is to direct, focus, at-
tain, sustain, and maintain the person. In doing
so, hearing calls for nursing is continuous and
momentarily complete. Knowing persons allows
the nurse to use technologies in articulating calls
for nursing. The empirical, personal, ethical, and
esthetic ways of knowing that are fundamental
to understanding persons as whole increase the
likelihood of knowing persons in the moment.
Unpredictable and dynamic, human beings
are ever-changing moment to moment. This
characteristic challenges the nurse to know
persons continuously as a whole, rejecting the
traditional concept of possibly knowing persons
completely at once, to prescribe and predict
their expressions of wholeness. In continuously
knowing persons as whole through articulated
technologies in nursing, the nurse can perhaps
intervene to facilitate patients’ recognition of
their wholeness in the moment.
Applications of the Theory
Locsin’s theory is relatively new. Applications of
the theory of technological competency as caring
in nursing have been documented, although
mostly anecdotal references exist as these are
shared and its utility explained. Through these
anecdotes received in various occasions, especially
after presentations and conversations and
through personal communications via e-mail,
these positive declarations continue to provide
and affirm that the theory is useful particularly in
nursing practice demanding technological profi-
ciency such as in critical care settings. Likewise,
during class presentations and in scholarly/
academic conferences, students and participants
express their claims that the theory resonates well
in their practice, affirming their understanding
of nursing, and confirming their appreciation of
knowing persons through technologies as prac-
tice. However, there has been an absence of
comments from practitioners who have signified
that the theory has guided their practice, or of
any researcher who has claimed that he or she
has used the theory as framework in any study.
Nevertheless, the claims that the theory has
affirmed one’s practice exist (Fig. 26-3).
458 SECTION VI • Middle-Range Theories
Future Research
• Experiences of ‘caring for’
• Lived experiences of being ‘cared for’
• Ethics and technological dependence
• Cloning and bionic parts and the experience
of being with
• Design and development of instrument to
measure technological competency as caring
in nursing
• Testing of instrument to measure patient
experience with technologies
• Genetics and the future of humans as
posthumans
• Burnout phenomenon and the prospective use
of robots in the practice of nursing
• Nursing administration calls to care for nurses
in high-tech environments
• Universality of technological competency
as caring in varying nursing settings
Fig 26 • 3 Future research.
3312_Ch26_449-460 26/12/14 3:23 PM Page 458
CHAPTER 26 • Rozzano Locsin’s Technological Competency as Caring in Nursing 459
Practice Exemplar: Knowing Persons in the Moment
The following is a nursing situation involving
a nurse’s act to direct her care to what was
important for her patients.
One of my patients requested a new IV on
her opposite arm, even though the one she
had was safely infusing her IV fluids. I was
extremely far behind, but I knew that her IV
would not get changed until much later if at
all, as shift change was occurring, and she did
not have veins that were easily accessed. I
requested the vein finder instrument from the
supervisor and successfully inserted a new IV.
My patient was so happy and told me that no
one else had been able to “get a vein” on the
first try. It seemed like a simple task, but it
made such a difference to her. I can appreci-
ate that through competent use of the vein
finder instrument, I was able to allow my
patient to use her dominant hand instead of
limiting her range of motion because of the
IV location. She was able to experience her-
self as more “whole” through the use of her
dominant extremity. This was such a simple
an act, and yet it mattered to her quality of
life in the moment for both her and me.
This nurse explains, “As I reflect on Locsin’s
theory, I can appreciate that as nurses we
strive to know our patients as whole.”
According to Locsin (2010), “Nurses want to
use creative, imaginative, and innovative ways
of affirming, appreciating, and celebrating
humans as whole persons” (p. 461). This
desire will often lead nurses to understand
that these “intentions” can be realized
through “expert, competent use of nursing
technologies” (p. 461).
■ Summary
The purpose of this chapter is to describe and ex-
plain “knowing persons as whole,” a framework
of nursing guiding a practice grounded in the
theoretical construct of technological competency
as caring in nursing (Locsin, 2005). This frame-
work of practice illuminates the harmonious
relationship between technological competency
and caring in nursing. In this model, the focus
of nursing is the person. The chapter introduces
technological knowing, a way of knowing in
nursing engaging the competent use of tech-
nologies of care to come to know persons as
whole. Through technological knowing, both
the nurse and one nursed are appreciated as
whole persons whose hopes, dreams, and aspi-
rations matter most in living their lives fully as
whole persons.
Critical to understanding the phenome-
non of technological competency as caring in
nursing are the conceptual descriptions of
technology, caring, and nursing. Assumptions
about human beings as persons, nursing as
caring, and technological competency are
presented as foundational to the process of
knowing persons as whole in the moment—a
process of nursing grounded in the perspec-
tive of technological competency as caring in
nursing.
The process of knowing persons as whole is
explicated as technological knowing—efficiency
in using clinical nursing practices. The model
of practice is illustrated through the under-
standing of technology and caring as coexisting
in nursing.
The process of knowing persons is contin-
uous. In this process of nursing, with calls and
responses, the nurse and nursed come to know
each other more fully as persons in the mo-
ment. Grounding the process is the apprecia-
tion of persons as whole and complete in the
moment, of human beings as unpredictable, of
technological competency as an expression of
caring in nursing, and of nursing as critical to
health care.
3312_Ch26_449-460 26/12/14 3:23 PM Page 459
460 SECTION VI • Middle-Range Theories
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Smith, J. (1983). The idea of health: Implications for the
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Swanson, M. (1991). Dimensions of caring interventions.
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Watson, J. (1985). Nursing: Human science and human
care. East Norwalk, CT: Appleton-Century-Crofts.
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Chapter 27Marilyn Anne Ray’s Theory of
Bureaucratic Caring
MARILYN ANNE RAY
AND MARIAN C. TURKEL
Introducing the Theorist
Overview of the Theory
Application of the Theory
Practice Exemplar
Summary
References
461
Introducing the Theorist
Marilyn Anne (Dee) Ray, RN, PhD, CTN,
FAAN, is a Professor Emerita at Florida
Atlantic University (FAU), Christine E. Lynn
College of Nursing, in Boca Raton, Florida. She
holds a bachelor of science and a master of sci-
ence in nursing from the University of Colorado
in Denver, Colorado; a master of arts in cultural
anthropology from McMaster University in
Hamilton, Canada; and a doctorate from the
University of Utah in transcultural nursing.
She retired as a colonel in 1999 after 30 years of
service with the U.S. Air Force Reserve Nurse
Corps. As a transcultural nursing scholar and
certified advanced transcultural nurse (CTN-A),
she has published widely on the subjects of car-
ing in organizational cultures, caring theory and
inquiry development, transcultural caring, and
transcultural and communitarian ethics. She
has held faculty positions at the University
of California San Francisco, the University
of San Francisco, McMaster University, the
University of Colorado, and FAU and Scholar
positions at FAU and Virginia Commonwealth
University. Ray has enjoyed many diverse teach-
ing and learning assignments around the world.
She is featured in Who’s Who in America,
Who’s Who in the World (2010–2015), is a
Fellow of the American Society for Applied
Anthropology, and is a Fellow of the American
Academy of Nursing. She is a review board
member of the Journal of Transcultural Nursing
and Qualitative Health Research and a reviewer
for the International Journal of Human Caring.
Ray has conducted phenomenological, ethno-
graphic, and grounded theory research on dif-
ferent topics related to nursing administration
and practice, and in the U.S. military. Ray’s
Marilyn Anne Ray Marian C. Turkel
3312_Ch27_461-482 26/12/14 3:30 PM Page 461
initial research revolved around the culture
of organizations that included technological,
political, legal, and economic structures and is-
sues related to caring in complex organizations
resulting in the development of the theory of
bureaucratic caring in 1981. Her research over
the past 2 decades, conducted with Dr. Marian
Turkel, has used both qualitative and quantita-
tive research methods to study and design
patient and professional questionnaires of the
complex nurse–patient relational caring process
and its impact on economic and patient
outcomes in hospitals. Ray and Turkel (2012)
advanced the theory of relational caring com-
plexity. Ray (2010) also developed the model of
transcultural caring dynamics in nursing and
health care in her book by the same name. In
her role as professor emerita, Ray is actively en-
gaged in mentoring new faculty members and
guiding doctoral students, both in the United
States and abroad, whose studies focus on the
research of administrative and clinical caring
practice, including the clinical nurse leader role,
patient safety, the ethical practice of nursing,
and transcultural nursing.
Overview of the Theory
This chapter presents a discussion of contem-
porary nursing culture and shares theoretical
views in nursing and those related to the au-
thor’s theoretical vision and development of
professional nursing. The theory of bureau-
cratic caring is discussed first as a grounded
theory (both substantive and formal) and then
as a holographic theory. Within this chapter,
Dr. Marian Turkel, Director of Professional
Nursing Practice and Magnet Holy Cross
Hospital, Fort Lauderdale, Florida, integrates
the relevance of the theory in administrative
and clinical practice.
The Generation of Bureaucratic
Caring Theory
The theory of bureaucratic caring was generated
in a hospital organization from a qualitative
research study using three research approaches
more than 30 years ago (Ray, 1981). The theory
has been published in the book by Ray (2010),
A Study of Caring Within an Institutional
Culture: The Discovery of the Theory of Bureau-
cratic Caring. Data analysis involved the descrip-
tion of the hospital as a culture (ethnography),
the meaning of caring in the life world (phenom-
enology), and the discovery of conceptual
categories and subcategories and theories of the
structure and process of caring in the complex
organization (grounded theory method). Substan-
tive theory called differential caring was gener-
ated from the diversity and dominant meanings
of caring expressed by participants on different
units in the hospital. Formal theory was discov-
ered and developed from insight and interpre-
tation of the initial qualitative data and data
related to complex systems, such as tenets of
bureaucracy. The culture of the hospital was a
dynamic unity illustrating caring as not only
humanistic (physical), ethical, spiritual/
religious, social-cultural, and educational but
also as part of the structural—political, eco-
nomic, legal, and technological—characteristics
of a complex organization. These codetermining
processes related to the thesis of caring and the
antithesis of bureaucracy were synthesized into
the theory of bureaucratic caring (Fig. 27-1).
The initial research revealed that economic and
political patterns of meaning were more domi-
nant followed by the technical and legal dimen-
sions and finally the social and ethical/spiritual
dimensions within the complex system of the
hospital. Subsequently, the model was pictured
with coequal dimensions. After additional
research and continued reflection on what was
occurring in science and in nursing science, Ray
revisited the theory and discovered that the the-
ory itself incorporated many concepts from the
new sciences of complexity (the science of change,
interconnectedness, wholeness [holography]
and emergence). The theory, as shown in Figure
27-2, was subsequently revealed as holographic
(Coffman, 2006, 2010, 2014; Ray, 2006; Ray &
Turkel, 2010; Turkel, 2007; holography is
explained further later in this chapter). The
current holographic model depicts the primacy
of caring as spiritual–ethical and the other
dimensions as equal, indicating the holistic
nature of the interface between the spiritual and
ethical and the bureaucratic dimensions. In the
462 SECTION VI • Middle-Range Theories
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holographic model, caring (the center of the
model) is highlighted as spiritual and ethical in
relation to the physical (humanistic), the social–
cultural and educational, and the more struc-
tural dimensions of a complex organization: the
political, economic, legal, and technological.
Thus, spiritual–ethical caring honors the good
of caring, commits to the moral position of
caring and virtue, the ethics of compassion,
integrity, courage, and humility, (University of
San Francisco Curriculum, 2013). Moreover,
spiritual-ethical caring engages the theological,
the virtues of faith, hope, and love; the process
is creative and shows the integration of the
networks of relationships in complex organiza-
tional or bureaucratic systems. This holographic
model shows overall that spiritual–ethical caring
is multidimensional, complex, holistic, and
dynamic. Interactions and symbolic systems of
meaning by nurses and others are formed and
reproduced from the constructions or dominant
values held and evolving within the human-
environment organization. In some respect,
the holographic model depicts that “we are the
organization.” The theory of bureaucratic caring
as a holographic model will facilitate and
increase our understanding of the practice of
nursing in complex contemporary health-care
environments.
Holographic Emergence in the Theory
of Bureaucratic Caring
The holographic paradigm in complexity sci-
ence(s) and emergent in the theory of bureau-
cratic caring recognizes the following:
• that the ontology or “what is” of the universe
or creation is the interconnectedness of all
things;
• that reality is composed of neither wholes nor
parts but of wholes/parts or holons, the
whole is in the part and the part in the whole;
• that the epistemology or knowledge that
exists is in the relationship rather than
in the objective world or the subjective
experience of it;
• that uncertainty is inherent in the relation-
ship because everything is in process and
emerging; and
• that information and choice hold the key to
grasping the holistic and complex nature of
the meaning of holography or the whole
(Cannato, 2006; Davidson, Ray, & Turkel,
2011; Harmon, 1998; Peat, 2003; Wilber,
1982).
Holography thus means that the implicate
order (the whole) and explicate order (the
part) are interconnected, that everything is a
holon, including humans, in the sense that
everything is a whole in one context and a part
CHAPTER 27 • Marilyn Anne Ray’s Theory of Bureaucratic Caring 463
Ethical
Spiritual/
religious
Educational/
social Economic
Political
Legal
Technological/
physiological
CARING
SPIRITUAL-
ETHICAL
CARING
Physical Social-
cultural
Educational
Economic
Political
Legal
Technological
Fig 27 • 2 Holographic theory of bureaucratic caring.
Fig 27 • 1 Grounded theory of bureaucratic caring
(differential caring and bureaucratic caring theories).
3312_Ch27_461-482 26/12/14 3:30 PM Page 463
in another—each part being in the whole and
the whole being in the part (Cannato, 2006;
Peat, 2003). For example, “The molecule
depends on the atom, the cell depends on the
molecule, and all depend on the stability of
the interconnected system in order to thrive”
(Cannato, 2006, p. 98). All cycles of activities
are linked coherently together; the more en-
ergy is stored within systems, the more sub-
cycles there are. It is the relational and
reciprocal aspect of relationship itself, infor-
mation and choice, that makes it holistic
rather than mechanistic, which subsequently
opens all systems to diversity and emergence
(integrated sets of possibilities; Davidson &
Ray, 1991; Ray, 1998a, 1998b; Thoma, 2003).
Holistic science is a human–environmental
mutual process and a dynamic unity and a
transformative or emergent process. Holistic
science (and art) thus captures the idea that
all systems, including health-care systems,
are living systems, are both wholes and parts,
and depend on networks of relationships, in-
formation, choice, and communication flow.
The human–environmental mutual process
is not a new idea to nursing. It was a central
theoretical perspective of Martha Rogers
(1970; Smith, 2011) and central to beliefs in
anthropology and transcultural nursing ad-
vanced by Leininger (1991), and it was a foun-
dation for other theories, such as those of
Parse, Newman, and Reed (Alligood, 2014).
This notion is seen again at a different time
and through a different lens. In the author’s
work, the focus is on the caring patterns of the
nurse–patient relationship within the bureau-
cratic context of a hospital. The Bureaucratic
Caring Theory, already considered paradoxical
(bureaucratic caring), identified the linkage
between caring as humanistic, social–cultural,
educational, and spiritual–ethical and the
organizational hospital system as political, eco-
nomic, legal, and technological. Caring is a
relational pattern; it is the flow of nurses’ and
others’ own experiences in the structural con-
text of the organization. This simultaneous
process illuminates the idea that the whole
and parts are one and the same; all cycles of
activities are linked coherently together, but
each may be doing different things at different
paces; all the parts are participating in the
whole, and the whole is participating as a part
in different contexts of meaning (Davidson et
al., 2011; Rogers, 1970; Smith 2011; 2013a;
2013b). Information (caring and system data)
unfolds and emerges at the same time in the
same space without contradicting itself. The
theory of bureaucratic caring as a holographic
theory furthers the vision of nursing and or-
ganizations as complex, dynamic, relational,
integral, informational, and emergent—open
to sets of possibilities because of the syn-
chronicity of interacting parts and the whole.
Everything interconnects; we are all creative
manifestations of the oneness of the environ-
ment (context), moving in relationship, and
continually transforming (emerging—growing
and developing; Thoma, 2003). Because of the
knowledge of complexity science/s as hologra-
phy (holistic science and art), we all need to
become more aware of the meaning of partic-
ipatory life and ways of relating to the reality
of complex organizations or bureaucracies.
Rather than continuing mechanistic ap-
proaches of prediction and control that may
have worked to some extent to gain precise
knowledge in the past, we must now give
way to new understanding. Nurses and other
professionals must be open to change, to the
integral nature of the dynamic unity of the
human and environment, and to phenomena
that are coherent and emergent wholes (body,
mind, spirit, and context) that make up our
world of caring, health, healing, and well-
being (Davidson et al., 2011; Rogers, 1970;
Smith, 2011).
Contemporary Nursing Practice as
Complex, Dynamic, Relational,
Caring, and Emergent: Foundations
of the Theory of Bureaucratic Caring
The practice of nursing is dynamic, always
changing, and emerging with new possibilities
as people relate to each other. Contemporary
nursing practice, however, continues to occur
in organizations that are generally bureau-
cratic or systematic in nature. Although there
has been much discussion about the “end of
464 SECTION VI • Middle-Range Theories
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bureaucracy” to cope better with 21st-century
innovation and work life within complex sys-
tems (Leavitt, 2005; Perrow, 1986; Sorbello,
2008a, 2008b), bureaucracy remains a valuable
tool to identify and understand the fundamen-
tally different structural principles that under-
gird coordinated and relational organizational
systems. Bureaucracies are organizational sys-
tems that can be viewed as cultures. Organi-
zational cultures have a rich heritage and have
been studied as both formal and informal
systems since the 1930s in the United States
(Bolman & Dial, 2008; Brenton & Driskill,
2005; Morgan, 1997; Porter-O’Grady &
Malloch, 2003, 2007; Ray, 1981, 1984, 1989a,
2006, 2010a, 2010b, 2010c; Ray in Coffman,
2006, 2010, 2014 ; Ray & Turkel, 2010, 2012;
Swinderman, 2005, 2011; Turkel & Ray,
2000, 2001; 2004; Wheatley, 2006). Informal
organizational culture integrates codes of ethics
and conduct encompassing commitment,
identity, character, coherence, and a sense of
community in social-cultural interaction and
the social environment. The informal organi-
zational culture is considered essential to the
successful functioning or the administering of
the formal organization: political power
and authority, technology and technological
computation, economic exchange and legal
methods and judgments. Thus, the formal
organization comprises political, economic,
legal, and technical systems within organiza-
tional cultures (the typical phenomena of
bureaucracies). Bureaucracies themselves cre-
ate their own cultural orientations, patterns,
goals, rituals, languages, and norms within the
structural elements of the political, economic,
legal, and technological dimensions (Britain
& Cohen, 1980; Ray, 2013).
What distinguishes “organizations as cul-
tures” from other paradigms, such as organi-
zations as machines, brains, or other images
(Morgan, 1997), is its foundation in anthro-
pology or the study of how people act in
communities or formalized structures and the
significance or meaning of work life (Brenton &
Driskill, 2005; Cuilla, 2000; Louis, 1985).
Organizational cultures, therefore, are viewed
as social constructions, symbolically formed
and reproduced through interaction (Sawyer,
2005).
The beliefs about work emerge in organiza-
tions through relationships and organizational
mission and policy statements. A nation’s
prevailing tenets and expectations about the
nature of work, leisure, and employment are
pivotal to the work life of people; hence, there
is interplay between the macrocosm of a
national/global culture and the microcosm of
specific organizations (Eisenberg & Goodall,
1993; Schein, 2004; Wheatley, 2006). In
recent years, organizational cultures have
emerged as globalizing corporate systems with
multiple descriptions of meaning. However,
economics, or the “bottom line,” is the potent
equalizer of most macro- and microcultures
(Eisler, 2007; Henderson, 2006). There is an
ever-greater concentration of economic and
political power in a handful of corporations,
which separate their interests (usually profit-
driven) from the interests of humans, which
are life-centered (Eisler, 2007; Henderson,
2006; Ray, 2010c; Ray, Turkel, & Cohn,
2011; Turkel & Ray, 2000, 2001).
Health care and its activities are tightly
interwoven into the social and economic fabric
of nations. Values that drive a nation are
experienced in the health-care arena. For
example, for the most part, “cost and profit”
have transformed health care in the United
States. As health-care organizations continu-
ally are affected by issues of cost and profit and
prompt healthcare systems to undergo im-
mense change, such as the health-care reforms
of the Patient Protection and Affordable Care
Act in the United States (January 5, 2010).
Over recent years, confidence in major health-
care institutions and their leaders have fallen
so low as to put the legitimacy of executives
who manage health-care systems at risk. Trust
is a major issue (Ray, Turkel, & Marino, 2002;
Ray & Turkel, 2012, 2014). Old rules of loy-
alty and commitment to employees, invest-
ment in the worker, fairness in pay, and the
need to provide good benefits are in jeopardy.
Health-care systems have fallen victim to the
corporatization of human enterprise. Conse-
quently, the conflict between health care as a
CHAPTER 27 • Marilyn Anne Ray’s Theory of Bureaucratic Caring 465
3312_Ch27_461-482 26/12/14 3:30 PM Page 465
business and caring as a human need has
resulted in a crisis in professional nursing, pa-
tient safety issues, and the quality of care pro-
vided by health-care organizations (Anderson
& McDaniel, 2008; Davidson et al., 2011;
Eisler, 2007; Institute of Medicine, 2010).
The actual work of nurses, although under-
valued in terms of both cost and worth (Ray,
1987a; Ray & Turkel, 2012; Turkel & Ray,
2000, 2001), is currently being evaluated in
terms of issues of patient safety and clinical
nurse leadership (Page, 2004). Since the Insti-
tute of Medicine (2010) report, a resurgence
of interest is taking place in the meaningfulness
of work and patient safety in many hospitals.
Nursing education and the clinical nurse leader
role are highlighted as bridges to quality
(Sherman, Edwards, Giovengo, & Hilton,
2009). As such, the language of trust and
morally worthy work (Cuilla, 2000; Ray et al.,
2002; Ray & Turkel, 2012, 2014) is beginning
to replace the language of downsizing and
restructuring at the same time that mergers
and acquisitions still hold sway in contempo-
rary corporate environments. Cuilla (2000)
stated that “[t]he most meaningful jobs are
those in which people directly help others [pro-
vide care] or create products that make life
better for people” (p. 225). Although the tra-
ditional work of nurses is defined as directly
helping others through knowledgeable caring
(Watson, 2008), contemporary nurses’ work
and its meaning is also defined by and within
the organizational context—the structural di-
mensions of political, economic, legal, and
technological systems (Ray, 1989a, 2006, 2013;
Ray & Turkel, 2012; Turkel, 2007). Urging
nurses, physicians, and administrators to find
cohesion among these dimensions in organiza-
tions and the dynamics of unity of human be-
ings (body, mind, and spirit integration) call for
the reinvention of work (Fox, 1994). In health
care, there is a movement underway for advanc-
ing interprofessional education and practice
(Keller, Eggenberger, Belkowitz, Sarsekeyeva,
& Zito, 2013). Incorporating business princi-
ples and creativity of caring, the “work of the
soul” or inner work of spiritual–ethical rela-
tional caring leads to more emancipatory praxis
and relational self-organization (Ray, 1994a,
1998a; Ray et al., 2002; Ray & Turkel, 2014)
means leading in a new way (Porter-O’Grady
& Malloch, 2007; Ray, 2010a, 2010b, 2010c;
Ray & Turkel, 2012, 2014; Turkel, 2014;
Turkel & Ray, 2004, 2012). Spiritual–ethical
caring is a witness to the power and depth of
transformation in nursing and complex organ-
izations: reseeing the good of nursing, search-
ing for meaning in life and society, creating
caring organizations, and finding new meaning
in the complexities of work itself.
Organizational Cultures as
Transformational Bureaucracies
The transformation of nursing toward a greater
understanding of relational self-organization
and creativity (work of the soul—spiritual–
ethical caring) is not necessarily a new pursuit
for the profession; what it reveals is a focus on
and movement from invisibility to visibility.
Identifying professional nurse caring work as
having spiritual–ethical value and being an
expression of one’s soul or one’s creative self at
work and at the same time, understanding
and identifying nurses’ value as an economic
resource replaces the notion of nursing as
performing only machinelike tasks.
Bureaucracy, still considered by some as a
machinelike metaphor, as we have identified,
continues to play a significant role in the
meanings and symbols of health-care organi-
zations (Coffman, 2006; 2014; Perrow, 1986;
Ray, 2010a, 2010b, 2013; Ray & Turkel, 2012,
2014). The social theorist Max Weber (1999)
actually predicted that the future belonged to
the bureaucracy and not to the working class.
Weber, who saw bureaucracy as an efficient
and superior form of organizational arrange-
ment, predicted that the bureaucratization of
enterprise would dominate the world (Bell,
1974; Weber, 1999). This, of course, is wit-
nessed by the current globalization of com-
merce and technical information systems. In
terms of global commerce, recent acquisitions
and mergers of industrial firms and even
health-care systems, especially in the United
States, are larger and hold more power than
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some world governments. Yet, to maintain the
integrity of large scale, for-profit corporations,
often governments have to step in with in-
creased regulation and infuse systems with
monetary guarantees. Information technology
systems often are in the hands of a few who
direct and guide knowledge. The concept of
bureaucratization is thus a worldwide phe-
nomenon (Ray, 1989, 2010a, 2010b, 2010c).
Although they are considered less effective
than other forms of organization, Britain and
Cohen (1980) stated that
“[l]ike it or not, humankind is being driven to a
bureaucratized world whose forms and functions,
whose authority and power must be understood if
they are ever to be even partially controlled. . . . The
study of bureaucracies is, in effect, the study of the
most salient and powerful organizations of the con-
temporary world. (p. 27).
As bureaucracies grow, so too will the im-
portance of family, kin, community, organiza-
tional life, culture, ethnicity, and what is now
termed panethnicity, and an understanding of
diversity within wholeness, ethics, healing, and
caring (Britain & Cohen, 1989; Ray, 2010a,
2010b, 2010c).
The characteristics of bureaucracies are as
follows:
• A division of labor based on roles, depart-
ments, leadership, and authority
• A hierarchy of offices [bureaus or units]
with diverse social-cultural orientations
• A set of general policies and rules that govern
performance
• A separation of the personal from the official
• A selection of personnel on the basis of
technical/professional qualifications
• A movement toward interprofessionalism
and collaboration
• Equal treatment of all employees or stan-
dards of fairness, ethical applications, and
reimbursement
• Employment viewed as a career by participants
• Protection of dismissal by tenure or evaluation
(from Eisenberg & Goodall, 1993; Leavitt,
2005; Perrow, 1986).
Bureaucracy thus incorporates within the
human and ethical dimension the political
(power and authority), legal (policies and rules),
economic (cost systems), and technical (profes-
sional, informational, and computational)
dimensions. At the same time, bureaucracies
integrate the whole social and cultural system.
Bureaucracy, although condemned by some
as associated with red tape and inflexibility,
continues to provide the most reasonable way
in which to view systems and facilitate the
preservation and understanding and transfor-
mation of organizations. In the past 2 decades,
there has been a call for decentralization and
the “flattening” of organizational structures—
to become less bureaucratic and more partici-
pative or heterarchical (Porter-O’Grady &
Malloch, 2005, 2007). Many firms have begun
to hold to new principles that honor creativity
and imagination, and a vision of spiritual and
ethical caring and healing (Morgan, 1997;
Turkel & Ray, 2004; Ray & Turkel, 2014).
Even nursing has advanced in a more collabo-
rative or decentralized manner by its focus on
patient-centered nursing and a movement from
more centralized control and administration to
more decentralized self-governance (Allen,
2013; Nyberg, 1998; Wheatley, 2006). But cre-
ative views still need to be marked with under-
standing of structural systems of bureaucracy as
globalization, information, and economics
sweep the world.
Leadership models, which are fundamen-
tally hierarchical because of the need for order,
continue to head the short-lived participative
movement toward decentralization. Even the
new clinical nurse leader role sets a nursing
leader apart from his or her peers in terms of
knowledge and role responsibility. Power is
still in the hands of a few. As local and global
economic markets rule, there is a call for cre-
ating a “caring economics” and a need to be
creative and ethical in terms of the worldwide
technological and economic transformation
taking place (Eisler, 2007; Ray, 1987a, 2010c;
Ray & Turkel, 2012, 2014; Turkel, 2001,
2013a, 2013b). We have to look at the social,
psychological, and spiritual factors that shape
our societies and organizations. As a result, the
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concept of bureaucracy does not seem as bad
as was once thought because it addresses
human, and in many respects, humane action.
It can be considered as a much less radical
paradigm than the business paradigm that
focuses only on competition and response to
market forces, subsequently eradicating stan-
dards of fairness or social justice for humans
in the workplace (Ray & Turkel, 2014).
Caring as the Unifying Focus of Nursing
Caring in nursing speaks of relationships,
compassion, human dignity, ethics, justice,
and competent and knowledgeable caring
practice (Ray, 1981, 1989b, 2010a, 2010b,
2013; Roach, 2002; Smith, Turkel, & Wolf,
2013; Turkel, 1997; Watson, 2005, 2008).
Caring science and art is holistic, humane,
and dynamic; thus, it facilitates growth and
development of human persons and helps to
make things work in health-care agencies. As
such, caring science and art is considered by
many nurse scholars to be the essence of nurs-
ing (Boykin & Schoenhofer, 2001; 2013;
Boykin, Schoenhofer, & Valentine, 2013;
Leininger, 1981a, 1981b, 1991, 1997; Ray,
1989a, 1989b, 1994a, 1994b; Ray & Turkel,
2012; Smith et al., 2013; Watson, 1985,
1988, 1997, 2008). Although not uniformly
accepted, Newman, Sime, and Corcoran-
Perry (1991) and Newman (1992) character-
ized the social mandate of the discipline of
nursing as caring in the human health expe-
rience. Newman, Smith, Pharris, and Jones
(2008) further emphasized her initial idea
that relationship is the focus and health is the
rhythmic fluctuations of the life process, as
well as caring, consciousness, mutual process,
patterning, presence, and meaning. Caring
and health thus are influential concepts. The
expression “caring” in the human health ex-
perience emphasizes the social mandate to
which nursing has responded throughout its
history and encompasses the scope of the dis-
cipline (Roach, 2002; Watson, 2008). Caring,
with multiple meanings, however, is mani-
fested in different and complex ways in the
nursing discipline and profession (Morse et al.,
2013; Smith et al., 2013).
Evolution and Development of the
Theory of Bureaucratic Caring
Facing the challenge of the economic and
patient safety crises in health care and nurs-
ing, the disillusionment of registered nurses
about the disregard for their caring services,
and the concern of the nursing profession and
the public about the effects of the shortage of
nurses (Institute of Medicine, 2010), working
for the good of the profession and preserva-
tion of the nurse–patient caring relationship
is imperative. Running away from the chaos
of hospitals or misunderstanding the meaning
of work life cannot become the norm. Wher-
ever nurses go, they will be “haunted” by
bureaucracies, some functional, many prob-
lematic. What, then, is the deeper reality of
nursing practice? The following is a presen-
tation of theoretical views that relate to the
theory of bureaucratic caring, culminating in
a vision for understanding the deeper signif-
icance of nursing life as holistic, spiritual and
ethical, relational, cultural, contextual, and
the dynamics of complexity.
Complexity and Nursing Theory
To understand this significance, and holo-
graphic nature of the theory of bureaucratic
caring, an overview of complexity science(s)
is necessary. “Complexity theory is a scientific
theory of dynamical systems collectively
referred to as the sciences of complexity”
(Ray, 1998a, p. 91). They illuminate the na-
ture and creativity of science itself. Revolu-
tionary approaches to new scientific theory
development have transpired, such as quan-
tum theory and actually “beyond the quan-
tum,” the science of wholeness, holographic
and chaos theories, fractals or the idea of
self-similarity, networks of relationships and
complex information systems, and the con-
cepts of choice and self-organization/relational
self-organization (Bar-Yam, 2004; Battista,
1982; Briggs & Peat, 1989, 1999; Davidson
& Ray, 1991; Davidson et al., 2011; Lindberg,
Nash, & Lindberg, 2008; Peat, 2003; Ray,
1998a; Ray & Turkel, 2012; Wheatley, 2006;
Wilber, 1982).
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Complexity theory is replacing other theo-
ries, such as Newtonian physics and even
Einstein’s beliefs and those of other scientists
as well, that the physical world is governed by
laws and order. New scientific views illustrate
that the fundamental force in the universe is
dynamic (always changing), chaotic, nonlinear,
nonpredictable, relational, moving toward
self-organization, and open to possibilities. As
such, phenomena that are antithetical actually
coexist—determinism with uncertainty and
reversibility with irreversibility (Nicolis &
Prigogine, 1989; Peat, 2003). “Opposing
things can happen at the same time, in the
same space, without contradicting each other”
(Thoma, 2003, p. 17). Thus, both linear and
nonlinear and simple (e.g., gravity) and com-
plex (economic and cultural) systems exist to-
gether (for example, the paradoxical nature of
the theory of bureaucratic caring). One of the
tools or metaphors in the studies of complexity
is chaos theory. Chaos deals with life at the
edge, or the notion that the concept of order
exists within disorder at the system communi-
cation or choice point phases where old pat-
terns disintegrate or new patterns emerge
(Davidson & Ray, 1991; Davidson et al., 2011;
Lindberg et al., 2008; Newman et al., 2008;
Ray, 1994a, 1998b, 2011; Ray et al., 1995).
This new science, which signifies interrelation-
ship of mind and matter, interconnectedness
and choice, carries with it a moral responsibil-
ity and the quest toward wisdom, which
includes awareness, information systems, net-
works of relationships, patterns of energy, cre-
ativity, information about the environment
and emergence (Davidson & Ray, 1991;
Davidson et al., 2011; Fox, 1994). The concep-
tion of the interconnectedness and relational
reality of all things, the interdependence of all
human–environmental phenomena, and the
discovery of order in a chaotic world demon-
strate the pioneering story of 20th-century
science and how the insightful idea of belong-
ingness and relationality (a powerful nursing
concept) is shaping the science of the 21st
century (Peat, 2003).
Within nursing, certain nursing theorists
have embraced the notion of nursing as
complexity in which consciousness, human–
environmental mutual relationship, caring, and
choice-making are central concepts (Davidson
& Ray, 1991; Davidson et al., 2011; Lindberg
et al., 2008; Newman, 1986, 1992; Newman
et al., 2008; Ray, 1994a, 1998a; Rogers, 1970).
Given the nature of nursing as unitary, holistic,
relational, and caring, and of health as expanding
consciousness (Newman et al., 2008; Pharris,
2006), there is a coherent link between the im-
portance of theory as wakefulness (awareness)
and professional practice. Ray and Turkel hold
the position that nurses do need to be exposed
to ideas and need diverse nursing theories to
stimulate thinking. The only way that nursing
can critique itself is by understanding the intel-
lectual views of scholars in the complex world
of nursing science, research, education, and
practice. Theories, as the integration of knowl-
edge, research, and experience, highlight the way
in which scholars and practitioners of nursing
interpret their world and the context where
nursing is lived. Theories in this sense are also
philosophies or ideologies that serve a practical
purpose. Thus, the idea that theories are the pure
viewing of truth (wakefulness or awareness; van
Manen, 1982) and that they can be judged in
light of their practical consequences (Bohman,
2005) underscores the importance of nursing
theory as both a scholarly enterprise and a wise
practice that identifies and participates in the
complexities of inquiry about relationships,
knowledgeable caring, health, healing, complex
organizations, and the universe.
Description of Bureaucratic Caring
Theory
In the original qualitative study of caring in the
organizational context conducted by Ray (1981,
1984, 1989a, 2010b), the research revealed
that nurses and other professionals struggled
with the paradox of serving the bureaucracy
and serving humans, especially patients,
through caring. Caring, however, had multiple
meanings and was expressed differently in terms
of the way a particular unit was organized. The
system phenomena of political, economic, legal,
and technological became integrated into the
meaning system of caring just as the humanistic,
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social, educational, ethical, and spiritual. The
discovery of bureaucratic caring resulted in both
substantive theory (grounded in the context of
meaning) and formal theory (integrated from
the substantive theory and general understand-
ing of dimensions of complex bureaucracies;
Ray, 1981, 1984, 1989a, 2010b).
The bureaucracy represented a living system.
Caring was expressed not only in the more
interpersonal relational patterns of humanness
and compassion but also in the official structures
of the bureaucracy, especially the political and
economic structures, and both expressions were
infused into the meaning system of profession-
als. Even patients saw the “system” as affecting
how they understood caring in their own health-
care experiences (Ray, 1981, 1989a, 2010b; Ray
& Turkel, 2001–2004, 2012, 2014; Ray et al.,
2011). The substantive theory (grounded)
emerged as differential caring theory and showed
that caring in the complex organization of the
hospital was complex and differentiated itself
in terms of meaning by its specific context—
dominant caring dimensions related to areas of
practice or units wherein professionals worked
and patients resided. Differential caring theory
showed that professionals and patients on differ-
ent units espoused different and dominant
caring meanings based on their professional roles
and personal and organizational goals and
values. For example, participants in the oncology
unit espoused caring as intimate and spiritual;
in contrast, participants in the intensive care unit
espoused caring as more technological; and in
administration, participants espoused caring as
maintaining economic viability. The formal
theory of bureaucratic caring symbolized a
dynamic structure of caring, which was synthe-
sized from a dialectic using the tenets of the
philosophy of Hegel (thesis, antithesis, and
synthesis); the dialectic between the thesis of
caring as humanistic, social, educational, ethical,
and religious/spiritual (dimensions of human-
ism, morality, and spirituality), and the antithesis
of caring as economic, political, legal, and tech-
nological (dimensions of bureaucracy; Coffman,
2014; Ray, 1981, 1989a, 2006; 2010a, 2010b;
Ray et al., 2011; Ray & Turkel, 2010, 2012,
2014; Turkel, 2007).
The Theory of Bureaucratic Caring as
Holographic Theory
How can the theory of bureaucratic caring be
viewed as a holographic theory? As previously
discussed, the theory arose initially from inter-
pretations and choices that were made about the
meaning and structure of caring in organiza-
tional life. The process parallels ideas from com-
plexity sciences and specifically holography:
consciousness or awareness; intentionality of the
mutual human–environmental caring relation-
ships; quality of the caring transactions; and the
effective ability to analyze, negotiate, make
choices, and reconcile paradoxes between caring
and the system demands. The humanistic nurse–
patient care needs and professional responsibil-
ities in terms of the structural considerations of
the system (political, economic, legal, and tech-
nological dimensions) were always emerging
from sets of caring possibilities. Awareness of
belongingness/interconnectedness, the mutual
human–environmental relationship, the impli-
cate (the whole) and explicate (the part) order
(the whole is reflected in the part, and part reveals
the whole), respect for the good of all things, and
communication, choice and emergence—all of
these are central to holistic science. Similarly, as
revealed through this research, these concepts
were central to the interpretation of caring as a
whole in the complex organization. The dialectic
of caring (the thesis, the implicate order, or the
whole of caring as humanistic and spiritual-
ethical) in relation to the various organizational
structures (the antithesis of the system, explicit
order, or part, the organization as political-
economic-technical-legal) is reconciled and
transformed by a synthesis of the polar opposites
into the theory of bureaucratic caring. The syn-
thesis of the theory of bureaucratic caring shows
that everything is interconnected, even human-
istic spiritual–ethical caring and the organiza-
tional system. The whole is in the part, and the
part is in the whole; therefore, nursing in the
system is a holon, and the theory is holographic.
Transforming the Organization
The theory of bureaucratic caring reveals that
knowledge of holistic caring interconnectedness
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is possible to motivate nurses to continue to
embrace the human dimension within the cur-
rent political, economic, legal, and technologic
bureaucratic environment of health care. Can
higher ground thus be reclaimed for the 21st
century? Higher ground requires that we make
excellent and ethical choices at the “edge of
chaos” where possibilities exist in relationships
and systems/organizations to either transform
or disintegrate (Peat, 2003). Understanding of
spiritual–ethical caring in the holographic the-
ory of bureaucratic caring helps us to connect at
our deepest level. Nurses and others in complex
systems can reclaim higher ground by doing the
“work of the soul” (understanding and engaging
creatively, spiritually, and lovingly, and taking
ethical responsibility for self and other and the
organizational system). Our choice(s) depends
on a commitment and ethical social action
to cocreate caring-healing relationships and
communities (Ray & Turkel, 2014; Turkel &
Ray, 2004). The model (see Fig. 27-2) presents
a vision of nursing as spiritual–ethical caring,
but it is also based on the reality of practice.
Through continuous research and observation,
the model emphasizes a direction toward the
unity of experience. Spirituality involves creativ-
ity and choice and refers to genuineness, vitality,
and depth. It is revealed in attachment, love,
and community and comprehended within each
of us as intimacy and an unfolding of virtue and
the sacred art of divine love (Cannato, 2006;
Harmon, 1998; Ray, 1997a, 1997b; 2010a;
Secretan, 1997). Ethics deals with our moral
accountability to self and caring for self, and
responsibility to one another and to the organ-
izations within which we work. Secretan states:
“Most of us have an innate understanding of
soul, even though each of us might define it in
a very different and personal way”(p. 27).
As such, Fox (1994) calls for the theology
of work—a redefinition of work as spiritual
and ethical. Because of the crisis in our work
life mainly due to economic and political con-
straints, and in general our relationship to
work, we are challenged to reinvent it. For
nursing, this is important because work puts
us in touch with others, not only in terms of
personal gain, but also at the level of service to
humanity or the community of patients/clients
and other professionals. Work must be spiri-
tual and ethical, with recognition of the cre-
ative spirit at work in us. Nurses must be the
“custodians of the human spirit” (Secretan,
1997, p. 27).
The ethical imperatives of caring that join
with the spiritual relate to questions or issues
about our moral obligations to others. The ethics
of caring involve never treating people simply as
a means to an end or as ends in themselves but
rather as beings that have the capacity to make
choices about the meaning of life, health, healing,
and caring. Ethical content—principles of doing
good, doing no harm, allowing choice, being
fair, and promise-keeping—functions as the
compass directing our decisions to sustain hu-
manity in the context of the bureaucracy—the
political, economic, legal, and technological
issues and situations within organizations.
Roach (2002) pointed out that ethical caring is
operative at the level of discernment of princi-
ples, in the commitment needed to carry them
out, and in the decisions or choices to uphold
human dignity through love and compassion.
Furthermore, Roach (2002) remarked that
health is a community responsibility, an idea that
is rooted in ancient Hebrew ethics. The expres-
sion of human caring as an ethical act is inspired
by spiritual traditions that emphasize charity.
For nursing, spiritual–ethical caring does not
question whether or not to care in complex
systems but intimates how sincere deliberations
and ultimately the facilitation of ethical choices
for the good of others can or should be accom-
plished. By integrating knowledgeable caring
creatively, by staying intentional and conscious
of dynamic movements within the circle of
life, love, and relationships, and by leading in a
new way in complex systems/bureaucracies,
nurses are engaging in new and exciting work
(Davidson et al., 2011; Eisler, 2007; O’Grady &
Malloch, 2007; Ray, 1997b; Ray et al., 2002;
Ray & Turkel, 2012, 2014; Turkel & Ray,
2004). The theory of bureaucratic caring as a
holistic science and art bears witness to the
power and depth of transformation: reseeing the
good of nursing as spiritual and ethical, believing
in human potential, continually searching for
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meaning in life, creating caring organizations,
cocreating new possibilities, and finding new
meaning in the complexities of work life itself.
The scientist Sheldrake remarked:
The recognition that we need to change the way we
live [work] is gaining ground. It is like waking up from
a dream. It brings with it a spirit of repentance, seeing
in a new way, a change of heart. This conversion is
intensified by the sense that the end of the age of op-
pression is at hand. (1991, p. 207)
Application of the Theory
The theory of bureaucratic caring illuminated
in this chapter is a response to the end of the
age of oppression. The theory is holistic with a
practical purpose, thus responding to the call
for a translational science, translating caring
theory into practice or facilitating theory-
guided practice (Ray & Turkel, 2012; Smith
et al., 2013). Ray (1989a, p. 31) warned that
the “transformation of American and other
health-care systems to corporate enterprises
emphasizing competitive management and
economic gain seriously challenges nursing’s
humanistic philosophies and theories, and
nursing’s administrative and clinical policies.”
As nurses know, for more than 30 years, there
has been an intense focus on operating costs
and the bottom line in the American health-
care environment, and caring is often not
valued within the organizational culture.
However, caring scientists, nurse researchers,
nurse leaders, and nurses in practice have sought
out principles of caring science (Watson, 2008),
transcultural caring dynamics (Ray, 2010), and
relational caring complexity (Ray & Turkel,
2012). The application of the theory of bureau-
cratic caring as a framework to guide practice
and ethical decision making (Ray, 2010a,
2010b; Ray & Turkel, 2012; Ray et al., 2012;
Smith et al., 2013; Turkel, 2007, 2013b)
will transform a complex organization to a
community of caring where caring for self,
thoughtfulness for others through compassion,
integrity, courage, and humility can thrive
(Smith et al., 2013; University of San Fran-
cisco, 2013). Nurses must be encouraged to
continue the struggle not only to be caring but
to respond with confidence to the economic
issues and engage the political, legal, and tech-
nological questions and trials facing them.
With hospital system goals of decreasing
length of stay and increasing staffing ratios,
nurses need to be committed to establishing
trust and initiate a caring relationship during
their first encounter with a patient. As this
relationship is being established, nurses need to
focus on “being, knowing, and doing all at once”
(Turkel, 1997, 2013) within what Watson
(2008; 2013) calls the “caring moment.” From
a patient perspective, “being there” means
completing a task while simultaneously engag-
ing caringly with them. This approach to prac-
tice means not only viewing the patient as
a person in all of his or her complexity but
viewing the patient and the needs of profes-
sional nursing competently within the complex
organizational environment.
As a holographic and translational science,
we can see that the economic, political, techno-
logical, legal, and spiritual–ethical, humanistic
dimensions of bureaucratic caring, and in gen-
eral, the theory of bureaucratic caring can be
used to guide practice. Staff nurses can hold
close their core value that caring is the essence
of nursing and can still retain a focus on meeting
the issues of the bottom line (economics).
Empirical studies have firmly established a link
between caring and positive patient outcomes
(Watson, 2009). And positive patient outcomes
are needed for organizational survival in this
competitive and political era of health care.
Given this, professional nursing practice must
embrace and illuminate the caring philosophy
in relation to complex organizational phenom-
ena. As expressed, explicitly linking caring to
patient and organizational outcomes is integral.
For the first time since the inception of value-
based purchasing, one third of hospital reim-
bursement will be linked to patient satisfaction
data and two-thirds to patient quality/safety
data. This is the time for the economic value of
caring to be actualized with the organization
(Ray & Turkel, 2009).
Moving away from just focusing on patient
care to the economic justification of nursing
and health-care systems has prompted profes-
sionals to desire a fuller understanding of just
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how to preserve humanistic caring within the
educational, business, or corporate (economic
and political) culture (Miller, 1989; Nyberg,
1998, 2013; Turkel, 2007, 2013a; Boykin,
Schoenhofer, &Valentine, 2013; see also
Watson Caring Science Institute, www
.wcsi.org). In terms of application, the theory
thus, has been used as a foundation for addi-
tional research and observational studies of the
nurse–patient caring relationship and system
issues, such as in public health administration,
curriculum development, correctional facility
health care, technology and information tech-
nology, economics of caring, the clinical nurse
leader role, the charge nurse role, ethics and
the moral community, legal caring, pediatric
pain, and medication errors in complex organ-
izations, perioperative do not resuscitate
orders, the transtheoretical development of re-
lational caring complexity theory, and nursing
administration—the role of the nurse in shared
governance (Al-Ayed, 2008; Allen, 2013,
Coffman, 2006; Cross, 2014; Eggenberger,
2011a, 2011b; Gibson, 2008; Gomez, 2008;
Manworren, 2008; McCray-Stewart, 2008;
O’Brien, 2008; Ray, 1987b, 1993, 1997a,
1998a, 1998b; Ray et al., 2002; Sorbello,
2008a; Stedman, 2013; Swinderman, 2011;
Ray & Turkel, 2010, 2012; Turkel, 1997,
2007; Turkel & Ray, 2000, 2001, 2009).
Over the past three decades, Ray and Turkel
have conducted research and used dimensions
of the theory of bureaucratic caring to examine
the paradox between the concept of human
caring and political, economic, legal and tech-
nological dimensions in complex organizations,
and more specifically studies of the economics
of caring. Their research showed that staff
nurses value the caring relationship between
nurse and patient. However, nurses are practic-
ing in an environment where the economics
and costs of health care permeate discussions
and clinical decisions. The focus on costs is not
a transient response to shrinking reimburse-
ment; instead, it has become the catalyst for
change within health-care organizations. Be-
tween 2002 and 2004, Relational Caring Ques-
tionnaires were distributed to registered nurses,
patients, and administrators in five hospitals
(Ray & Turkel, 2005, 2009, 2012). Overall
mean scores on the questionnaires were then
compared to economic and patient outcome
data. It is of interest to note that the hospital
with the highest mean score of 3.30 for the
professional questionnaire had the lowest num-
ber (3.36) of full-time employees per adjusted
occupied bed and the lowest number of patient
falls. The hospital with the highest patient
mean score of 4.50 had the lowest cost ($1,265)
per adjusted patient day. These findings vali-
date what registered nurses verbalized in the
qualitative research, “Living the caring values
in everyday practice makes a difference in nurs-
ing practice and patient outcomes” (Ray &
Turkel, 2009). Through their focused research
on economic caring, they advanced the theory
of relational caring complexity (Ray & Turkel,
2012), which is beginning to be used to im-
prove the practice of nursing. It is a challenge
for nurses to combine the science and art of
caring within the complex health-care environ-
ment. However, these research efforts illustrate
how this can be done to help reshape organi-
zations and the health-care system in the
United States and other countries, such as
Canada, Australia, Japan, China, Columbia,
Chile, and some countries in Scandinavia, the
Middle East, and Africa.
Application of Theory of Bureaucratic
Caring to Excellence in Contemporary
Professional Nursing Practice
In addition to the earlier discussion of applica-
tion of the theory to practice, the American
Nurses Credentialing Center (ANCC) Magnet
Recognition Program® recognizes excellence in
professional nursing practice. Organizations
provide written narratives and sources of
evidence related to the development, dissemi-
nation, and enculturation of best practices,
quality care, technical skill, and patient prefer-
ence. This emphasis on professional nursing
practice within the Magnet Recognition Pro-
gram has resulted in organizations integrating
evidence-based practice, nursing research, and
professional models of care delivery informed
by nursing theory into the practice setting.
In the past, organizations provided sources of
evidence and written narratives illustrating the
dissemination, enculturation, and sustainability
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of the Fourteen Forces of Magnetism across the
organization (ANCC, 2005). A new model was
developed in 2008 (ANCC, 2008) and a revision
to this model was released in 2014. The new
model has five components that contain the
Forces of Magnetism. The five components
include transformational leadership; structural
empowerment; exemplary professional nursing
practice; new knowledge, innovation, and
improvements; and empirical quality results. The
theory of bureaucratic caring can be integrated
into each of these components.
Transformational leadership reflects nurs-
ing leadership that is transformational and
visionary. The chief nurse executive (CNE)
uses the theory of bureaucratic caring as the
theoretical framework when creating the nurs-
ing strategic plan and achieving the goal of
balancing caring and economics in clinical and
administrative decision making. The economic
dimension of the theory of bureaucratic caring
and tenets from relational caring complexity
serve as research-based references for the CNE
in advocating how the limited resources within
the organization will be allocated. Nursing
leaders may not be able to change reimburse-
ment from the government, but they can in-
fluence organizational decision making for the
improvement of the quality of care and caring.
Transformational leaders use ideas from direct
care registered nurses to improve the work
environment, which can include formal inte-
gration of self-care practices (Ray & Turkel,
2012; Turkel & Ray, 2004).
Structural (professional and organiza-
tional) empowerment represents professional
engagement, commitment to professional
development, teaching and role development,
commitment to community involvement,
and recognition of nursing. The CNE can
advocate for involvement in the conferences
sponsored by the International Association
for Human Caring (humancaring.org), where
nurses at all levels have an opportunity to
disseminate caring scholarship and hear ex-
amples of how caring theory has been used
to change practice and inform education and
research. Upon return from conferences,
direct-care registered nurses can make pre-
sentations to boards of trustees on how caring
science and theory make a difference in prac-
tice in terms of organizational, registered
nurse, and patient outcomes. Ongoing edu-
cation including interactive dialogue and
reflective practice related to the theory and
self-care practices can be part of internal
professional development for nurses at all
levels in the organization. As part of commu-
nity involvement, registered nurses are inte-
gral to community caring. Being in the
community requires integration of the social,
political, and cultural dimensions of the the-
ory. Having a formal practice theory supports
the professional image of nursing within the
organization and makes visible the outcomes
and contributions of nursing practice to the
organization (Turkel, 2007).
Exemplary professional practice includes
having a professional practice model and care
delivery system in place in complex organiza-
tions for registered nurses. Sources of evidence
relate to how the theory of bureaucratic caring
could be selected and used to guide practice.
Nursing situations reflecting professional and
interprofessional clinical decision making, and
examining staffing patterns balancing caring
and economics serve as examples of evidence
to support a professional model of care. For
consultation and resources, reference can be
made to external consultation with nursing
scholars as theorists, dissertation supervisors,
or consultants, and how attendance at profes-
sional conferences or other contacts, for exam-
ple, through Webinars or using Skype or
Adobe Connect make a difference in nursing
research, practice, and patient outcomes.
Under autonomy as a principle of the Code
of Ethics With Interpretive Statements (American
Nurses Association, 2001) for nurses, the com-
ponent of spiritual–ethical caring illustrates
how nurses promoting self-organization serve
as advocates for patients and families. The
educational dimension of the theory advances
the care delivery system as the professional
nurse develops innovative, individualized,
evidence-based patient education initiatives.
Organizations truly focused on innovation or
transformational leadership can expand the
theory to be interdisciplinary or interprofes-
sional and serve as the interdisciplinary plan of
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care for the patient, the family, and the health-
care system as a whole.
The component of new knowledge, innova-
tion, and improvements includes quality im-
provement. Unit-based patient care projects,
evidence-based best practice, and qualitative and
quantitative findings related to the theory serve
as exemplars included under this component.
The fifth component of the Magnet Recog-
nition Program®, empirical outcomes recognizes
the contribution of nursing in terms of patient,
nursing, and organizational outcomes. Results
from theory-guided research and evidence-based
projects related to the dimensions of the theory
of bureaucratic caring validating the difference
in patient and organizational outcomes serve as
evidence for this component.
Relevance of the Theory of
Bureaucratic Caring to Nursing
Education
The theory is relevant to nursing education be-
cause of its focus on caring in nursing practice
and the conceptualization of the health-care
system (Coffman, 2006, 2010, 2014). When
developing the curriculum for a baccalaureate
program, the faculty at Nevada State College
combined Ray’s theory of bureaucratic caring
with theoretical constructs from Watson
(1985) and Johns (2000) as a conceptual
framework. According to this framework, the
holographic theory of caring recognizes the in-
terconnectedness of all things and that every-
thing is a whole in one context and a part of
the whole in another context. Spiritual–ethical
caring, the focus for communication, infuses
all nursing phenomena including physical,
social–cultural, legal, technological, economic,
political, and educational forces (Nevada State
College, 2003, p. 2).
Turkel (2001) used the theory to guide cur-
riculum development in the master’s of science
program in nursing administration at Florida
Atlantic University. Dimensions from the
theory, including ethical, spiritual, economic,
technological, legal, political, and social, served
as a framework for the exploration of current
health-care issues. The economic dimension
of the theory was a central component in
several courses. Students analyzed the current
economic and reimbursement structure of
health care from the perspective of a caring lens.
Another example illuminates the creativity
of faculty. For example, a professor from the
University of San Francisco (2013) is imple-
menting ways to use virtue ethics (a component
of the School of Nursing curriculum) and com-
plexity science and highlight the theoretical
model for teaching and learning spiritual–ethical
caring and complex systems.
The application of the theory of bureaucratic
caring and the practice exemplar illustrate that
the foundation for professional nursing is the
blending of the humanistic and empirical/
organizational aspects of care—understanding
caring science and art in complex organizations.
In today’s environment, the nurse needs to inte-
grate caring, knowledge, and skills “all at once”
(being, knowing, and doing). Given political and
economic constraints, the art of caring cannot
occur in isolation from meeting the physical
needs of patients and incorporating the dimen-
sions of the economic, political, technological,
spiritual-ethical caring dimensions. When caring
is defined solely as science or as art—empirical
or esthetic nursing, respectively—neither is ade-
quate to reflect the reality of current practice.
Nurses must be able to understand and articulate
the politics and the economics of as well as caring
in nursing practice and health care. Classes that
examine the environment of practice generally,
and the politics and the economics of health care
in relation to caring, must be integrated into
nursing education and staff development curric-
ula. Nurses need to search continually for differ-
ent approaches to professional practice that will
incorporate caring in an increasingly political,
technical, and cost-driven environment. Doing
more with less no longer works; nurses must
“move outside of the box” to create innovative
practice models informed by nursing theory.
Nurses need to, in essence, move nursing from
being viewed as a “bed rate” in hospitals to nurs-
ing as a human caring science and practice AND
valued as a central economic resource within an
organization and the health-care system.
Administrative nursing research needs to
continue to focus on the relationship among
nursing, caring, patient outcomes, and complex
organizational economic outcomes. Ongoing
CHAPTER 27 • Marilyn Anne Ray’s Theory of Bureaucratic Caring 475
3312_Ch27_461-482 26/12/14 3:30 PM Page 475
476 SECTION VI • Middle-Range Theories
research is required to firmly establish the nurse–
patient relationship as an economic resource in
the new paradigm of evidence-based practice of
health-care delivery (Ray & Turkel, 2008, 2012,
2014; Turkel, 2013a). Findings from additional
qualitative and quantitative research studies will
continue to support the theory of bureaucratic
caring as a middle-range theory, a holographic
practice theory, and a general/universal theory.
Nurses need ongoing education related to
the politics, and economics and costs associ-
ated with health care as well as knowledge of
complex technological organizational environ-
ments. Lack of knowledge in these areas allows
others outside of nursing to continue to make
the political and economic decisions concern-
ing the practice of nursing. Having an in-
depth knowledge of the politics and economics
of health care allows nurses to use innovation
and creativity to both challenge and transform
the system. A new theory-guided model cre-
ated for nursing practice that supports human
caring in relation to the organization’s eco-
nomic, technical, and political values is an
exemplar of such innovation The multiple di-
mensions of the theory of bureaucratic caring
serve as a philosophical/theoretical framework
to inform both contemporary and future
research and theory-guided nursing practice.
Having this in-depth knowledge allows nurses
to continually question and transform complex
health-care organizations.
Ray and Turkel (2012) continue to advance
their collaborative ideas related to theory devel-
opment, caring science, and the paradox
between caring and economics within complex
systems. A metatheory (Ritzer, 1991) emerged
from the integration of the following: the theory
of bureaucratic caring (Ray, 1981, 2006), Strug-
gling to Find a Balance: The Paradox Between
Caring and Economics (Turkel 1997, 2001), and
relational complexity (Ray & Turkel, 2012;
Turkel & Ray, 2000). The metatheory is rela-
tional caring complexity, and it reveals the com-
plexity of today’s nursing practice situation while
providing a foundation for emerging profes-
sional practice models focused on caring and
healing, and innovative transdisciplinary re-
search looking at caring and economics. Con-
tinually giving voice to the value of caring in
nursing within and a part of complex organiza-
tions allows for spiritual–ethical caring to occur.1
1For additional practice exemplars please go to bonus
chapter content available at FA Davis
http://davisplus.fadavis.com
Practice Exemplar
The following exemplar from the practice setting
was previously published by Turkel (2007).* The
situation reflects the lived experiences of how the
theory of bureaucratic caring serves as a framework
for nursing practice and guides decision making.
Megan Smith, RN, MSN, was recently hired
as the chief nurse executive (CNE) for a 500-
bed inner-city hospital. The payer mix for this
patient population was once private insurance,
but now it is approximately 75% Medicare
and Medicaid. When Megan met with the
nursing staff, they stated, “We are not valued or
treated with respect. The administrators only see
us as numbers. We are implementing a new
computerized documentation system, getting
new monitors, being told that patient safety is
important and getting ready for a survey from
the Joint Commission. With all the rules and
regulations, it is stressful to find time to actually
care for our patients. Plus we need more help.”
Megan was committed to being an advocate
for nursing while realizing the professional
accountability of considering the economic,
political, and technological perspectives of her
decision making. Megan promised the nurses
that she would review the budget and follow-
up with their concerns. She explained to the
nurses that providing safe, high-quality patient
care in a caring and compassionate manner was
the top priority for the organization.
Later that week, Megan met with the chief
executive officer (CEO) to share the concerns
of the nursing staff. Her first priority was to
increase the number of registered nurses and to
3312_Ch27_461-482 26/12/14 3:30 PM Page 476
CHAPTER 27 • Marilyn Anne Ray’s Theory of Bureaucratic Caring 477
Practice Exemplar cont.
hire two additional clinical nurse specialists. The
CEO was reluctant to spend the additional
financial resources. Megan explained that in-
creasing the number of registered nurses would
decrease the number of falls and pressure ulcers
and increase compliance related to patient
safety. Additional registered nurses would in-
crease satisfaction for both nurses and patients,
as the nurses would have more time to focus on
developing caring relationships with patients
and their families. In addition, the registered
nurses would have time to focus on providing
patient teaching and discharge planning.
Megan presented the CEO with quantitative
data to demonstrate the costs associated with
falls, pressure ulcers, and patients returning
to the emergency department (ED) within 48
hours postdischarge because of inadequate
education or discharge planning. The request
for additional registered nurses and clinical
nurse specialists was approved. Six months
later, the number of falls, pressure ulcers, med-
ication errors, and return visits to the ED had
decreased. Scores on the patient satisfaction
survey related to nurses informing patients,
showing concern, and checking patient identi-
fication bands increased.
The additional clinical nurse specialists
served as mentors to increase the technical
skills of the inexperienced graduate nurses and
to demonstrate how the use of technology in
terms of cardiac monitoring would enhance
the caring interactions between the registered
nurse and patient. Customized programing of
the new clinical documentation system af-
forded nurses the opportunity to document in-
terventions related to specific dimensions of
the theory of bureaucratic caring.
*Permission to use this practice exemplar was
granted by Zane Robinson Wolf, RN, PhD,
FAAN, editor of International Journal for
Human Caring, January 15, 2014.
■ Summary
The values of nursing are deepening, and as a
discipline and profession, nursing is expanding
its consciousness (Newman et al., 2008; Ray
& Turkel, 2014). Nursing is being shaped by
the historical revolution occurring in science,
social sciences, and theology as well as the
revolution of its own commitment to caring
science, health care for all, and understanding
of holism and complex systems (Baer, 2013;
Davidson & Ray, 1991; Davidson et al., 2011;
Lindberg et al., 2008; Newman et al., 2008;
Ray, 1998a, 2006, 2010a, 2010b; Reed, 1997;
Watson, 2005). Freeman (in Appell & Triloki,
1988) pointed out that human values are a
function of the capacity to make choices and
called for a paradigm giving recognition to
awareness and choice. As noted in this chaper,
a revision toward this end is taking place in
nursing based upon the science/s of complexity
and a new holographic scientific worldview, as
well as specific theories of nursing, especially
this holographic theory of bureaucratic caring.
Nursing has the capacity to make creative and
moral choices for a preferred future. Con-
structs of consciousness and choice are central
and demonstrate that phenomena of the uni-
verse, including society and what happens in
nursing, organizations and societies arise from
the choices that are or are not made (Davidson
et al., 2011; Harmon, 1998; Newman et al.,
2008). The theory of bureaucratic caring has
reinforced, caring as the primordial construct
and consciousness of nursing within complex
bureaucratic systems. In nursing, the critical
task is to comprehend the meaning of the
networks and complexity of relationships,
between what is given in culture (the norms)
and what is chosen (the moral and spiritual).
In nursing, the unitary-transformative para-
digm and the state of the science (Newman,
et al., 2008), and various theories of Rogers,
Newman, Leininger, Watson, Parse, and Ray’s
holographic theory of bureaucratic caring
are challenging nurses to become more aware
3312_Ch27_461-482 26/12/14 3:30 PM Page 477
478 SECTION VI • Middle-Range Theories
and understand their future in terms of the
complexity of human–environment relation-
ship. The unitary-transformative paradigm of
nursing and its holographic tenets are consistent
with new science/s of complexity. However, the
other reality of nursing is that there continues
to be threats by the business/economic model
over its long-term human interests for facilitat-
ing health, healing and well-being of patients,
nurses and other professionals, and organiza-
tions (Davidson & Ray, 1991; Davidson et al.,
2011; Lindberg et al., 2008; Ray, 1994a, 1998;
Ray & Turkel, 2012; Reed, 1997; Smith, 2004;
Vicenzi, White, & Begun, 1997). However, the
creative, intuitive, ethical, and spiritual mind is
unlimited. Through “authentic conscience”
(Harmon, 1998), we must find hope in our
creative powers.
This presentation of the theory of bureau-
cratic caring is a creative enterprise. The theory
reflects spiritual and ethical caring, bureaucratic
system principles, and incorporation of tenets of
the new sciences of complexity highlighting
holography. Holographic theory illuminates
holistic science and art, the interconnectedness
of all things, human–environment integral rela-
tionships, scientific chaos theory, holographic
patterning (the whole is in the part, and the
part in the whole), informational networks, re-
lational self-organization, transformation,
change, choice, and emergence (Bar-Yam, 2004;
Davidson & Ray, 1991; Davidson et al., 2011;
Lindberg et al., 2008; Ray, 1991, 1994, 1998a,
2010a, 2010b; Turkel & Ray, 2000, 2001;
Thoma, 2003). In the theory of bureaucratic car-
ing, everything is infused with spiritual–ethical
caring (the center of the model) by its integrative
and relational connection to the structures of
complex organizations. Spiritual–ethical caring
is both a part and a whole, and every part secures
its purpose and meaning from each of the other
parts that can also be considered wholes. In
other words, the theoretical model shows how
spiritual–ethical caring is involved with qualita-
tively different yet similar processes or systems,
be they political, economic, technological, or
legal. The systems, when integrated and pre-
sented as open and interactive, are a whole and
must operate as such by conscious choice, espe-
cially by the ethical choice making of nursing,
which always has, or should have, the interest of
humanity at heart.
Envisioning the theory of bureaucratic caring
as holographic from its initial substantive and
formal grounded theories shows that through
research, creativity, and imagination, nursing can
build the profession it wants. Nurses are calling
for opportunities for expression of their own
spiritual and ethical existence, a reinvention of
work. Nurses are also calling for understanding
of the nurse–patient caring relationship in com-
plex organizations. The new scientific, spiritual–
ethical, and experiential approach to nursing
theory as holographic will have positive effects—
and that reality has been illustrated in this pres-
entation. The union of complexity science,
ethics, and spirituality will engender a new sense
of hope for transformation in the work world.
This transformation toward relational caring
organizations and communities of caring can
occur in the economic and politically driven
atmosphere of today. The deep values that
underlie caring and choice to do good for the
many will be felt both inside and outside organ-
izations. We must awaken our consciences and
act on this awareness and no longer surrender to
injustices and oppressiveness of systems that
focus primarily on the good of a few (Ray &
Turkel, 2014). “Healing a sick society [work
world] is a part of the ministry of making whole”
(Fox, 1994, p. 305). The holographic theory of
bureaucratic caring—idealistic yet practical, vi-
sionary yet real—can give direction and impetus
to lead the way.
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CHAPTER 27 • Marilyn Anne Ray’s Theory of Bureaucratic Caring 479
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Chapter 28Troutman-Jordan’s Theory of
Successful Aging
MEREDITH TROUTMAN-JORDAN
Introducing the Theorist
Overview of the Theory
Applications of the Theory in Research
Practice Exemplar
Summary
References
483
Introducing the Theorist
Dr. Troutman-Jordan began her nursing career
after graduating from Presbyterian Hospital
School of Nursing in Charlotte, North Carolina.
She earned her BSN from Queens College, and
her master’s degree is in Psychiatric Mental
Health Nursing from the University of North
Carolina at Charlotte. Her doctoral degree is in
nursing science from the University of South
Carolina at Columbia. She is certified as psychi-
atric mental health clinical nurse specialist from
the American Nurses Credentialing Center.
Dr. Troutman-Jordan received her inspira-
tion for development of a middle-range theory
of successful aging from her clinical practice
with older adults in home care. The theory
(Flood, 2002, 2006a) originated early during
Dr. Troutman-Jordan’s doctoral studies, and her
subsequent research has been based on testing
and refining this theory and developing and test-
ing an instrument to measure successful aging.
Her current research involves investigating the
effect of health promotion interventions on
successful aging and other health indicators.
Overview of the Theory
Although there is an array of theories detailing
what successful aging is or how it can be ac-
complished, there remains rather limited
theoretical work that provides practical guide-
lines for promoting successful aging. There-
fore, the impetus for developing the theory of
successful aging was enhanced understanding
of successful aging, captured from the older
adult’s perspective, and identification of foci
for interventions to foster successful aging.
One goal of Healthy People 2020 is to improve
the health, function, and quality of life of older
Meredith Troutman-Jordan
3312_Ch28_483-494 26/12/14 11:02 AM Page 483
adults (HealthyPeople.gov, 2012). Objectives
include increasing the proportion of older adults
with one or more chronic health conditions who
report confidence in managing their conditions
and reducing the number of older adults who
have moderate to severe functional limitations.
Optimal health and well-being of older adults
across multiple domains—physical health;
mobility; social, spiritual, and emotional well-
being—is consistent with successful aging.
Although there are commonly used definitions
of old age, there is no general agreement on the
age at which a person becomes old; the United
Nations agreed cutoff is 60+ years to refer to the
older population (World Health Organization,
2013). So the Healthy People 2020 goal aims to
improve health and quality of life of individuals
aged 60 and older. Similarly, the theory of suc-
cessful aging was intended for this age group.
Development of the theory of successful
aging began with a concept analysis of successful
aging that clarified the phenomenon. The con-
cept analysis was sparked by the question,
“What was it that could make such a dramatic
difference for two older adults with similar
health, environmental, and social situations?”
Although in similar circumstances, one might
give up, for example, refusing help from others
or trying to do for oneself, avoiding health-care
measures, withdrawing from relationships,
or becoming embittered. Another could main-
tain an optimistic, intrepid attitude and find
meaning, purpose, and satisfaction in life,
for example, accepting physical changes, actively
managing chronic health conditions, and stay-
ing socially engaged. Many of us have encoun-
tered similar older adults. So the question
became, “What describes the state of being of
the more favorably aging individual, and how
can nurses help older adults move toward this
state of being?
Walker and Avant’s (1995) framework was
used for this concept analysis, resulting in a
conceptual definition for successful aging: an
individual’s perception of a favorable outcome
in adapting to the cumulative physiological
and functional alterations associated with the
passage of time, while experiencing spiritual
connectedness, and a sense of meaning and
purpose in life. Older adults encountered in
clinical practice and research have validated
this idea, emphasizing the importance of both
coping mechanisms that mediate chronic
illness and the older adult’s perspective of his
own aging. Over the course of several years, the
theory of successful aging was developed.
Existing knowledge obtained deductively
from the Roy adaptation model (Roy &
Andrews, 1999) was synthesized with ideas
from Tornstam’s (1996) sociological theory
of gerotranscendence and other literature on
the concepts of successful aging. Adaptation
is a process in which individuals use conscious
awareness and choice to assimilate to their
environment (Roy, 2013). The theory was es-
tablished based on the following assumptions
derived from and based on the literature:
• Aging is a progressive process requiring
from simple to increasingly complex
adaptation.
• Aging may be successful or unsuccessful,
depending on where a person is along the
continuum of progression from simple to
more complex adaptation and the extensive
use of coping processes.
• Successful aging is influenced by the aging
person’s choices.
• The self is not ageless (Tornstam, 1996).
• Aging people experience changes, which
uniquely characterize their beliefs and per-
spectives as different from those of younger
adults (Flood, 2006a).
Roy Adaptation Model
The Roy adaptation model was used in the
development of the theory because of the the-
oretical fit of the successful aging assumptions
within the Roy model. The Roy adaptation
model is based on Helson’s (1964) adaptation
theory and von Bertalanffy’s (1968) general
systems theory. Roy (1997) referenced Erik-
son’s (Erikson, Erikson, & Kivnick, 1986)
developmental theory and stated that specific
medical problems may arise with age and
consideration should be given to the age of the
patient. Scientific and philosophical assump-
tions underlying the Roy adaptation model
484 SECTION VI • Middle-Range Theories
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but you have probably encountered others who
managed to persevere through considerable
health, financial, or psychosocial challenges.
Three coping processes make up the foun-
dation of the theory: functional performance
mechanisms, intrapsychic factors, and spiri-
tuality. These coping processes, shown in
Figure 28-1, describe the ways one responds
to the changing environment (Flood, 2006a).
Constructs within each of these coping
processes are measurable output (cognitive,
behavioral, or affective) responses, which
provide feedback to the person and are thus
interconnected by arrows. Solid arrows de-
note those exchanges that occur initially,
and broken arrows indicate exchanges that
occur subsequently (Flood, 2006a).
Functional Performance Mechanisms
Functional performance mechanisms describe the
use of conscious awareness and choice as an
adaptive response to cumulative physiological
and physical losses with subsequent functional
deficits occurring because of aging. Simply
put, this foundational coping process captures
the typical age-related declines that occur, such
as decreasing vascular flexibility, increasing
stiffness, and rise in blood pressure, and what
people do to manage them, if anything. Every-
one will experience change as a part of aging.
Think of an older adult you know or that you
recently worked with. What is one age-related
physiological or functional change he or she
experienced? How did he or she respond to
this change?
Indicators of the functional performance
mechanism coping process are health promo-
tion activities, physical health, and physical
mobility. Therefore, by assessing an older adult’s
participation in health promotion activities
(e.g., annual health examinations, good nutri-
tion), physical health state (history of illnesses,
current chronic and acute disease processes),
and physical mobility (e.g., gait stability and
speed, use of assistive devices), the nurse deter-
mines the adaptive state of his or her functional
performance mechanisms. Each of these output
responses is a manifestation of the human
adaptive response of functional performance
CHAPTER 28 • Troutman-Jordan’s Theory of Successful Aging 485
inform the theory of successful aging and are
explicated in the chapter on the Roy adapta-
tion model in this text (Chapter 10).
There are three adaptation levels (the condi-
tion of life processes, according to Roy, 2013)
that represent the condition of the life processes:
integrated, compensatory, and compromised.
One who is aging successfully has integrated
adaptation levels; he or she has effectively func-
tioning coping mechanisms and experiences
physical, mental, and spiritual well-being. A
compensatory adaptation level in someone
who is aging successfully might be seeking social
support from friends and family after an episode
of acute illness. An older adult with compro-
mised adaptation could be someone who expe-
riences a cerebrovascular accident and refuses
physical therapy or social support from family,
becomes hopeless, depressed, stops eating, and
ends up at increased risk for a thrombus related
to immobility. Within the context of the theory
of successful aging, this person could still age
successfully if he adapts to health and other
circumstances according to his optimum poten-
tial. This person can be best supported through
a multidisciplinary approach including nursing,
medicine, social work, physical therapy, pastoral
care, and nutrition counseling to promote
successful aging.
The Theory of Successful Aging
The theory of successful aging describes the
process by which individuals use various cop-
ing mechanisms to progress toward desirable
adaptation to the collective physiological and
functional changes occurring over their life-
time, while maintaining a sense of spirituality,
connectedness, and meaning and purpose in
life. The theory of successful aging is com-
prised of various degrees of coping processes, the
complex dynamics within the person according
to Roy & Andrews (1999). Every older adult
has some capacity for coping, and this is unique
to the individual. Consider various older adults
you have encountered in clinical practice; each
individual had potential for some growth
through enhanced adaptation. For some peo-
ple, this might have been rather limited; per-
haps they tended to “see the glass as half full,”
3312_Ch28_483-494 26/12/14 11:02 AM Page 485
mechanisms. A broad array of functional per-
formance mechanisms is possible, and the mix
and extent of functional performance mecha-
nism indicators is perhaps limitless. Therefore,
each older adult is unique, and increasingly
complex across the life span, as changes occur
over time. As individuals, older adults could
be viewed as unique histories to be explored,
understood, and valued by the nurse.
Intrapsychic Factors
Intrapsychic factors describe the innate and en-
during character features that may enhance or
impair an individual’s ability to adapt to change
and to problem-solving (Flood, 2006a). In-
trapsychic factors refer to an older adult’s use of
these inherent character traits to respond to
environmental stimuli. Output responses indica-
tive of intrapsychic factors include creativity, low
levels of negativity, and personal control.
To assess an older adult’s intrapsychic factors,
the nurse could engage him or her in a discus-
sion about creative activities he or she enjoys or
explore problem-solving skills that have been
useful. For example, the nurse might note, “You
did a pretty impressive job supporting three
children after losing your husband. How did you
manage?”
Creativity
There are numerous creativity assessments, and
the best way for measuring or assessing creativ-
ity is debated. Some well-known methods of
measuring creativity include the Torrance
(1974) Tests of Creative Thinking, Guilford’s
(1967) Alternative Uses Tasks, and Wallach
and Kogan’s (1965) Creativity Test. Although
the Torrance tests require a fee and special
training to administer, the others do not. These
tests as well as others can be accessed free on-
line (www.indiana.edu/~bobweb/Handout/d3
.ttct.htm). Administering one of these assess-
ments might stimulate conversation with the
older adult, which could lead to discussion on
problem-solving skills and/or exploration of
enjoyable, creative leisure activities. Further-
more, these tests might even be fun for the
older adult.
486 SECTION VI • Middle-Range Theories
Successful Aging
Meaning
Purpose in life
Geotransendence
Decreased death
anxiety
Purpose in life
Spirituality
Spiritual perspective
Religiosity
Functional Performance
Mechanisms
Health promotion
activities
Physical health
Physical activities Intrapsychic Factors
Creativity
(Low level) negative
affectivity
Personal control
Fig 28 • 1 Model for theory of successful aging.
3312_Ch28_483-494 26/12/14 11:03 AM Page 486
Positive and Negative Affect
Isen, Daubman, and Nowicki (1987) proposed
that positive affect should be viewed as influenc-
ing the way in which material is processed, sug-
gesting that good feelings increase the tendency
to combine material in new ways and see the
relatedness between divergent stimuli. Similarly,
the theory of successful aging proposes that low
levels of negative affectivity enhance or increase
creativity.
The nurse might recognize the need to eval-
uate personal control or negative affectivity.
The extent of these features presented over
time could facilitate or detract from successful
aging. Negative affect is defined as a general
dimension of subjective distress and unplea-
surable engagement that includes a variety of
unpleasant mood states, such as anger, con-
tempt, disgust, guilt, fear, and nervousness
(Watson & Clark, 1984). Low negative affect
is characterized by a state of calmness and
serenity. Watson and Clark (1984) described
negative affectivity as a mood-dispositional
dimension that reflects pervasive individual
differences in negative emotionality and self-
concept. Negative affect is not simply the op-
posite or lack of positive affect; in fact, the two
are quite distinct and nearly independent of
each other (Naragon & Watson, 2009). There-
fore, one could experience positive affect and
still have quite frequent or extensive negative
affect. Consider someone who is emotionally
responsive to events, who could have positive
or negative affect quite profoundly and fre-
quently. Is this person more often (and more
deeply) in a state of scorn, irritation, or
disgust? Or is this person more frequently and
intensely calm, relaxed, and contented?
A nurse might gauge degree of negative
affectivity by administering the Positive and
Negative Affect Schedule (PANAS; Watson,
Clark, & Tellegen, 1988), a 20-item self-
report measure of positive and negative affect
that includes two subscales. The negative affect
subscale includes descriptors such as distressed,
guilty, and afraid. Individuals self-rate the
extent to which they feel these emotions at the
time they complete the PANAS, or they may
respond based on the degree of their feelings
over the past week (Watson et al., 1988). The
PANAS is in the public domain and can be
obtained from the article in which the authors
published its initial use (Participation and
Quality of Life Project, 2012).
Assessing degree of negative affectivity in
the older adult could be an initial step toward
increasing self-awareness of feelings and how
often and intensely they are experienced. A
tool such as the PANAS might be used to ini-
tiate a conversation about this self-awareness,
with subsequent counseling or referral to a
therapist if indicated.
Personal Control
Personal control reflects individuals’ beliefs
regarding the extent to which they are able to
control or influence outcomes (MacArthur
Research Network on SES and Health, 2008).
Personal control expectancies relate to judg-
ments about whether actions can produce a
given outcome (e.g., a widow’s expectations
about how she will manage her household after
losing her spouse, or a man’s expectations of
his ability to reduce body mass index to a nor-
mal range). Greater levels of personal control
are proposed to contribute to successful aging.
Although personal control can vary depending
on the specific domain of interest (e.g., health
versus marital longevity or occupational suc-
cess), it can also be considered from a more
global perspective.
Pearlin and Schooler’s (1978) Mastery
Scale has become perhaps the most widely
used measure of personal control in health
research. This tool could be quite useful in
clinical practice as well, and it was used in
the MacArthur Successful Aging Study
(MacArthur Research Network on SES and
Health, 2008). The Mastery Scale consists of
seven items that are answered on a 4-point
Likert scale.
Nurses may encounter patients who demon-
strate little personal control, verbalizing helpless-
ness with limited or no ability to effect change
in his or her life. For example, a person with a
perception of limited personal control might
state, “Well, I am 67; it’s too late to change”
or “I am too old to exercise with my arthritis”
CHAPTER 28 • Troutman-Jordan’s Theory of Successful Aging 487
3312_Ch28_483-494 26/12/14 11:03 AM Page 487
Although low levels of personal control do not
enhance the likelihood of successful aging, their
presence is not entirely detrimental. The breadth
and extent of personal control (or lack thereof)
must be considered. If the older adult has little
sense of control over her ability to hike Mount
Everest, this may be realistic, depending on
her physical health, mobility, and past or present
health promotion activities such as exercise
involvement. But, more important, this task may
not be relevant if the older adult does not need or
aspire to climb Mount Everest. Therefore, the
individual and his or her aspirations must be
considered.
Think of an older adult with little sense of
control over learning about a new medication.
Perhaps this person does feel empowered to
mentor her grandchildren or complete some
household project. Focusing on areas of greater
personal control could help increase the older
adult’s confidence in the ability to self-manage
other areas of health and well-being.
Older adults vary widely in their adaptation
to functional performance mechanisms as well
as in their intrapsychic factors. One 77-year-
old man may be post–cerebrovascular accident
(CVA; physical health) but actively engage in
physical therapy and walking around his farm
for exercise (mobility, health promotion). This
man might view his CVA as a challenge (low
levels of negative affect) rather than a frustra-
tion and threat to his masculinity. He might
be determined to overcome (high levels of per-
sonal control) and use gardening as a (creative)
means of range of motion exercise. A similar
77-year-old man could also be post CVA and
resist physical therapy because it is “too painful
and difficult,” believing there is little he can do
at his age to help the situation. This man might
avoid visitors, stop physical therapy, and refuse
to ambulate, remaining in a wheelchair. Thus,
two individuals in similar situations could re-
spond quite differently, depending on their in-
trapsychic factors, resulting in very different
aging trajectories.
Spirituality
Another foundational coping mechanism is
spirituality, which is proposed to interact with
intrapsychic factors and functional perform-
ance mechanisms in a way that is facilitative of
successful aging. Spirituality encompasses the
personal views and behaviors that express a
sense of relatedness to something greater than
oneself; the feelings, thoughts, experiences,
and behaviors arising from the search for the
sacred (Flood, 2006a). Spirituality is essential
to successful aging; the sense of connection
and beliefs about a higher power the older
adult has help shape his values, beliefs, and be-
haviors while living, especially in terms of what
he believes happens after death. Acceptance of
the reality of death and one’s own mortality are
part of being able to age successfully.
Output responses representative of spiritu-
ality are spiritual perspective, prayer, and reli-
giosity. Spiritual perspective refers to beliefs
in the existence of something beyond what is
concrete and immediate without devaluing
the self (Reed & Larson, 2006). A spiritual
perspective is considered to be an important
resource for helping people transcend difficul-
ties faced in aging (Reed & Rousseau, 2007)
and may or may not include religious expres-
sion (Reed & Larson, 2006).
Indicators of spiritual perspective are con-
nectedness (with others, nature, the universe,
or God), belief in something greater than the
self, in an intangible domain, or a positively
life-affirming faith, and a constant, dynamic
creative energy (Haase, Britt, Coward, Leidy,
& Penn, 1992). Although these attributes can
be considered aspects of inherent spirituality,
it is the realization and development of these
features that are represented by the term spir-
itual perspective (Haase et al., 1992). More-
over, spiritual perspective is believed to enable
and motivate one to find meaning and purpose
in life (Banks, 1980; Hiatt, 1986; Highfield &
Caison, 1983; Hungleman, 1985; Jourard,
1974; Moberg, 1971), key indicators of suc-
cessful aging (Troutman, 2011).
The nurse could assess spiritual perspective
by administering the Spiritual Perspective Scale
(Reed, 1986), a 10-item, self-administered or
structured-interview formatted scale which
measures one’s perspectives on the extent to
which spirituality permeates his life and he
488 SECTION VI • Middle-Range Theories
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engages in spiritually related interactions.
Other means of assessing spirituality include
inquiring about the older adult’s engagement
in prayer or meditation; church (or other reli-
gious function) attendance; and discussing
and/or encouraging religious rituals (what these
mean to the older adult, ways these practices
might be healthful, etc.).
Integrated use of foundational coping
processes is unique for each individual and is
the initial adaptive process of successful aging.
People who are more creative and who have
lower levels of negative affectivity and greater
degrees of personal control will have more
effective adaptation of functional performance
mechanisms; they will be more likely to engage
in health promotion activities and mainte-
nance of physical mobility. Physical health can
be affected by intrapsychic factors, the rela-
tionship between immune function and emo-
tions, for example. Physical health also affects
intrapsychic factors (such as how one responds
psychologically to illness or accident).
The elements of successful aging interact
and reciprocate, creating a strong, flexible web
of support. More creativity, less negative affec-
tivity, and greater personal control enhance
spirituality through greater spiritual perspective
and more religiosity. If one is more creative,
then he is more receptive to new ideas and
innovative problem-solving methods. Lower
negative affectivity also makes one more ac-
cepting of circumstances and people, able to
consider a broader range of possible outcomes
to a situation, and it increases the possibility of
pleasant, positive interactions with others.
Greater personal control means that someone
is more likely to be proactive in health promo-
tion activities, problem-solving, and disease
management. A stronger or deeper sense of
spirituality contributes to one’s valuation of self
and sense of responsibility to appreciate and be
responsible for blessings in life such as health,
relationships, and resources.
Gerotranscendence
Gerotranscendence is a shift in metaperspective,
from a materialistic and rationalistic perspec-
tive to a more mature and existential one that
accompanies the process of aging (Tornstam,
2005). Experiencing gerotranscendence means
one develops a new outlook on and under-
standing of life, with broad existential changes;
changes in one’s view of the present self and
the self in retrospect; and developmental
changes (related to existential changes and
changes in the self; Tornstam, 2011). Gero-
transcendence is associated with positive aging
(Tornstam, 2005) and has been theorized as a
precursor to successful aging (Tornstam,
1994).
Gerotranscendence occurs when there is a
major shift in the person’s worldview, where a
person examines their place within the world
and in relation to others (Tornstam, 1997).
This means there is a radical change of one’s
outlook on life from a concern with mundane
issues to a concern with universal values
(Tornstam, 1989). The older adult examines
values held, and these may change from what
they were when that person was younger.
Three levels of age-related change occur with
gerotranscendence.
Cosmic dimension
The level of the cosmic dimension of life re-
lates to the feeling of being part of and at one
with the universe. There is a redefinition of
one’s sense of his or her place in the physical
world as well as the more global universe. Fur-
thermore, an increased understanding of the
spirit of the universe results in a redefinition of
the perception of time and, therefore, lessens
one’s concerns regarding the future (Tornstam,
1989). Thus, one has decreased concern or fear
of death because of a sense of continuity with
the universe; a newfound recognition of mean-
ing and sense of purpose in the greater scheme
of things occurs.
Self Dimension
A second level of gerotranscendent change deals
with one’s self-perception. Gerotranscendence
is believed to cause a new understanding of
fundamental questions regarding one’s existence
and a change in the way one perceives one’s
self and the world. The dimension of perception
of self concerns how one perceives self and the
CHAPTER 28 • Troutman-Jordan’s Theory of Successful Aging 489
3312_Ch28_483-494 26/12/14 11:03 AM Page 489
surrounding world. Tornstam (1999) observed
that many older adults look at their bodies with
aversion, perceiving them as an indication of
overall decline, and concluding that both their
mind and their sense of self-worth have likewise
declined. The gerotranscendent person, in con-
trast, recognizes the separateness of spiritual
growth and development apart from physical
deterioration. Tornstam suggests this ability to
separate physical and spiritual concerns provides
a new feeling of freedom, which might result
in finding the courage to be oneself and to
no longer fear both social norms and expected
roles. The gerotranscendent person feels free-
dom to self-discover new and perhaps unex-
pected aspects of himself. The individual may
also show an increase in time spent alone in
meditation or contemplation.
Social Dimension
The third level of change experienced in gero-
transcendence deals with an increase in a sense
of interrelatedness with others. The gerotran-
scendent person will begin to have greater need
to view self as a social being and will reevaluate
the meaning behind relationships with family,
friends, and other relationships. There is a
stronger sense of needing to feel part of
the human race. Tornstam suggests this need
results in an increased feeling of kinship or
connection with past and future generations,
along with a decreased interest in superficial or
casual social interactions. So the gerotranscen-
dent older adult may become more open and
responsive to other people while at the same
time becoming more selective with whom they
engage and interact.
Tornstam (1989, 1997) asserts gerotran-
scendence is closely associated with wisdom
because gerotranscendence and wisdom both
involve a transcendence beyond right and
wrong, accompanied by an increased broad-
mindedness and tolerance, usually followed
by an increase in life satisfaction. In the the-
ory of successful aging, indicators of gero-
transcendence are decreased death anxiety,
engagement in meaningful activities, changes
in relationships with others, self-acceptance,
and wisdom.
Gerotranscendence could be assessed using
the Gerotranscendence Scale (GS) (Tornstam,
1994). The GS consists of 10 items designed
to capture what Tornstam (2005) calls “retro-
spective change” (p. 93), or how older adults
see they have changed since age 50. The GS is
brief and easily administered; it may also pro-
vide an opportunity to initiate discussions
about gerotranscendence with older adults.
Another means of assessing gerotranscendence
is by evaluating the older adult’s affective and
emotional response to specific interventions.
For example, does the older adult seem to
enjoy solitude? Does he or she talk about death
without fear, and as a transition, rather than
an endpoint? If the nurse finds that an older
adult patient does these things, then she could
initiate further conversation with the patient
about his perspectives and feelings or even
describe the topic of gerotranscendence as
Wadensten (2005) did finding that older
adults recognized features of gerotranscen-
dence in themselves.
A reasonable and well-balanced integration
of the outputs of each foundational coping
process for each individual, rather than an ideal
amount or combinations of features from
within the foundational coping processes, must
be present in order for the aging person to
experience gerotranscendence. The successful
ager does not necessarily have ideal physical
health; he or she likely has one or more age-
related chronic conditions but manages them
as well as possible, participating in health
promotion activities (such as physical activity
and good nutrition) and maintaining physical
mobility to the best of his or her ability. This
person finds innovative ways to deal with
struggles and may be involved in more tradi-
tional creative activities such as painting or
woodwork. On most days, the successful ager
maintains low negative affectivity, seeing
the glass as “half full rather than half empty.”
The successfully aging individual feels empow-
ered to influence his own health and aging
(personal control), though he recognizes that
God or some Higher Power has a role in life
also. The balance of intrapsychic factors en-
hances the older adult’s spirituality. These
490 SECTION VI • Middle-Range Theories
3312_Ch28_483-494 26/12/14 11:03 AM Page 490
foundational coping mechanisms increase the
possibility of experiencing gerotranscendence,
in which the older adult has a major shift in
metaperspective and reevaluates where he is in
the larger scheme of the world and what lies
beyond. There may be pervasive change, as the
older adult self-examines values, aspirations,
and fundamental existential beliefs. When
these foundational coping processes and gero-
transcendent changes, greater life satisfaction
and a sense of purpose and meaning in life
ensue. This person is aging successfully.
Nurses could assess successful aging with
the Successful Aging Inventory (SAI), a 20-
item questionnaire with a 5.9 grade reading
level. Each statement is brief, positively
worded, and numbered 0 to 4 with higher
values indicating more frequent/stronger re-
sponses. For example, one statement includes
“I have been able to cope with the changes that
have occurred to my body as I have aged.”
Respondents indicate the point to which they
agree or disagree with the statement or the
extent to which they believe the statement
applies to them. Higher scores are indicative
of more successful aging.
Applications of the Theory in
Research
A growing number of studies have used or
expanded on the theory of successful aging.
One of these (Flood & Scharer, 2006) inves-
tigated the relationship between functional
performance, creativity, and successful aging.
Although the creativity intervention (story-
telling, writing poetry, reminiscing) did not
increase creativity levels or successful aging,
racial differences were observed, with Black
participants scoring higher on creativity and
successful aging compared with White par-
ticipants. A subsequent study (Flood, 2006b)
examined the relationships between creativ-
ity, depression, and successful aging. Level of
depressive symptoms had a moderating effect
on the relationship of creativity to successful
aging; that is, the presence of depressive
symptoms weakened the relationship between
creativity and successful aging. Significant
differences in creativity, depressive symp-
toms, and successful aging were found by
racial group and education level, with Black
participants having higher creativity levels
and more depressive symptoms, compared
with White ones.
McCarthy (2009) used the theory of
successful aging as a guiding framework to
investigate adaptation, transcendence, and
successful aging. She found that adaptation
and gerotranscendence were significant pre-
dictors of successful aging, which was meas-
ured with the SAI. And, together, adaptation
and transcendence accounted for almost half
of the variance in successful aging. Thus,
McCarthy’s study provided support for the
theory of successful aging and demonstrated
sound psychometric properties for the SAI.
Other research has also used the theory
(Barnes, 2012; Cozort, 2008; White, 2013),
providing validation.
CHAPTER 28 • Troutman-Jordan’s Theory of Successful Aging 491
Practice Exemplar
Mr. P., a 69-year-old male, suddenly and unex-
pectedly lost his wife after she had a pulmonary
embolus. He had known her since she was 15.
Mr. P. had a third-grade education, limited
literacy, and a very modest income. He was
devastated by this loss. Although he had recently
become the primary homemaker because of
Mrs. P.’s surgery and declining health, he
had rather advanced macular degeneration,
postherpetic neuralgia, and arthritis. Despite
these limitations, he had been his wife’s
primary caregiver, maintained the home, and still
preached occasionally at the church where he had
been a pastor. After her death, although it was a
struggle, he managed to walk in the parking lot
of a church near his home every day with the aid
of a cane. Remaining in the home was very im-
portant to him; his ability to be as independent
Continued
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492 SECTION VI • Middle-Range Theories
■ Summary
The theory of successful aging offers a frame-
work for understanding a multidimensional,
complex phenomenon and for planning nurs-
ing interventions geared toward promoting
successful aging in various groups, making suc-
cessful aging a possibility for a broader range of
older adults. The theory provides an empirically
supported (Cozort, 2008; Flood, 2006b; Flood
& Scharer, 2006; McCarthy, 2009; Troutman,
Bentley, & Nies, 2011; Troutman, Nies, &
Mavellia, 2011) organizing framework for
assessment, planning, interventions, and eval-
uation of older adults that is individualized to
the needs and situations of unique individuals
and sensitive to the importance that the older
adult places on various aspects of aging.
Practice Exemplar cont.
as possible permitted him a greater sense of per-
sonal control. Therefore, he let his daughters
help by delivering meals and doing his laundry
regularly, although he “really didn’t like” to give
up these tasks or rely on others. But he recog-
nized that he had to make this concession to
remain in his home. He had figured out inno-
vative ways to live alone without his wife; for
example, he placed toiletries in bottles of certain
shapes and sizes because he could no longer see
well enough to read labels to determine con-
tents. He devised an organization system for
storing food items in the kitchen so that he
could locate things by memory. He carried “a
big stick” when he went walking in case he
encountered any strange dogs. Mr. P. noticed
that if he tried to focus on “what I do have and
not what I don’t” that it seemed easier to cope
day to day.
Although the loss of his wife was almost un-
bearable, Mr. P. grew to accept the notion that
“it was her time, and the Lord took her,” and
he found comfort and strength in prayer and
listening to prerecorded sermons several times a
week. Mr. P. found himself thinking of his wife
often, as he now lived alone. Sometimes he
talked to her because he sensed she could hear
him. He began to enjoy having his home to
himself, after having raised six children there,
and the freedom of “not having to set an exam-
ple for anyone.” Sometimes he would put on
his nightclothes early and eat cereal for dinner.
Despite his chronic health conditions and the
loss of his wife, Mr. P. grew to enjoy his solitude
and the freedom to “just be myself,” although he
derived great satisfaction from spending time
with his grandchildren.
Superficially, Mr. P. might seem like an
average, or perhaps disadvantaged, older adult.
Despite his health limitations and significant
loss, he continues to engage in health promo-
tion and strives to maintain his mobility. He
demonstrates creativity in the efforts and mod-
ifications to do these things. He also makes
decisions that optimize his sense of personal
control and makes a conscious effort to have
low levels of negative affect through positive
self-talk. His spirituality has deepened since
the death of his wife; he now sees death as a
transition to some other state of being rather
than an end. Similarly, he finds a new appre-
ciation of his life and his views of the world,
with a newfound sense of who he is, his pur-
pose, and the meaning in his life.
Mr. P. appears to be aging successfully. The
nurse could encourage continued walking
(health promotion and maintenance of physical
mobility) and regular contact with his primary
care provider. Likewise, his strategies to prob-
lem-solve related to home maintenance and
activities of daily living could be commended
to encourage their continuation. The nurse
could encourage continued time spent in prayer
and assist Mr. P. to negotiate transportation
to church services. Mr. P. might also benefit
from introduction to the idea of gerotranscen-
dence and time spent reminiscing or quietly
reflecting.
3312_Ch28_483-494 26/12/14 11:03 AM Page 492
CHAPTER 28 • Troutman-Jordan’s Theory of Successful Aging 493
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Chapter 29Barrett’s Theory of Power as
Knowing Participation
in Change
ELIZABETH ANN MANHART BARRETT
Introducing the Theorist
Overview of the Theory
Applications of the Theory
Practice Exemplar
Summary
References
495
Introducing the Theorist
Elizabeth Ann Manhart Barrett, RN, LMHC,
PhD, FAAN, is Professor Emerita, Hunter
College, City University of New York; a re-
search consultant; a Health Patterning Thera-
pist; in private practice in New York City; and
co-president of Power-Imagery Partners.
From the University of Evansville in Indiana,
she holds a BSN, summa cum laude, an MA,
and an MSN; she earned a PhD in nursing sci-
ence from New York University. Dr. Barrett
has more than 40 years of experience as a
practitioner, educator, researcher, and admin-
istrator at universities and medical centers in
New York and Indiana. She is one of the
founders and first president of the Society of
Rogerian Scholars.
Dr. Barrett’s scholarly endeavors have evolved
from her commitment to carry forward Martha
E. Rogers’s Science of Unitary Human Beings.
The primary focus of her research has been the
Barrett theory of power as knowing participation
in change® and the Power as Knowing Participa-
tion in Change Tool (PKPCT). Colleagues have
conducted more than 100 studies using the the-
ory and/or measurement instrument. The
PKPCT has been translated into Japanese, Ko-
rean, Swedish, Danish, Portuguese, French, and
German. Dr. Barrett has authored nearly 100
publications including articles and book chapters
and has coedited three books. Two years after
she crafted the first Rogerian practice method-
ology, she edited Visions of Rogers’ Science-Based
Elizabeth Ann Manhart
Barrett
3312_Ch29_495-508 26/12/14 3:33 PM Page 495
Nursing, which received the American Journal of
Nursing Book of the Year Award. This was one
of the first books to provide chapters on research,
education, and practice focused entirely on one
nursing conceptual framework/nursing theory.
Dr. Barrett has presented her work on power in
Australia, Scotland, Canada, the Netherlands,
Germany, South Korea, and the Philippines as
well as throughout the United States. Her article
in Nursing Science Quarterly that won the best
paper award for 2012 was the lead article in
an issue devoted to her work. She currently
is writing a book on the power theory for the
general public. Dr. Barrett’s websites can be
viewed at www.drelizabethbarrett.com and
www.powerimagery.com.
Overview of the Theory
Certain things happen that sometimes change
the entire direction of our lives. So it was that
I transplanted myself from Indiana to begin
doctoral studies with Martha E. Rogers at New
York University more than 35 years ago. Study-
ing with Martha changed my professional and
personal thinking, values, and actions as she
became my teacher, my dissertation advisor, and
later my colleague and friend. And so the power
theory journey began and continues to this day.
The passion and excitement I experienced in
those early days is still with me and moves
onward, primarily through the work of other
nurses.
Rogers wove the conceptual framework of
the science of unitary human beings (SUHB)
as threads in the irreducible, unpredictable
tapestry of the universe and many, like
myself, continue to weave this changing fab-
ric of our participatory world. In this chapter,
I describe the flow from Rogers’s science
to the power theory to the research and prac-
tice applications. Figure 29-1 provides an
overview of this process. Although it appears
to be linear, in truth, it is a nonlinear, evolv-
ing, mutual process. Figure 29-1 also serves
as an outline that tracks the unfolding of the
theory and practice developments described
in this chapter. It will be helpful to refer to
it frequently.
Theoretical Underpinnings
Butcher and Malinski discuss the theoretical
matrix of the postulates and principles of the
SUHB in depth elsewhere in this book, and so
only a cursory overview will be presented here.
Keep in mind that development of the power
theory required theoretical consistency with the
postulates and principles of Rogerian science.
This is one of the most difficult and yet critically
important aspects involved in creating both the-
oretical and practice applications of the SUHB.
The postulates of the SUHB are energy
fields, openness, pattern, and pandimensional-
ity. We don’t have energy fields; we are energy
fields. There are two fields: the human and the
environment. The environment encompasses all
that the individual or group is not. These basic
units of the living and nonliving are irreducible;
they are unitary (Rogers, 1992). Parse (1998)
defined unitary as ever changing, indivisible,
and unpredictable.
We live in a universe of openness, so fields
are open—all the way, all the time. There
are no boundaries. Pattern is the distinctive
defining characteristic of energy fields. Pattern
is what makes you you and me me. Pattern
cannot be directly observed; we observe man-
ifestations of pattern. Pandimensionality is a
way of perceiving reality; it is a nonlinear
domain without temporal or spatial attributes
(Rogers, 1992)
The three principles of the SUHB are about
change. Resonancy is how change takes place:
from long, slow waves to short, fast waves.
Helicy is the nature of change, and integrality is
the mutual process of humans and their envi-
ronments (Phillips, 1994). These four postulates
and three principles are the blueprint. All work
developed from this theoretical perspective
needs to be consistent with them.
Concepts of Barrett’s Theory of Power
as Knowing Participation in Change®
Rogers did not write about power in the
SUHB, but she did emphasize that human
beings can knowingly participate in change.
Even though continuous participation in
change is a given, participation in that change
496 SECTION VI • Middle-Range Theories
3312_Ch29_495-508 26/12/14 3:33 PM Page 496
may not take place in a knowing manner.
I searched for a definition of power that would
be consistent with the postulates and principles
of the SUHB and connect with the literature
where, for centuries, the primary propositions
maintained that power was about change and
about causality, although there was some mea-
ger support for an acausal view of power.
Finally, the light bulb turned on. Power is the
capacity to participate knowingly in change.
Initially, I connected this definition with the
literature in terms of change, but not in terms
of causality because my purpose was to derive
an acausal theory of power consistent with
Rogers’s conceptual model. This acausal theory
was differentiated from other causal power
theories that can be summarized by May’s
(1972) definition that power is the ability to
cause or prevent change. Only much later did
it become clear that the definition of power as
the capacity to participate knowingly in change
also described causal ideas of power.
CHAPTER 29 • Barrett's Theory of Power as Knowing Participation in Change 497
Acausal worldview
Causal worldview
Postulates Energy fields Openness Pattern Pandimensionality
Principles
Theory
Research
Application
Resonancy Helicy
Power-as-freedom
Integrality
Awareness Choices Freedom
to act
intentionally
Supported
Practice
Health patterning
Practice methodolgy
Health patterning modalities
Power prescriptions
Living power-as-freedom
Rejected
Involvement
in creating
change
Power-as-control
Numerous forms
(some same, some different)
Hypothesis testing
Numerous forms
(some same, some different)
Awareness Choices Freedom
to act
intentionally
Involvement
in creating
change
Fig 29 • 1 Barrett’s theory of power as knowing participation in change. (Copyright © Elizabeth Ann Manhart
Barrett, RN, LMHC; PhD; FAAN.)
3312_Ch29_495-508 26/12/14 3:33 PM Page 497
Through readings in various relevant areas
and synthesizing my own ideas, the conceptual
manifestations of the inseparable dimensions
of power were identified as awareness, choices,
freedom to act intentionally, and involvement
in creating change. These concepts were vali-
dated as consistent with the SUHB through
a judges’ study with New York University
faculty, who were considered knowledgeable
in Rogerian thought.
Power is the capacity to participate know-
ingly in change by being aware, making
choices, feeling free to act intentionally, and
involvement in creating change. In a nutshell,
power is being aware of what one is choosing
to do, feeling free to do it, and doing it inten-
tionally (Barrett, 1986, 1989, 1990a, 2010).
The theory describes power in groups as well
as in individuals. The inseparable association
of a person’s or a group’s power strengths or
weaknesses is known as their Power Profile.
Power-as-Freedom and
Power-as-Control
While my initial interest was in developing an
acausal view of power, I was often puzzled re-
garding why the four dimensions of awareness,
choices, freedom to act intentionally, and in-
volvement in creating change seemed to also
describe power from a causal perspective. After
many years and for the second time, the power
light bulb turned on. One day while walking
down the street, I realized that the power
theory did indeed describe two types of power.
The difference is simply that one reflects an
acausal worldview and the other reflects a
causal worldview. We live in two worlds, and
power as a phenomenon that exists in the
universe lives in both of them. So I named
these two types of power—power-as-freedom
and power-as-control. For example, in the
extreme situation of murder, if the murderer is
aware of what she is choosing to do and feels
free to act on that intention and is, actually,
involved in creating that change, this is power
as surely as the acausal type of power that does
not interfere with another person’s freedom.
Freedom is incompatible with causality be-
cause causality allows for control, prediction,
and reduction. Some of the forms in which
power manifests can be for purposes of control,
such as money that can be used to control
people, places, or things. On the other hand,
money can be used for purposes of freedom
through such things as philanthropy, educa-
tion, meeting basic needs, but never interfering
with the freedom of others. Knowledge can
also be used for purposes of control or freedom.
I would further suggest that we can view
the many variations of power theories, such as
social power, political power, positional power,
personal power, empowerment, and others as
forms in which power manifests. They can be
further understood in terms of the definition
of power with its four dimensions of aware-
ness, choices, freedom to act intentionally, and
involvement in creating change, along with
the 12 characteristics used to measure power
as knowing participation in change. It is
important to note that these new insights
changed nothing I had previously written
concerning power, but they expanded the
theory to describe how power operates in the
two worlds we live in—the causal and acausal
worlds. Of course, although practice applica-
tions continue to focus on power-as-freedom,
clients more easily understand how to live
power-as-freedom when it is contrasted with
power-as-control, the usual way people under-
stand power and witness it in our everyday
world. Power-as-control is often described in
terms of force, dominance, or manipulation in
subtle or not-so-subtle varieties of control.
Figure 29-2 contrasts these two worldviews.
The Power as Knowing Participation
in Change Tool (PKPCT, Version II)
Following a second judges’ study, a paper-and-
pencil research instrument using semantic differ-
ential technique was developed to measure
power as knowing participation in change. The
PKPCT, Version II consists of the four power
dimensions, each measured by 12 bipolar adjec-
tive pairs randomly reversed and randomly
ordered for each dimension. A thirteenth adjec-
tive pair is not included in the score because it
is a retest reliability item that is used only for
research purposes. A complete accounting of the
498 SECTION VI • Middle-Range Theories
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tool development, along with a copy of the
PKPCT, Version II and the Scoring Guide is
presented elsewhere (Barrett, 1990b, 2003), so
only a brief summary is discussed here to aid
understanding of how it is used in practice. Al-
though the adjective pairs appear to be linear, in
truth they are not to be conceptualized in that
manner when one attempts to move from the
less powerful adjective to the more powerful
adjective. “In a world where time and space exist,
the words from and to would be a linear process.
However, in a pandimensional universe, change
takes place throughout the human and environ-
mental fields that are without spatial or temporal
attributes” (Phillips, 2010, p. 57).
After a pilot study of 267 men and women,
revised versions of the PKPCT, Version I and
Version II, were further tested in a national
study using a volunteer sample of 625 men and
women with participants from every state. The
response rate was 61%, and the sample com-
prised men and women with a minimum of a
high school education who were diverse in
terms of age (21–60 years), marital status, city
size, geographic residence, and occupation.
This sample was used to test the dissertation
hypothesis that human field motion and power
were correlated. I reasoned that the greater the
effortless, rhythmic flow of human field mo-
tion in one’s life, the greater one’s capacity to
participate knowingly in creating change. The
hypothesis was supported with two statistically
significant moderately strong canonical corre-
lations of .61 and .16. Reliability, measured
as the variances of factor scores, ranged from
.63 to .99; and validity coefficients, computed
as factor loadings, ranged from .56 to .70
(Barrett, 1986, 1990b, 2003). The findings
from these studies provided support for using
the theory and measurement tool in nursing
practice. Most other researchers who have used
the PKPCT, Version II computed reliability
using Chronbach’s alpha with the majority
reporting higher coefficients than what I had
found (Caroselli & Barrett, 1998; Kim, 2009).
Although I use Version II in my practice
and most researchers select this version as well,
Version I also has acceptable reliability and
validity (Barrett, 1986). The difference is that
in Version I the power dimensions are meas-
ured in relation to self, family, and work.
Applications of the Theory
Research
I have completed eight additional studies, both
quantitative and qualitative, most with col-
leagues, both funded and unfunded. In 1998,
Caroselli and I published a review of the power
as knowing participation in change research lit-
erature (Caroselli & Barrett, 1998); and Kim
(2009) published an update of the power as
knowing participation in change research in
2009. Currently, more than 90 studies have been
conducted using the theory and/or measurement
instrument. The tool has been translated into
Japanese, Korean, Swedish, Danish, Portuguese,
French, and German. These translations allow
CHAPTER 29 • Barrett's Theory of Power as Knowing Participation in Change 499
Material worldviewSpiritual worldview
Power-as-freedom
Awareness Choices Freedom
to act
intentionally
Involvement
in creating
change
Power-as-control
Numerous forms
Awareness Choices Freedom
to act
intentionally
Involvement
in creating
change
Numerous forms
Barrett’s Theory of Power as Knowing Participation in Change:
Spiritual and Material Worldviews
Fig 29 • 2 Barrett’s theory of power as knowing participation in change: spiritual and
material worldviews. (Copyright © Elizabeth Ann Manhart Barrett, RN-BC, LMHC; PhD; FAAN.)
3312_Ch29_495-508 26/12/14 3:33 PM Page 499
for testing a basic premise of the power theory
that the capacity to participate knowingly in
change is a quality of all people, regardless
of race, ethnicity, nationality, or country of
residence.
Practice Methodology
Shortly before finishing my doctoral studies,
I completed a postgraduate program in holis-
tically oriented psychotherapy to enhance the
knowledge gained through a MSN in psychi-
atric/mental health nursing and experience
teaching students and working in mental
health settings. So I began a private nursing
practice called Health Patterning as an alter-
native to traditional psychotherapy.
Soon I developed the first practice method-
ology for Rogerian nursing practice (Barrett,
1988). In the revised version, it consisted of
two processes: pattern manifestation knowing
and voluntary mutual patterning (Barrett,
1998). Butcher (2006) modified the method-
ology to include Cowling’s (1990, 1997)
methodology from his theory of unitary
pattern appreciation. Incorporating Butcher’s
revision, the two phases are termed pattern
manifestation knowing and appreciation and
voluntary mutual patterning. There is no se-
quential order; both processes are continuously
shifting and/or going on simultaneously.
Phase I: Pattern Manifestation Knowing
and Appreciation
My first question when someone sits down in
my office is “What do you want?” I’m interested
in knowing what changes people want in their
lives since that will be the focus of the health
patterning sessions. Relevant historical infor-
mation will unfold as our dialogue proceeds;
I do not take a typical initial health history.
Phase II: Voluntary Mutual Patterning
Another initial question is “Where do you see
yourself in your life right now?” If a person is
having difficulty zeroing in, I might ask, “If you
only had one sentence rather than 45 minutes,
what would you say?” As you can see, the three
principles of change are operating as we mutu-
ally explore the nature of change in their lives
(helicy) as well as the mutual process through
which the change occurs (integrality) and how
that change evolves (resonancy) as we focus our
intention on creating change without attach-
ment to outcomes or results. Intentions, aims,
or directions are consistent with the acausal
postulates and principles of the SUHB,
whereas setting goals involves end points and,
like outcomes, end points are not appropriate.
Clients learn quickly that there is no causal
“If I do this, then that will happen.” They
are often relieved to learn that the way this
works is that “If I do this, then I will see what
happens.” The phenomenology of the moment
is present-oriented with little focus on the past,
which is gone, or the future, which hasn’t been
created yet, nevertheless recognizing that we
are actually using our power to participate in
creating that future at every moment. There is
no focus on pathology or diagnosis. The idea
of power as knowing participation in change
helps people change limiting beliefs, disturbing
emotions, and other difficulties in living. Most
people easily understand ideas of wholeness,
unitary human beingness, and the mutual
process with the entirety of their environment,
including other people, places, and things. We
are not in charge of how things turn out as that
involves everyone and everything else partici-
pating, knowingly or unknowingly, in the
mutual process. Our power concerns what we
think, feel, say, and do.
Health Patterning
Quite simply, health patterning is exploring
with people ways to make the changes they
want to make. More formally, health patterning
is a power enhancement therapy that guides
people to use their power-as-freedom to partic-
ipate knowingly in creating the changes they
want to make in their lives by becoming increas-
ingly aware, making more powerful choices,
feeling free to act on their intentions, and in-
volving themselves in creating change. It is not
talk therapy. It is pattern manifestation knowing
and appreciation and voluntary mutual pattern-
ing coming alive in a moment-by-moment
unfolding process. How is that different from
talk therapy? The focus is not on simply “talking
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about”; rather, the focus is on the person’s
intentions and involvement in participating
knowingly in change. There are no labels, no
agendas, and no expectations.
My clients, for the most part, are people
who want some sort of change in their lives
that they haven’t been able to accomplish, even
when the change means accepting what cannot
be changed in ways they desire. Often there is
a crisis revolving around one or more of four
major areas of life: oneself, health, relation-
ships or career. My intention is to teach people
how to find the authority and clarity in them-
selves by becoming aware of their intentions,
by making choices from the options that are
open to them, and learning to give themselves
the freedom to carry through on their choices
as they go about creating change in their lives.
After initiating a dialogue of meaning and
asking clients to identify what they want to
accomplish in our work together by telling me
specifically three things, I ask clients to com-
plete the PKPCT. I tell them nothing about
the tool except how important it is to follow
the instructions. It is important that they
respond to the items honestly and frankly in
order to get an accurate, meaningful reading.
I point out that the tool is a reflecting mirror;
it reflects back to people who they tell it they
are. Afterward, I inquire about their notion
about what the tool is assessing; they are
usually shocked to learn it is power. This pro-
vides an opportunity to teach them the power
theory by briefly describing the definition, the
two types, the four dimensions, and a few
examples of the numerous forms in which both
types of power manifest. In the following
session, I will have scored the power tool
and can discuss the person’s Power Profile
strengths and weaknesses as well as ways our
work together may enhance their Power Pro-
file and facilitate accomplishment of what they
are seeking through health patterning. For
those who do not wish to complete the tool,
there are many other optional modalities.
This process is quite different from using
the PKPCT in quantitative research in which
the interest is in group scores and what is
learned is about the group, and group scores
can be compared with scores of other groups,
and all the other possibilities available through
quantitative methods. In Health Patterning,
the PKPCT scores provide the Power Profile
for one individual. This is a qualitative, phe-
nomenological process. I do not tell or show
the person his or her scores. The scores are
used only to help the nurse or clinician assess
the relative strengths and weaknesses not
only of the four dimensions but also of the
12 opposite adjective pairs used to measure the
dimensions. These 12 characteristics are pat-
tern manifestations of power and often repre-
sent a person’s belief systems concerning
power. Dwelling with this data is quite a com-
plex process. In the power-imagery process
(described later in the chapter), sophisticated
algorithms fine-tune the mechanics of the
method. The point here is that using the tool
with an individual is a mutual process of the
client and the nurse; a computer cannot dupli-
cate this human encounter. Power enhance-
ment occurs when the weaker areas are
reversed toward their stronger opposites using
various health patterning modalities and
Power Prescriptions.® This is not the work of
a day, yet the power tool can be a valuable
entrée to defining the person’s Power Profile
of greater and lesser areas of strength and pro-
viding direction for working with different
modalities, such as creating a shift to the
opposite, for example, from chaotic to orderly
or from constrained to free.
Health Patterning Modalities
When clients, like all of us, are attempting to
create an intended change, it is helpful for them
to understand the acausal nature of the universe
and appreciate the patterning manifesting in
their experiences, perceptions, and expressions
(Cowling, 1997). Interestingly, clients grasp
simple examples of acausality quickly as they,
like most of us, have learned that wanting
something to happen, certainly does not mean
that it will. It is often a relief to realize none
of us is the sole generator of what occurs in
our lives, and yet we can use our power to
knowingly participate in the relative present.
That’s where health patterning modalities come
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in, yet these avenues for creating change in a
knowing way are not magic bullets. Nor does
one size fit all.
Even though the battle between free will
and determinism is believed to go back as far
as the pre-Socratics and continues to rage on,
the SUHB and Barrett’s power theory accept
the acausality of free will as a given. Power-
as-freedom is just that—freedom to powerfully
create change without interfering with the
freedom of someone else. Nor is power-
as-freedom about forcing yourself to do some-
thing you don’t want to do; rather, it is about
making aware choices, feeling free to carry
out those choices, and then doing so in a
way that is true to your values, such as those
that pertain to health and well-being. This
approach requires practice methods and
modalities to be consistent with this world-
view. It does not, however, require clients to
view the world in this way.
Health patterning modalities are general
approaches used to help people use their power
in new ways. The general focus includes lifestyle
changes, struggles with illness, difficulties in
living, and enhancement of power-as-freedom
through involvement in the healing encounter.
These modalities are selected within the con-
text of what is happening in a person’s life and
in relation to the nurse’s knowledge and skill
in using them as well as the client’s personal
preferences. They take place in a life affirming,
caring environment, described by Rogers as
unconditional love.
Examples of health patterning modalities
include imagery, Therapeutic Touch (TT),
meditation, dream reading, love-power reso-
nance, centering, prayer, power-imagery
process, Power Profile process, and techniques
of will. Imagery exercises can often be created
from the content of what comes up during the
session. However, here is an exercise that can
be used to focus on any intention that the
client wants to manifest. The title is health
patterning, and it incorporates light, sound,
color, and motion. These are modalities Rogers
believed would be frequently used in the
future. The intention for this health patterning
imagery is a change the person wants to make
in her life.
Health Patterning Imagery Exercise
Sit up straight. Get comfortable. Close your eyes.
Find yourself breathing in an even and regular
way with long, slow out-breaths through your
mouth and briefer in-breaths through your nose.
Breathe out with a long, slow breath through your
mouth, releasing pain and suffering, and through
your nose breathe in love and light. After breathing
out with another slow, releasing breath letting go
of any distress you may be experiencing, breathe in
the blue of the sky and the gold of the sun in beau-
tiful blue-golden light. Breathe out slowly one more
time and then breathe any way you like.
Now, see and know that your hands are made
of sky and earth. With these hands, you are able to
weave your own life. Know that you are able to
weave your own life with the threads and colors
you choose. See and recognize the working out
of the health patterning that your own weaving
is creating. In doing so, know that by freely
making choices with awareness, you are finding
your own way to powerfully participate know-
ingly in bringing about change. Now think of your
intention to create a specific change.
Breathe out one time. See yourself choosing
with awareness.
Breathe out one time. See yourself acting freely.
Breathe out one time. See how you are involv-
ing yourself in participating in creating the
change you want to see in your life.
Breathe out and open your eyes.
It is important after completion of any im-
agery exercise to ask the client how she is feel-
ing. If the person is uncomfortable in any way,
it is necessary to continue voluntary mutual
patterning to explore her experience, percep-
tion, and expression until comfort returns.
Health patterning modalities can be used in
most situations that nurses encounter. People
often come to me seeking relief from emo-
tional pattern manifestations related to physi-
cal illness. Other people come with conditions
that include pattern manifestations such as
anxiety, depression, grief, anger, fear, guilt,
troubling human field image, meaninglessness,
creative blocks, substance use dependency, dis-
ease prevention, eating disorders, many types
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of pain, pre–post surgical procedures, prosper-
ity or employment career concerns, spiritual
distress, end-of-life issues, or a combination of
these or other difficulties in living. The focus
is on people as unitary wholes with their
unique perceptions, experiences, and expres-
sions. The practice arena is ripe with opportu-
nities for nurses to research how the power
theory can be used to advance practice by in-
vestigating ways health patterning modalities
can promote healing.
Power Prescriptions
Power Prescriptions are the specific ways the
health patterning modalities are used with a
particular individual or group, as opposed to
the general category of health patterning
modalities. Again, they are designed to en-
hance power-as-freedom and are individual-
ized depending on each person’s wants and
needs. As power-as-freedom grows, the person
is less vulnerable to power-as-control tactics
from others or from themselves with others
and with themselves. This is one way people
heal. With enhanced power-as-freedom, they
find the strength to change limiting beliefs and
behaviors.
Power Prescriptions are not like medical
prescriptions. It is not as if you follow the pre-
scribed regimen expecting a particular result.
Rather than “if this, then that,” the aim of
Power Prescriptions is to guide people toward
developing awareness, making more powerful
choices, feeling free to act on their intentions,
and becoming involved in creating specific
changes in their lives.
Sometimes clients create their own Power
Prescriptions. A client whom we will call Julia
came to see me when she finished chemother-
apy for non-Hodgkin’s lymphoma. Sometimes
she creates her own exercises that often come
as images to her during Therapeutic Touch
treatments. Along with other clients, she
shares her remarkable story on my website
(www.DrElizabethBarrett.com) as a way to
contribute to the well-being of others. There
you will find an example of an imagery exercise
she created called “The Hapuna Chair.” To ac-
cess “The Hapuna Chair,” click on “What
I Do” on the menu bar. Then click “Real Sto-
ries. Real People. Real Power—Julia’s Story”
on the drop-down menu.
The Power-Imagery Process
The power-imagery process, or PIP as Gerald
N. Epstein and I named it when we began
developing it several years ago, basically works
like this. A person completes the PKPCT. The
findings, called the Power Profile, identify
the stronger and weaker areas of power. Then,
the client begins working through imagery ex-
ercises and techniques of will created to enhance
the weaker areas in both the four power dimen-
sions and the 12 power characteristics. This is a
three-step, 21-day process designed to enhance
people’s power through imagery. In the first
week, imagery exercises are focused on the four
dimensions. In the second week, the focus is on
the 12 characteristics. We call this process the
Power Plan, which is a way to create a shift from
lesser to greater power pattern manifestations,
for example, from chaotic or orderly or from
constrained to free. In the third week, the
process involves the PowerGram exercises that
put together the power dimension exercises from
the first week with the exercises for the charac-
teristics that were the focus during the second
week. We have used this process with groups in
the corporate and nonprofit worlds, with indi-
viduals in our private practices, and with group
workshops. An online version is available at
www.powerimagery.com. One nursing professor
required her students to complete the online PIP
as part of their professional development course.
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504 SECTION VI • Middle-Range Theories
Practice Exemplar: True Stories of the Power-as-Freedom Journey of
Two Friends
Although all nursing experiences are mean-
ingful, some remain with us forever. So it
was with Allison and Kay. Allison and Kay
struggled with their own illnesses and yet
maintained a healing partnership with each
other even though their illnesses took quite
different directions; it was a mutual process
partnership that manifested love-power
resonance. Although it was many years ago
that these two young women crossed the
threshold of my office door to begin health
patterning, the memory lingers on. Love-
power resonance was the glue that united the
three of us.
Love-power resonance is a health pattern-
ing modality I developed to further understand
the nurse–client healing process—a way to
capture the meaning of the love that goes on
between the nurse and client. It is well known
that love heals—both the giver and the
receiver—while hate destroys, and the absence
of love hinders healing and can be deadly.
Love is the most potent form of power-
as-freedom, and hate may be the most intense
emotion motivating extreme forms of power-
as-control, such as abuse, oppression, and
murder. Love and freedom are intimately con-
nected, as are hate and control.
I believe that love is the fire that lights the
power-as-freedom furnace. In love-power res-
onance, the frequency vibrations of both love
and power accelerate one another, and healing
manifests through resonating waves of change.
The illusion of separation disappears, and the
will is used for intentional healing events that
enliven health. Love-power resonance teaches
people to become “in power” in the same sense
as being “in love,” where two people become
part of something greater than themselves and
healing manifests through resonating waves of
change. Helicy describes the nature of this
change, resonancy describes how this change
takes place, and integrality is the process
whereby the change occurs (Phillips, 1994).
In love-power resonance, love is like power
without effort—it just flows. It taps into
consciousness and spirituality, where con-
sciousness is defined as the Spirit in all that is,
was, and will be, and spirituality is defined as
experiencing the Spirit in all that is, was, and
will be. Phillips (2010) uses the term ener-
gyspirit to describe consciousness. I hypothe-
sized that love-power resonance created an
opportunity for change by accelerating the mo-
mentum of commitment to go forward with
one’s intentions, while acknowledging that the
outcome is unknown and unpredictable.
First came Allison shortly after she had fin-
ished surgery, chemotherapy, and radiation for
treatment of synovial sarcoma of the hip.
Allison’s picture and story are published on my
website at www.drelizabethbarrett.com.
Pattern manifestation knowing and appre-
ciation revealed that Allison was experiencing
bilateral foot drop and that she was walking
with an awkward gait that she perceived, ex-
perienced, and expressed as painful. It was ap-
parent that this was affecting her human field
image. After the chemotherapy, her latent ge-
netic predisposition to Charcot-Marie-Tooth
Disease (CMT) had emerged. Voluntary mu-
tual patterning included discussion of this de-
generative nerve demyelination disorder and
how it had produced a progressive muscle
atrophy of her legs, hands, and feet. A year
later the sarcoma reoccurred, and she again
underwent surgery and radiation. We worked
together for another year, and since then she
has come for a health patterning session occa-
sionally for what she calls her “power boost.”
Allison learned the power-as-freedom way
using imagery exercises, techniques of will,
prayer, and dream reading as her health pat-
terning modalities, individualized as Power
Prescriptions, to transcend the initial devasta-
tion she experienced with the cancer and
CMT. She used a daily imagery exercise in
which she imagined a magic wand tapping her
legs, ankles, and feet and bringing the nerves
to life. She remains cancer free, yet she still
struggles with the pattern manifestations of
CMT. She and her husband have two children,
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CHAPTER 29 • Barrett's Theory of Power as Knowing Participation in Change 505
Practice Exemplar: True Stories of the Power-as-Freedom Journey of Two Friends cont.
even though she was told if she had a child
she would spend the rest of her life in a wheel-
chair.
By the end of our formal time together, Al-
lison had decided to channel her fighting spirit
and advocacy for others toward starting a
foundation, the Hereditary Neuropathy Foun-
dation (HNF), to search for a “cure” for
CMT. HNF is now a thriving client advocacy
and research-oriented nonprofit organization
that provides educational information to per-
sons living with CMT, professionals, and the
general public. Allison had this to say: “Health
patterning helped me view my illnesses as op-
portunities for learning how to deal with life
circumstances, not as tragedies, but as experi-
ences that helped me become a more powerful
person” (www.drelizabethbarrett.com). You
can find the HNF website at http://hnf-
cure.org.
Allison met Kay as they entered the eleva-
tor of the building where they both lived. By
the time they arrived at their floors, they had
revealed to each other that they both had can-
cer; the seeds for love-power resonance be-
tween them had been planted. Soon Allison
referred Kay to me.
Kay began her almost-continuous, 10-year
battle with cancer when she was 21. First, can-
cer claimed her left breast, then the right
breast, then it went to the spine and other
bones and then the lungs and finally the brain.
Kay came to me for health patterning fo-
cused on Therapeutic Touch and imagery to
relieve pain at the time the cancer had spread
to her spine. Later, she became paraplegic
and was told by her physicians that she
would have to spend the rest of her life in a
wheelchair. She refused to accept this ulti-
matum. When she was no longer able to
come to my office, I began going to her
home to give her TT treatments, and she
also began to work with a physical therapist.
During one of the TT treatments, she sud-
denly cried out, “I can feel sensations in my
spine.” As the tears rolled down her cheeks,
she looked up at me and said, “This is what
I prayed for.” Soon she could walk with a
walker and for short distances with a cane,
and that was the last she ever saw of a wheel-
chair. She shocked the physicians the first
time she walked into their offices on her
husband’s arm, using just a cane.
During those sessions at Kay’s apartment,
Allison would often join us. Pattern manifes-
tation knowing and appreciation and voluntary
mutual patterning kept the sessions focused on
a dialogue of meaning. Here’s a brief sample
of how the health patterning conversations
would take place.
Kay: Why do we have to be sick when we want
so much to be healthy?
Elizabeth: Are illness and health incompatible?
Allison: What is health, anyway?
Kay: I’m confused.
Elizabeth: I see health as a process of actualizing
possibilities for well-being by participating
knowingly in change.
Allison: Can health be different for different people?
Elizabeth: Yes. Health is a value that people
define for themselves, so different people see
it differently.
Kay: I’ve known people who are sick or at least
have some disease, and I think they are healthy
in what I’ve been seeing as the bigger picture.
Allison: Me, too.
Elizabeth: Illness can simply be a way a person’s
health is manifesting at a certain time, some-
times serving as a wake-up call or a trigger
for transformation.
Kay: These new ideas are hopeful, and they are
giving me courage.
Allison: It’s hard not to ask, “why me?” Why
do Kay and I have to struggle with these
devastating diseases?
Elizabeth: Illness and disease can have many
sources and many meanings, and sometimes
those sources remain a mystery.
(Allison hands Kay a tissue to wipe her eyes.)
My efforts were not to get Kay to face her
so-called death or work through stages of
death and dying. My purpose was to help her
live the way she chose, and live she did. She
lived her dying in a power-as-freedom way
that was uniquely her own.
Continued
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506 SECTION VI • Middle-Range Theories
Practice Exemplar: True Stories of the Power-as-Freedom Journey of Two Friends cont.
On a few occasions, she asked me to tell her
what I thought it would be like “at the end.” I
told her for me there is no end, as we never
die; our energy simply transforms. We talked
about the fact that some persons who have had
a near-death experience describe a deep sense
of peace and well-being and they sometimes
describe passing through a tunnel of great
darkness into a bright light on the other side,
where a world of indescribable beauty awaits.
She asked questions such as, “How can I stay
alive while dying?” and “What about people
without illness who are dying or may be almost
already dead?”
Many times Kay talked about feeling a
sense of closeness with her spirituality that for
her connected healing with a sense of holiness.
This was a new way she was experiencing
her power-as-freedom, as a kind of prayerful
reverence. She often asked me to pray with
her. During this time, she also returned to
her religious roots and developed a personal
relationship with her God.
Kay needed frequent TT treatments, and it
wasn’t possible for me to go to her home that
often. So I decided to offer her an opportunity
to try a love-power resonance experiment.
I explained that imagery and TT are pow-
erful nonlinear Power Prescriptions that do not
depend on physical proximity and that healing
possibilities are enhanced when we leave the
visible realm of ordinary time and space and
enter the invisible realm of pandimensionality,
which is a domain where there are no temporal
or spatial attributes. I invited Kay to meet with
me over the phone for 5 minutes daily. We
agreed that during this 5 minutes we would
unite our intentions for her healing to manifest
in whatever way that might happen. We were
both clear that there could be no attachment to
outcomes; yet the pattern manifestations that
emerged included decreased pain, improved
memory, less disturbed sleep, unlabored breath-
ing, and an uplifted spirit. Over time, she came
to understand that healing is far more than
curing a disease; it is about healing the whole
person, and it is not defined by the presence or
absence of disease.
Some days, our 5-minute love-power res-
onance experiment consisted of a brief im-
agery exercise lasting less than a minute before
doing healing at a distance with my hands
hovering over a Polaroid photograph of her.
The imagery often incorporated the powerful,
pandimensional healing modalities of light,
sound, color, and motion. Some days, I asked
her to define a specific intention for her heal-
ing for that session. In keeping with our pre-
vious discussions, her intentions did not focus
on outcomes.
For the first year, we did what we called
“our thing” almost daily and after that three or
four times a week. Kay found this love-power
resonance experiment a meaningful way to
maintain her optimistic courage and relieve
pain and other symptoms despite the progres-
sion of the disease. She was an inspiration to
me, and we shared what Parse calls “meaning
moments” many times as she continued her
healing journey. Although she didn’t deny her
illness, she was healthy in spite of it. Cancer
may have ravaged her body, but not her soul—
not her energy field.
Rumi (1988) described the transformation
I witnessed as the months went by when he
said: Journeys bring power and love back into
you. If you can’t go somewhere, move in the
passageways of yourself. They are like shafts of
light, always changing and you change when
you explore them.
I asked Kay to remind herself that she was
living her power-as-freedom by repeating daily
the following power mantra: “I am free to
choose with awareness how I participate in
changes I intend to create.” The days turned
into weeks, months, and eventually over 2 years.
She often would tell me during our 5-minute
exchange that she was going into the hospital
for another gamma knife treatment or radiation
or chemotherapy, procedures she considered
helpful and “no big deal,” and amazingly she
quickly bounced back to her optimistic self.
Early on, Allison made a commitment to con-
tact Kay several times a week and was a source
of strength to Kay in ways that I could not be
since they had both experienced cancer.
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CHAPTER 29 • Barrett's Theory of Power as Knowing Participation in Change 507
Practice Exemplar: True Stories of the Power-as-Freedom Journey of Two Friends cont.
Finally, Kay’s husband called to tell me she
had been admitted to the hospital. When I
arrived, she was propped up in bed in a sitting
position, but hunched over with her forehead
near her chest. She was semiconscious and
hadn’t spoken for the 2 days she had been
there, although her husband and parents
thought she recognized them. Her family left
the room so that we could have private time
together. I asked her if she wanted to do “our
thing,” and she nodded her head. When I told
her we were finished, I was amazed that she
looked over at me with a slight smile. I held
her hand. Soon her husband came into the
room, and he and I were talking softly. All of
a sudden, Kay rose up and called out her hus-
band’s name, saying, “I love you. I love you so
very much.” He was overcome with joy and
ran out of the room to tell her parents and
brother who returned immediately. Kay called
out first to her father, “Daddy, Daddy, I love
you” and then to her mother and brother.
These were moments of love-power resonance.
She passed on 3 days later having completed a
10-year healing journey. In the words of my
imagery teacher of blessed memory Colette
Aboulker-Muscat, “The bridge between us will
always exist—now and forever” (Laura Gold-
stein, personal communication, January 10,
2004). For me, what I witnessed that day at
the hospital was evidence that imagery, Ther-
apeutic Touch, and prayer used during the
love-power resonance experiment had made a
difference in her healing.
The love-power resonance experiment was
not a scientific experiment testing the princi-
ple of resonancy; it was simply a process of dis-
covery that I sometimes experienced like a
laser moving in unison between us, focused on
our intention for her healing.
Love is a higher frequency vibration
rippling through the universe; it has greater
power to impact the universe than the lower
frequency vibrations of negative phenomena.
Everything we do makes a difference in
terms of our mutual process with all that
is. The more love we manifest, the stronger
the power to bring peace and well-being to
the world.
In closing, I am grateful that for more than
40 years, I have been privileged to be a profes-
sional nurse and to have experienced my pro-
fession by participating in the roles of
practitioner, teacher, administrator, and re-
searcher. Although all these roles were mean-
ingful, practice has always been my first love,
and Allison and Kay are two of the many
clients that remain in my heart.
■ Summary
In this chapter a description of the flow from
Rogers’ science of unitary human beings to
Barrett’s power theory to research and practice
applications is presented. Major assumptions
include (1) power is a phenomenon that exists
in the universe; (2) human beings are born
with power; (3) no one can give power to
another, and no one can take power away;
and (4) human beings have free will and can
knowingly participate in creating change.
The definition of power as the capacity to
participate knowingly in change was derived
from Rogers’ conceptual model and describes
both power-as-freedom and power-as-control.
The PKPCT measurement instrument and
the research basis for practice are reviewed.
Health patterning is a power enhancement
therapy that guides people to use their power-
as-freedom to participate knowingly in creating
the changes they want to make in their lives
by becoming increasingly aware, making more
powerful choices, feeling free to act on their
intentions, and involving themselves in creat-
ing change. Health Patterning modalities
are individualized by using Power Prescrip-
tions. A practice exemplar illustrates the way
the theory is used to teach people how to live
power-as-freedom.
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508 SECTION VI • Middle-Range Theories
References
Barrett, E. A. M. (1986). Investigation of the principle of
helicy: The relationship of human field motion and
power. In V. M. Malinski (Ed.), Exploration on Martha
Rogers’ science of unitary human beings (pp. 173–188).
Norwalk, CT: Appleton-Century-Crofts.
Barrett, E. A. M. (1988). Using Rogers’ science of
unitary human beings in nursing practice. Nursing
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Barrett, E. A. M. (1989). A nursing theory of power for
nursing practice: Derivation from Rogers’ paradigm. In
J. Riehl (Ed.), Conceptual models for nursing practice
(3rd ed., pp. 207-217). Norwalk, CT: Appleton &
Lange.
Barrett, E. A. M. (1990a). Health patterning with clients
in a private practice environment. In E. A. M.
Barrett (Ed.), Visions of Rogers’ science-based nursing
(pp. 31-44). New York: National League for Nursing.
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methodology for health patterning. Nursing
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participation in change. In O. Strickland & C. Dilorio
(Eds.), Measurement of nursing outcomes: Self care and
coping (2nd ed., Vol. 3, pp. 21–39). New York:
Springer.
Barrett, E. A. M. (2010). Power as knowing participation
in change: What’s new and what’s next. Nursing
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based nursing practice. In E. A. M. Barrett (Ed.),
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tary science practice of reaching essence. In
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participation in change. A literature review update.
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Chapter 30Marlaine Smith’s Theory of
Unitary Caring
MARLAINE C. SMITH
Introducing the Theorist
Overview of the Theory
Applications of the Theory
Practice Exemplar
Summary
References
509
Introducing the Theorist
Marlaine C. Smith is currently the Dean and
Helen K. Persson Eminent Scholar at the
Christine E. Lynn College of Nursing at
Florida Atlantic University. Dr. Smith has
been a nurse since 1972 and has practiced in
acute care and public health settings in large
metropolitan areas and a rural small town. She
graduated from Duquesne University with a
BSN, the University of Pittsburgh with two
master’s degrees in public health and nursing
with a specialty in oncology and nursing
education, and New York University with a
PhD in nursing. Dr. Smith held faculty and
academic administrative positions at Duquesne
University, Penn State University, LaRoche
College, and University of Colorado before her
current position.
Dr. Smith is known for her work in two
areas: metatheory, or the study of nursing the-
ories and theoretical issues, and research
related to healing through touch therapies.
She has studied, written about, and conducted
research related to Rogers’s science of unitary
human beings, Parse’s man-living-health
(now humanbecoming), Watson’s theory of
transpersonal caring, and Newman’s health as
expanding consciousness, and has written
many commentaries on issues related to nurs-
ing theory development. She conducted five
studies examining how the touch therapies of
massage, therapeutic touch, hand massage, and
simple touch can affect pain, symptom distress,
quality of life, sleep, and other important
outcomes for persons in acute and long-term
care settings. The last completed study was
funded by the National Institutes of Health,
National Center for Complementary and
Alternative Medicine.
Marlaine C. Smith
3312_Ch30_509-520 26/12/14 10:45 AM Page 509
Dr. Smith has been interested in transtheo-
retical work—that is, looking across nursing
theories for points of convergence. The unitary
theory of caring developed while studying the
literature on caring in nursing, and then analyz-
ing this literature through the theoretical lens of
the science of unitary human beings. Dr. Smith
was the recipient of the National League for
Nursing’s Martha E. Rogers Award for the
Advancement of Nursing Science, is a Distin-
guished Alumna of New York University’s
Division of Nursing Alumni Association, and is
a fellow in the American Academy of Nursing.
Overview of the Theory
A significant body of literature in nursing
explicates caring as a phenomenon that is
central to nursing’s focus as a discipline and
profession (Boykin & Schoenhofer, 1993,
2001; Leininger, 1977; Roach, 1987; M. C.
Smith, Turkel & Wolf, 2013; Stevenson &
Tripp-Reimer, 1990; Watson, 1979, 1985).
At the same time, there has been a correspon-
ding body of literature critiquing the assertion
that caring is an identifying concept for
the discipline and that the existing literature
related to caring is ambiguous and provides
no direction for meaningful inquiry (Morse,
Solberg, Neander, Bottorf, & Johnson, 1990;
Rogers in Smith, 1988; Paley, 2001; M. J.
Smith, 1990). An analysis of the caring
literature revealed that caring was a multidi-
mensional concept that assumed multiple
meanings depending on the framework within
which it was situated or the lens from which
it was viewed (M. C. Smith, 1999). Paley
(1996) argued that a concept acquires its
meaning within the context of the theory
within which it resides. Concepts are theoret-
ical niches, and to understand a concept fully,
the theory in which the concept lives and
derives its meaning must be clearly explicated.
This chapter is the explication of a middle
range theory of caring within the perspective
of the unitary–transformative paradigm. For
this reason, the theory is called unitary caring.
This chapter contains a description of the
theory development process, the assumptions
underpinning the theory, the concepts and
propositions of the theory, the empirical
referents of the theory, applications of the
theory, and a practice exemplar that illustrates
the major concepts.
Process of Theory Development
This process of developing a middle-range the-
ory was guided by the question: “What is the
substantive domain of caring knowledge from
a unitary perspective?” Through a unitary lens
the question was framed as: What is the quality
of being in mutual process that is called
“caring” within other theoretical contexts? This
question was answered through a process of
concept clarification that evolved from Paley’s
assertion that concepts were niches within the-
ories. This concept clarification involved the
following processes: (1) identifying the existing
meanings of the concept in context, (2) identi-
fying theoretical niches, (3) synthesis of the
concept through identifying constitutive mean-
ings, and (4) instantiation of the concept (M. C.
Smith, 1999). Identification of the existing
meanings of the concept occurred through re-
viewing the literature on caring that described it
as a way of being. Exemplar sources (Boykin &
Schoenhofer, 1993; Eriksson, 1997; Gadow,
1980, 1985, 1989; Gaut, 1983; Gendron, 1988;
Leininger, 1990; Mayeroff, 1971; Mont-
gomery, 1990; Rawnsley, 1990; Ray, 1981,
1997; Roach, 1987; Sherwood, 1997; Swanson,
1991; Watson, 1979, 1985) were reviewed in
this process. From these sources semantic ex-
pressions, or phrases that captured the essential
meaning of caring as a way of being, were
listed. Next, the literature written by unitary
scholars (Barrett, 1990; Cowling, 1990, 1993a,
1997; Krieger, 1979; Madrid, 1997; Madrid &
Barrett, 1992; Newman, 1994; Quinn, 1992;
Rogers, 1994) was examined for existing
concepts that corresponded to the semantic ex-
pressions of caring. These were identified as
theoretical niches in the unitary literature.
Constitutive meanings, phrases that captured
the meaning of a cluster of semantic expres-
sions, were named using language consistent
with a unitary perspective. Five constitutive
meanings were developed (M. C. Smith,
510 SECTION VI • Middle-Range Theories
3312_Ch30_509-520 26/12/14 10:45 AM Page 510
1999). Since the initial publication, the work
was expanded with assumptions and empirical
referents (Cowling, Smith, & Watson, 2008)
to form a middle-range theory. The theory
is connected philosophically to the unitary–
transformative paradigm, has five concepts that
describe the phenomenon of caring from a
unitary perspective, and can guide practice be-
haviors and research questions at the empirical
level (M. J. Smith & Liehr, 2008).
Assumptions
Assumptions of the unitary theory of caring
come from Rogers’s science of unitary human
beings (1970, 1994), Newman’s theory of health
as expanding consciousness (1994, 2008), and
Watson’s Theory of Transpersonal Caring
(1985, 2005; Watson & Smith, 2002). To fully
understand the meaning of the theory, readers
will benefit from studying these sources.
1. Human beings are unitary or irreducible,
in mutual process with an environment
that is coextensive with the Universe,
participating knowingly in patterning,
and ever-evolving through expanding
consciousness (Barrett, 1989; Newman,
1994; Rogers, 1992).
2. Caring is a quality of participating
knowingly in human–environmental field
patterning (M. C. Smith, 1999).
3. Caring is the process through which
human wholeness is affirmed and that
potentiates the emergence of innovative
patterning and possibilities (Cowling et al.,
2008, E44).
4. Caring is a manifestation and reflection of
expanding consciousness potentiating
greater meaning, insight, and transformative
ways of relating to self and others (Cowling
et al., Smith, & Watson, 2008).
5. Caring consciousness is resonating with the
pandimensional universe (Rogers, 1994;
Watson, 2005; Watson & Smith, 2002).
Concepts
After establishing the theoretical linkages to
the unitary-transformative paradigm, the five
concepts of this theory are explicated. The five
concepts were developed from an analysis of
literature on caring and similar concepts
described by unitary scholars. The theoretical
concepts have their underpinnings in each of
the assumptions.
Manifesting Intentions
Manifesting intentions is the first concept in
the unitary theory of caring; it was originally
defined as creating, holding, and expressing
thoughts, feelings, images, beliefs, desires, will,
purpose and actions that affirm possibilities for
human health and healing (Smith, 1999).
From this point of view, the nurse is a healing
environment, creating sacred space through
her thoughts, feelings, intentions, and actions
(Quinn, 1992). Understanding intentionality
in this way comes with an assumption that
underlying the world of form that is accessed
by sensory perception, there is the primary re-
ality that is pandimensional (Rogers, 1994)
and beyond access through the five senses
alone. David Bohm’s (1980) concept of the
holographic universe with implicate–explicate
orders of reality is consistent with this point of
view. The implicate order is the primary, un-
seen pattern, whereas the explicate order is the
manifestation of this underlying pattern that
is accessible through the senses. Caring is
engaging with both orders of reality, holding
intentions through affirmations and images,
and expressing these intentions through
actions. Thoughts, feelings, perceptions, and
images are as potent as our words and actions.
Intentions are meaningful energetic blue-
prints for transformation (M. C. Smith,
1999). What we hold in our hearts matters
(Cowling et al., 2008, p. E46). Manifesting
intentions encompasses actions that create
healing environments, preserve dignity, hu-
manity, and reverence for personhood, focus
attention to and concern for the other, and
facilitate authentic presence.
Appreciating Pattern
Appreciating pattern is the second concept in
this theory. It is apprehending and understand-
ing the mysteries of human wholeness and di-
versity with awe. This concept was referenced
CHAPTER 30 • Marlaine Smith’s Theory of Unitary Caring 511
3312_Ch30_509-520 26/12/14 10:45 AM Page 511
by both Dolores Krieger (1979) and Richard
Cowling (1990, 1993a, 1993b, 1997), and
defined by Cowling (1997) as “seeing under-
neath all that is fragmented to the real existence
of wholeness and acknowledging that with
awe” (p. 136). Cowling (1997) describes the
process of approaching knowing the other with
gratitude and enjoyment. This contrasts with a
clinical problem-solving approach. While
appreciating pattern is an existing concept in
unitary theory, it corresponds to many impor-
tant meanings within caring theories including
valuing and celebrating the wholeness and
uniqueness of persons, acknowledging pattern
without attempting to change it, recognizing
the person as perfect in the moment, being
sensitive to the unfolding pattern of the whole,
and coming to know the other. Pattern is
reflected in meaning, so finding out what is
meaningful to the other becomes primary in
knowing pattern (Newman, 2008). Appreciat-
ing pattern is coming to know the uniqueness
of the other. It is grasping the wholeness of
the other (individual, family, and community)
not through analysis, but through sensing,
coexploring experiences, and listening to the
other’s story. This happens through letting go
of preconceptions and the need to categorize,
classify, diagnose, or judge. When we resist
labeling and diagnosing we can glimpse the
dynamic being that is sharing this moment
with us. Appreciating pattern is being-with in
wonder at this work of art before us, this life
that reflects the diversity of creation.
Attuning to Dynamic Flow
Attuning to dynamic flow is the third concept
in this unitary theory of caring. Attuning to
dynamic flow is sensing of where to place focus
and attention in mutual process. It was origi-
nally described as “dancing to the rhythms
within continuous mutual process” (M. C.
Smith, 1999, p. 23). Caring is flowing with the
cocreated rhythms of relating in the moment.
It happens by being truly present in the moment
and is a back and forth movement of relation-
ship building through a “vibrational sensing of
where to place focus and attention” (M. C.
Smith, 1999, p. 23). This includes expressions
of caring and unitary relating from the literature
such as attuning to the subtle cues in the
moment (Montgomery, 1990), shifting per-
spectives and patterns of response (Mayeroff,
1971), relating in a complex synchronized inte-
gration (Gendron, 1988), and experiencing
energetic resonance (Quinn, 1992). It is hearing
the call that may be spoken or unspoken.
Newman (2008) describes the process of reso-
nance as a way of knowing that presents itself
through intuitive insights and feelings. Intellec-
tualization can actually break this resonant field
that is created through true presence. Caring is
not taking the lead and telling the person what
he or she needs to do. It is understanding where
the other wants to go and moving with him or
her in the struggle to get there. It is going to the
relationship without an agenda, a plan, a bag of
tricks, but trusting in the transformative power
of healing presence.
Experiencing the Infinite
The next concept in the theory is experienc-
ing the infinite. This concept is defined as
“pandimensional awareness of coextensive-
ness with the universe occurring in the con-
text of human relating” (M. C. Smith, 1999,
p. 24). This is described by many caring
theorists as spiritual union (Watson, 1985),
Divine Love (Ray, 1997), or an actual caring
occasion (Watson, 1985). Experiencing the
Infinite is the recognition that the nurse–
person relationship is sacred, we meet the
Holy in it, and when we are with others in
this way, there are no limits to the possibili-
ties. Miracles happen! There are miracles of
healing that happen with our patients every
day that can be potentiated through love and
caring. This can be recognizing who one
really is, appreciating the Oneness of Being
with all there is, and finding hope in the
darkest of hours. All of this is mediated by
our outlook, how we view our world, and
what we entertain as possibilities. William
Blake (1790–1793) said, “The tree which
moves some to tears of joy is in the eyes of
others only a green thing that stands in the
way.” Experiencing the infinite occurs in
moments of grace, experiencing the presence
512 SECTION VI • Middle-Range Theories
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of God in relationship with others. In those
moments, there is an experience of connect-
edness to all-that-is extending beyond space–
time boundaries that defies description in
ordinary language.
Inviting Creative Emergence
The final concept in this theory of unitary
caring is inviting creative emergence. It is
attending the birth of innovative, emergent
patterning through affirming the potential for
change, nurturing the awareness of possibili-
ties, imagining new directions, and clarifying
hopes and dreams. This concept was taken
from Quinn’s (1992) description of healing
and Newman’s (1994, 2008) descriptions of
transforming presence. Descriptions of caring
in the literature that correspond to this concept
are a “transformative experience wherein the
constant birthing of love in caring actions is
the growth of spiritual life within” (Roach,
1987), allowing a person to grow in his/her
own time and way (Mayeroff, 1971), and call-
ing to a deeper life, the spiritual life, of each
person (Ray, 1997). Caring is inspiring the
other to birth oneself anew in the moment. It
might be through an activity, realization,
decision, a new role, a new life pattern. The
nurse creates a safe space for this new life to
emerge through supporting, coaching, and
providing confidence when it is lacking. This
concept relates caring to healing. Caring is the
vehicle through which healing occurs. Caring
takes trust and patience. People change and
grow in their own ways and in their own time.
They know their way and we journey with
them. This invitation for creative emergence is
gentle and encouraging. Quinn (1992) calls it
being a midwife to healing.
Propositions
The following are propositional statements
that further clarify concepts of the theory.
Manifesting intention is:
• Preparing self to participate knowingly in
cocreating an environment for healing.
• Focusing images, thoughts and intentions
for health and healing.
• Expressing intentions in actions that
support health and healing.
Appreciating pattern is:
• Seeing wholeness in perceived fragmentation.
• Valuing uniqueness and diversity of
patterning with wonder.
• Acknowledging what is without attempting
to change or fix.
• Exploring what is meaningful in the
moment.
• Coming to know by listening to the other’s
story.
Attuning to dynamic flow is:
• Being truly present in the flow of relating.
• Attending to the subtleties of meaning.
• Synchronizing rhythms of self with other.
• Trusting intuition in the mutual process.
Experiencing the infinite is:
• Acknowledging the sacred in human
relating.
• Believing in limitless possibilities.
• Igniting hope in despair.
• Connecting to a pandimensional universe.
Inviting creative emergence is:
• Honoring the unique timing, pace and
direction of change.
• Calling attention to possibilities and
potentialities hidden from view.
• Inspiring new life to emerge in the
moment.
• Trusting in the wisdom of knowing one’s
own way.
Empirical Indicators
An empirical indicator is a “concrete and spe-
cific real world proxy for a middle range theory
concept” (Fawcett, 2000, p. 20). It is taking a
conceptual abstraction and moving it to a place
where it lives...where it can be seen, heard,
felt, experienced, or measured. There are em-
pirical indicators for both practice and research.
Those for practice are useful in translating
the theoretical concept to guides for nursing
practice. Those for research can be used to
generate research questions, develop measures
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3312_Ch30_509-520 26/12/14 10:45 AM Page 513
of the concept, or develop paths of inquiry
where the concept might be explicated through
experiences. Each of the concepts is discussed
at the empirical level.
Manifesting Intentions
As far as the concept of manifesting intentions,
nurses enter a caring relationship with intention,
through preparing to become the energetic
environment that potentiates healing. Nurses
prepare by centering or connecting to the True
Self, going to that place within where it is
possible to hear the still small voice. Nurses pre-
pare by focusing on the present moment, leaving
behind the thoughts racing in their heads that
interfere with being truly present. Nurses pre-
pare for caring by holding intentions that change
the vibratory pattern of the energy field. Marcus
Aurelius (171–175) said, “The soul becomes
dyed by the color of its thoughts.” The soul of
our practice is dyed by our pattern of thinking.
If we cultivate the habit of focusing, centering,
and setting intentions before any encounter; we
can create the space for caring and healing. This
way of being-with can be developed through self
reflection, expressing intentions through touch
and energy work, centering exercises, spiritual
practices such as meditation and prayer, mantra
repetition, and experiences in nature (Cowling
et al., 2008). The development of an inner life
is critical for the full expression of caring in
nursing. If caring is a way of being, nurses must
develop these competencies as much as any
other to evolve as caring beings. Rituals can
structure the process of setting intentions that
are manifest in the nursing situation. Watson
(2008) gives an example of creating a hand-
washing ritual in which nurses use this daily
practice as a way of centering and leaving behind
any thoughts that might interrupt presence.
Morning huddles are used in some settings as a
ritual to come together as a team and set the
intentions for the day. Nurses can develop rituals
related to giving report that signify the duty to
care (Cowling et al., 2008).
The concept of manifesting intentions can
be studied. Activities such as centering, setting
an intention, affirmations, meditations, prayers,
values-based decision making, and use of
mantras could be tested using any variety of
outcomes associated with nurses or their
clients. One could explore how nurse centering
before care influences outcomes related to
patient safety or how the handwashing ritual
described above might improve patient satis-
faction. One could study if there were healing
outcomes associated with Reiki, Therapeutic
Touch, or prayer because intentionality is
integral to these practices.
Appreciating Pattern
In a unitary theory of caring, nurses would
approach coming to know their patients in an
entirely different way. The nursing process, or
the problem-solving process, would not be
consistent with caring from this point of view.
It would involve knowing the other through
using the sensory and extrasensory abilities to
grasp wholeness. Nursing assessments would
include exploring the unique life patterns of
the person, exploring what is most important
in the moment, and hearing the person’s story.
Perhaps the first questions that we ask our
patients should be “What is important to you
right now?” and “What matters most in this
moment?” (Boykin & Schoenhofer, 2006).
Cowling (1997) and Newman (1994, 2008)
have both developed clear praxis methods that
focus on pattern appreciation and pattern
recognition. Nurses need to develop their
abilities to appreciate pattern. Skills of pattern
seeing, listening, grasping the essence, and art
and music appreciation correspond to this
ability of appreciating pattern (Cowling et al.,
2008). In interdisciplinary team conferences,
nursing is the voice that represents the whole-
ness of the person; no other discipline does
this. Instead of describing a community by its
census and health statistics, we can come to
know it by asking its members to describe the
essence of the community. Nurses can use
bulletin boards in patient rooms as places that
persons and families can display their unique-
ness and what is most important to them.
Research related to pattern appreciation
already exists (Cowling, 2005; Repede, 2009)
Cowling’s unitary pattern appreciation is a praxis
method (combines research and practice) in
514 SECTION VI • Middle-Range Theories
3312_Ch30_509-520 26/12/14 10:45 AM Page 514
which he and the participant/client explore
patterning together; this is then captured and
shared through aesthetic expressions. Through
using Newman’s praxis method, nurses engage
persons in an exploration of the meaningful
events and relationships in their lives toward
recognizing pattern and making choices about
those patterns.
Attuning to Dynamic Flow
Attuning to dynamic flow is lived in practice
through sensing the readiness to begin to talk
about sensitive issues or the willingness to take
on a major life change. An example is staying
engaged with a person and family members as
they struggle together with the decision to
transition to hospice care. Another example is
knowing when a person needs the nurse to be
tough, urging him to get out of bed and walk
after surgery or to be soft, facilitating some
quiet space for a person to be alone for awhile.
Nurses need to cultivate their abilities related
to this through sensing, hearing and moving
with rhythms, presencing, and focusing.
Learning to listen for shifts and pauses and
learning to listen to and trust intuitive insights
is important. There are hospital myths about
the nurse who walks by a patient’s room and
knows that the patient is going to code. This
may be an example of being sensitive to
changes and shifts within a situation, attuning
to the information that is embedded in the
field of consciousness.
There are research possibilities related to this
concept. It would be interesting to study how
nurses attune to the dynamic flow of relation-
ship with an unconscious person or a neonate.
What are the cues that they pick up and act on?
What are the ways that they sense beyond
the senses to understand what is happening or
what is being communicated to them? The
study of intuition in practice is an example of
an empirical indicator of this concept.
Experiencing the Infinite
One example of experiencing the infinite is
seeing the sacred in mundane activities. It is
recognizing the extraordinary in the ordinar-
iness of our activities. This might be made
concrete by practice rituals that can help us
to recognize and celebrate the work of nurs-
ing. One such ritual that has been used is the
“blessing of the hands.” Another way to expe-
rience the infinite in practice is to validate its
existence through nursing practice stories. We
don’t take the time to really appreciate the in-
credible moments experienced in caring with
others. The sensitivity to experience the infi-
nite in our practice may be developed through
spiritual practice or a practice that fosters deep
reflection. This could be meditation, prayer,
centering, being in nature, or walking a
labyrinth (Cowling et al., 2008, p. E48).
The research questions that are related to
this concept might be studying nurses’ and
patients’ stories of the extraordinary moments
experienced in nursing practice.
Inviting Creative Emergence
There are many examples in nursing practice
that can illustrate how caring can invite
creative emergence. This can happen when
we help women become mothers through
teaching them the necessary skills to care for
their babies and help them to grow, or when
we connect people to resources in the com-
munity that allow them to live with greater
ease in the midst of a family crisis. It is help-
ing others live their lives differently and
discover new ways of becoming.
The empirical indicators for research might
be developing an instrument to measure
satisfaction or pride associated with life
changes. Studies could be structured to ex-
plore differences in outcomes when lifestyle
change is approached with a nondirective
model suggested by this concept, rather than
a structured directive approach to lifestyle
change.
Applications of the Theory
The middle-range theory of unitary caring
has been advanced as a model for palliative
care practice. Reed (2010), a palliative care
clinical nurse specialist, has described how
unitary caring is used as a guide for his prac-
tice. Reed’s (2011) dissertation explored
CHAPTER 30 • Marlaine Smith’s Theory of Unitary Caring 515
3312_Ch30_509-520 26/12/14 10:45 AM Page 515
experiences in providing and receiving
massage and simple touch at end of life. The
study was a secondary analysis of qualitative
interviews from persons with advanced cancer
who had received massage or simple touch as
part of their participation in a research study.
Three themes were identified from the data
that describe their experiences of receiving
touch: (1) pattern recognition and wholeness,
(2) caring relationships, and (3) transforma-
tion and transcendence. These themes were
related to unitary caring, the theoretical
framework for the study.
Unitary caring is used as a guiding theory
for studying nursing at St. Thomas University
in Houston, Texas. This program has a unique
curriculum model built on the tenets of unitary
caring.
516 SECTION VI • Middle-Range Theories
Practice Exemplar
Sue is a family nurse practitioner working in
a community-based family practice with a
physician colleague. She practices from a
nursing model, using theories in the unitary-
transformative paradigm as a guide for her
practice. Beth is a 55-year-old attorney who
has been seeing Sue for her primary care for
some time. She is waiting in the examining
room.
Sue has had a busy morning with time pres-
sures and some difficult patient encounters.
She is “backed up” with two patients waiting
for her. She approaches the examining room
and pulls out the chart. She smiles as she sees
Beth’s name. In front of the door, she pauses,
closes her eyes, takes several deep breaths and
centers herself, repeating her mantra. She sets
an intention to be fully and authentically pres-
ent with Beth in this encounter and to enter a
relationship with her that facilitates their
mutual well-being.
Sue opens the door and finds Beth sitting
on the chair fully clothed. Sue approaches her
warmly, holding out her hand and touching
her on the shoulder. She pulls up her chair and
puts the chart aside. “OK, Beth, what’s going
on? How are you?”
Beth talks rapidly, wringing her hands and
tugging on her sleeve. “I was on vacation last
week in North Carolina with my friends. We
were having a relaxing time, and as I was get-
ting out of the car I felt myself go into atrial
fibrillation. My heart rate went way up like it
does to about 270, and I felt just awful, like I
couldn’t breathe, lightheaded . . . I thought I
was going to die.”
“Oh, how scary . . . that’s awful.”
“I know. I ended up in the emergency room
of this tiny hospital where they treated me
with IV antiarrhythmic drugs, and finally my
heart rate went down, and I converted to sinus
rhythm in about 3 hours. But this is the third
time that this has happened to me, and the
second time when I’ve been away from home.
I just need to get to the bottom of this. I’m
frustrated and scared.”
“Of course you are,” Sue continues. “OK
tell me how things are going with you gener-
ally and anything unusual that you were doing
on vacation that might have precipitated this
episode.”
“Well, you know I had that episode of
diverticulitis before I left for vacation, and you
prescribed the Cipro for me. Well, I was not
feeling great on vacation, the pain was better,
but I had constipation, but took the Miralax
and the fiber that I always take. We went on a
boat trip the day before and I took some
Dramamine, too. Also, my friends and I were
drinking wine every night. That’s all I can
think of.”
“What about home and work?”
Beth looks down at her hands. “Well, Bob
still can’t find a job, and things have been crazy
at work. I just can’t seem to get ahead of it. I
have a major brief due in a couple of weeks . . .
It was hard to leave for vacation. I love being
with my friends, but I was torn about taking
the time.”
Sue pauses then says, “Tell me more about
this feeling of being torn between what you
love and what you have to do.”
3312_Ch30_509-520 26/12/14 10:45 AM Page 516
CHAPTER 30 • Marlaine Smith’s Theory of Unitary Caring 517
“I guess I’m in that space a lot lately, Sue.”
Beth begins crying. “I don’t think I’m doing
what I love to do . . . I feel like I’m not in
control of my life.”
Sue hands Beth some tissues and sits qui-
etly with her, gently touching her arm as Beth
sobs. In the moment Beth sobs for the loss of
joy in her life now, and at the memory of her
mother telling her she had to go into a practi-
cal career like law, not fiction writing. In the
moment Sue imagines holding and rocking
Beth in the space between them. In her mind’s
eye she whispers comforting words. In silence,
they both experience an intimacy that is
beyond language.
When Beth stops crying she looks up and
asks, “What do I do now?”
“Let’s take care of the A-fib issue first, Beth.
Are you still on the same dose of the beta-
blocker that your cardiologist prescribed?”
“Yes, Toprol 25 mg.”
“OK. I want you to get in to see the cardi-
ologist as soon as possible and discuss this with
him. You have some options with ablation or
other antiarrhythmics. You might want to talk
with an electrophysiologist as well. I’ll make a
referral. Also, I just checked the side effects of
Cipro, and atrial fibrillation is a rare side effect.
So taking the Cipro could have triggered this
event given your history. And of course
Dramamine and alcohol could have con-
tributed. And at the time this happened you
were just getting over diverticulitis and weren’t
feeling great. But, we also need to focus on this
distress that you are experiencing related to
your work. I’d like you to do some journaling
for a period of 2 weeks. Write down the things
that you love, your passions, what makes your
heart sing? Don’t overthink it, Beth. If you
have images or messages that come to you, jot
them down. Make an appointment in 2 weeks,
and we’ll talk about what you discovered. OK?
“Yes, OK.” Beth nods tentatively.
“Before you leave I’m going to listen to
your heart and check your blood pressure
again. Hop up on the table.” Sue auscultates
Beth’s heart sounds and measures her blood
pressure. “Everything is fine. Your heart rate
is regular at 60, and your blood pressure is
OK, but a bit higher than we’d like it to be:
130/82. I know you experience some “white-
coat hypertension.” We’ll check it again next
week. You check it too at the machine in the
grocery store and keep track. Bring that back
in 2 weeks too.”
Sue puts two hands on Beth’s shoulders. “I’m
in this with you. You’ll figure this out. Change
can be hard, but it’s how we grow. Anything else
that we need to talk about today?”
“No, I feel better . . . thanks, Sue.”
“Thank you! I’ll see you in 2 weeks.”
(The encounter took 15 minutes.)
The five concepts of the unitary theory of
caring were evident. First, manifesting intention
was visible in the preparation before Sue
entered the room. She was aware that she, as
nurse, is an environment for healing (Quinn,
1992). Sue set an intention and entered the
nursing situation being fully present to Beth.
She shared her intentions with Beth when she
said, “I’m in this with you,” and in her use of
touch and eye contact to communicate her
desire to be present and in partnership with
Beth. Appreciating pattern was evident as Sue
asks Beth about what was going on with her,
how she was, and if there was anything different
about the time that led up to the episode of
atrial fibrillation. Sue values the uniqueness of
Beth’s experience and Beth’s own insights about
events that led up to the episode, affirming that
Beth’s knowledge of her own pattern had
validity. Intuitively, Sue asked the questions,
“What about home and work?” and “Tell me
more about this feeling of being torn between
what you love to do and what you have to do.”
This second question emerged from Sue’s
tuning into meaning and resonating with the
whole, illustrating the concept of attuning to
dynamic flow. This led to the revelation of Beth’s
life pattern that could have remained undis-
closed had Sue not attended to the intuitive
flash. As Sue silently sat with Beth as she
sobbed, they both experienced an intimacy
beyond words, and a pandimensional awareness
of past–present–future in the moment. This is
an example of the concept of experiencing the
Practice Exemplar cont.
Continued
3312_Ch30_509-520 26/12/14 10:45 AM Page 517
518 SECTION VI • Middle-Range Theories
infinite. Finally, when Beth expresses that she
is not doing what she loves, Sue is inviting
creative emergence by asking her to attend to any
cues she may receive about what she would love
to do and to record this in a journal. She asks
her to return for a follow-up visit in 2 weeks.
Often, the argument is advanced that
“there is no time to care in this way,” but this
encounter took 15 minutes, no longer than a
conventional, medically focused primary care
visit. It isn’t the time we have; it is what we do
with that time that counts.
Practice Exemplar cont.
■ Summary
The unitary theory of caring provides a constel-
lation of concepts that describe caring from a
unitary perspective. The theory is constituted
with five concepts: manifesting intentions,
appreciating pattern, attuning to dynamic flow,
experiencing the Infinite, and inviting creative
emergence. Assumptions of the theory were
explicated, each concept was described, and
examples of empirical indicators for practice and
research were offered. The unitary theory of car-
ing is new; it can grow through those who invest
in it through testing it in practice and research.
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3312_Ch30_509-520 26/12/14 10:45 AM Page 520
Chapter 31Kristen Swanson’s
Theory of Caring
KRISTEN M. SWANSON
The Journey of Theory Development
Evolution of a Middle-Range
Theory of Caring
As It Progresses: Caring and Healing
The Journey Continues: The Couple’s
Miscarriage Project
The Connection Between Caring
and Healing
Summary
References
521
In this latest revision, I have kept just about all
of the content that was included in previous
versions of this chapter and have added some
updated materials. Most notably, I have added
a bit of information about results of a recent
randomized trial and some thoughts about the
connections between the five caring categories
and healing. For ease of reading, I have placed
the new material in the section titled “As It
Progresses: Caring and Healing.”
The Journey of Theory
Development
I have updated answers to questions posed by
students and practitioners who have wanted
to know more about the origins and progress
of my research and theorizing on caring. I
have situated myself as a nurse and as a
woman so that the context of my scholarship,
particularly as it pertains to caring, may be
understood. I consider myself to be a second-
generation nursing scholar. I was taught by
first-generation nurse scientists (that is, nurses
who received their doctoral education in fields
other than nursing). My struggles for identity
as a woman, nurse, and academician were, like
many women of my era (the baby boomers), a
somewhat organic and reflective process of
self-discovery during a rapidly changing social
scene (witness the women’s and civil rights
movements). Third-generation nursing schol-
ars (those taught by nurses whose doctoral
preparation is in nursing) may find my “yearn-
ing” somewhat odd. To those who might offer
critique about the egocentricity of my ponder-
ing, I offer the defense of having been brought
up during an era in which nurses dealt
with such struggles as, “Are we a profession?
Have we a unique body of knowledge? Are
Kristen M. Swanson
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we entitled to a space in the full (i.e., PhD-
granting) academy?” I fully appreciate that
questions of uniqueness and entitlement have
not completely disappeared. Rather, they have
faded as a backdrop to the weightier concerns
of making a significant contribution to the
health of all, keeping patients safe, educating
and retaining a supply of nurses prepared to
provide comprehensive patient-centered care
to an aging population with increasingly com-
plex and chronic health conditions, working
collaboratively with consumers and other
scientists and practitioners, practicing in a
highly technological environment, embracing
pluralism, and acknowledging the socially
constructed power differentials associated
with gender, race, poverty, and class.
Turning Point
In September 1982, I had no intention of
studying caring; my goal was to study what it
was like for women to miscarry. It was my
dissertation chair, Dr. Jean Watson, who
guided me toward the need to examine caring
in the context of miscarriage. I am forever
grateful for her foresight and wisdom.
I believe that the key to my program of
research is that I have studied human responses
to a specific health problem (miscarriage) in a
framework (caring) that assumed from the start
that a clinical therapeutic had to be defined. So,
hand in glove, the research has constantly gone
back and forth among “What’s wrong and what
can be done about it?” “What’s right and how
can it be strengthened?” “What’s real to women
(and most recently their mates) who miscarry
and how might care be customized to that real-
ity?” and “How can we measure the impact of
caring-based interventions on couples’ healing
after miscarriage?” The back-and-forth nature of
this line of inquiry has resulted in insights about
the nature of miscarrying and caring that might
otherwise have remained elusive.
Predoctoral Experiences
My preparation for studying caring-based
therapeutics from a psychosocial perspective
began in a cardiac critical care unit. After
receiving my BSN at the University of Rhode
Island, I was wisely coached by Dean Barbara
Tate to pursue a job at the brand-new Univer-
sity of Massachusetts Medical Center in
Worcester. I was drawn to that institution
because of the nursing administration’s clear
articulation of how nursing could and should
be. It was exciting to be there from day one.
We were all part of shaping the institutional
vision for practice. It was phenomenal witness-
ing our collective capacity as nurses, physi-
cians, respiratory therapists, and housekeepers
to collaboratively make a profound difference
in the lives of those we served. However, what
I learned most from that experience came from
the patients and their families. I realized that
there was a powerful force that people could
call on to get themselves through incredibly
difficult times. Watching patients move into
a space of total dependency and come out
the other side restored was like witnessing a
miracle unfold. Sitting with spouses in the
waiting room while they entrusted the hearts
(and lives) of their partners to the surgical
team was awe-inspiring. It was encouraging to
observe the inner reserves family members
could call upon in order to hand over that
which they could not control. I felt so privi-
leged, humbled, and grateful to be invited into
the spaces that patients and families created
in order to endure their transitions through
illness, recovery, and, in some instances, death.
After a year and a half at the University
of Massachusetts, I was still a fairly new
nurse and unclear what all of these emotional
insights had to do with nursing. I saw them
as something related to my spiritual beliefs
and me, rather than about my profession. At
that point, what mattered most to me as a
nurse was my emerging technological savvy,
understanding complex pathophysiological
processes, and conveying that same informa-
tion to others. Hence, I applied to graduate
school. Approximately 2 years after complet-
ing my baccalaureate degree, I enrolled in the
Adult Health and Illness Nursing program
at the University of Pennsylvania.
While at Penn, I served as the student
representative to the graduate curriculum
committee and, as such, was invited to attend
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a 2-day retreat to revise the master’s program.
I distinctly remember listening in amazement
to Dr. Jacqueline Fawcett as she spoke about
health, environments, persons, and nursing;
she claimed that these four concepts were
the “stuff” that truly comprised nursing. I
was hearing someone put voice to the inner
stirrings I had kept to myself back in Massa-
chusetts. It really impressed me that there were
nurses who studied in such arenas. Shortly
after the retreat, I received my MSN and
was hired at Penn on a temporary basis to
teach undergraduate medical-surgical nursing.
I immediately enrolled as a postmaster’s stu-
dent in Dr. Fawcett’s new course on the con-
ceptual basis of nursing. It proved to be one
of the best decisions I ever made, primarily
because it helped me to figure out an answer
to the constant question, “Why doesn’t a smart
girl like you enter medicine?” I finally knew
that it was because nursing, a discipline that I
was now starting to understand from an expe-
riential, personal, and academic point of view,
was more suited to my beliefs about serving
people who were moving through the transi-
tions of illness and wellness. It is safe to say
that I was beginning to understand that my
“gifts” lay not in the diagnosis and treatment
of illness, but in the ability to understand and
provide care to people as they lived through
transitions of health, illness, and healing.
Doctoral Studies
Such insights made me want more; hence, I
applied for doctoral studies and was accepted
into the graduate program at the University
of Colorado. My area of study, psychosocial
nursing, emphasized such concepts as loss,
stress, coping, caring, transactions, and per-
son-environment fit. Having been supported
by a National Institute of Mental Health
traineeship, one requirement of our program
was a hands-on experience with the process of
undergoing a health promotion activity. Our
faculty offered us the opportunity to carry out
the requirement by enrolling ourselves in some
type of support or behavior-change program of
our own choosing. Four weeks into the same
semester in which I was required to complete
that exercise, my first son was born. I decided
to enroll in a cesarean birth support group as a
way to deal with the class assignment and the
unexpected circumstances surrounding his
birth. It so happened that an obstetrician had
been invited to speak to the group about
miscarriage at the first meeting I ever attended.
I found his lecture informative with regard
to the incidence, diagnosis, prognosis, and
medical management of spontaneous abortion.
However, when the physician sat down and
the women began to talk about their personal
experiences with miscarriage and other forms
of pregnancy loss, I was suddenly overwhelmed
with the realization that there had been a
one-in-five chance that I could have miscarried
my son. Up until that point, it had never oc-
curred to me that anything could have gone
wrong with something so central to my life. I
was 29 years old and believed, quite naively,
that anything was possible if you were only
willing to work hard at it.
Two profound insights came to me from
that meeting. First, I was acutely aware of the
American Nurses’ Association (ANA) Social
Policy Statement, that “[n]ursing is the diag-
nosis and treatment of human responses to
actual and potential health problems” (ANA,
1980, p. 9). It was clear to me that whereas the
physician had talked about the health problem
of spontaneously aborting; the women were
living the human response to miscarrying.
Second, being in my last semester of course
work, I was desperately in need of a disserta-
tion topic. From that point on, it became clear
to me that I wanted to understand what it
was like to miscarry. The problem, of course,
was that I was a critical care nurse and knew
little about anything related to childbearing.
An additional concern was that during the
early 1980s, there was a strong emphasis on
epistemology, ontology, and the methodolo-
gies to support multiple ways of understanding
nursing as a human science; however, our
methods courses were traditionally quantita-
tive. Luckily, two mentors came my way.
Dr. Jody Glittenberg, a nurse anthropologist,
agreed to guide me through a predissertation
pilot study of five women’s experiences with
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miscarriage in order that I might learn about
interpretive methods. Dr. Colleen Conway-
Welch, a midwife, agreed to supervise my trek
up the psychology-of-pregnancy learning curve.
Evolution of a Middle-Range
Theory of Caring
Twenty women who had miscarried within
16 weeks of being interviewed agreed to partic-
ipate in my phenomenological study of miscar-
riage and caring. These results have been
published in greater depth elsewhere (Swanson,
1991; Swanson-Kauffman, 1985, 1986b).
Through that investigation, I proposed that
caring consisted of five basic processes:
• Knowing
• Being with
• Doing for
• Enabling
• Maintaining belief
At that time, the definitions were fairly
awkward and definitely tied to the context of
miscarriage. In addition to naming those five
categories, I also learned some important
things about studying caring:
1. If you directly ask people to describe what
caring means to them, you force them to
speak so abstractly that it is hard to find
any substance.
2. If you ask people to list behaviors or words
that indicate that others care, you end up
with a laundry list of “niceties.”
3. If you ask people for detailed descriptions
of what it was like for them to go through
an event (i.e., miscarrying) and probe for
their feelings and what the responses of
others meant to them, it is much easier to
unearth instances of people’s caring and
noncaring responses.
4. Although my intentions were to gather
data, many of my informants thanked me
for what I did for them.
As it turned out, a side effect of gathering
detailed accounts of the informants’ experi-
ences was that women felt heard, understood,
and attended-to in a nonjudgmental fashion.
In later years, this insight would become the
grist for a series of caring-based intervention
studies.
I have often been asked if my research
was an application of Jean Watson’s theory
of human caring (Watson, 1979/1985,
1985/1988). Neither Dr. Watson nor I have
ever seen my research program as an applica-
tion of her work per se, but we do agree that
the compatibility of our scholarship lends
credence to both of our claims about the nature
of caring. I have come to view her work as
having provided a research tradition that other
scientists and I have followed. Watson’s
research tradition asserts the following:
1. Caring is a central concept and way of
relating.
2. Multiple methodologies are essential to
understanding caring as a concept and way
of relating.
3. It is important to study caring so that it
may be better understood, consciously
claimed, and intentionally acted upon to
promote, maintain, and restore health and
healing.
Refining the Theory Through Research
Postdoctoral Studies
Approximately 9 months after I completed the
dissertation, my second son was born. He
had a difficult start in life and spent a few days
in the newborn intensive care unit (NICU).
Through this event, I became aware that in my
experience of childbearing loss (having a not-
well child at birth), I, too, wished to receive the
kinds of caring responses that my miscarriage
informants had described. Hence, my next
study, an individually awarded National Re-
search Service Award postdoctoral fellowship
(1985-1987), was inspired. With the mentor-
ship of Dr. Kathryn Barnard, at the University
of Washington, I spent over a year “hanging
out” in the NICU at the University of
Washington Medical Center (the staff gave me
permission to acknowledge them and their
practice site when discussing these findings).
The question I answered through the NICU
phenomenological investigation was “What is
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it like to be a provider of care to vulnerable
infants?” In addition to my observational data,
I did in-depth interviews with some of the
mothers, fathers, physicians, nurses, and other
health-care professionals who were responsible
for the care of five infants. The results of
this investigation are published elsewhere
(Swanson, 1990). With respect to understanding
caring, there were three main findings:
1. Although the names of the caring categories
were retained, they were grammatically
edited and somewhat refined so as to be
more generic.
2. It was evident that care in a complex context
called upon providers to simultaneously
balance caring (for self and other), attaching
(to people and roles), managing responsibili-
ties (self-, other-, and society-assigned),
and avoiding bad outcomes (for self, other,
and society).
3. What complicated everything was that each
NICU provider (parent or professional)
knew only a portion of the whole story
surrounding the care of any one infant.
Hence, there existed a strong potential
for conflict stemming from misunderstand-
ing others and second-guessing one
another’s motives. In many ways, this study
foreshadowed much of the current emphasis
in health care regarding communication,
transparency, protecting the patient experi-
ence, and sustaining safety through avoid-
ance of actions that result in bad outcomes.
While I was presenting the findings of the
NICU study to a group of neonatologists, I
received an interesting comment. One young
physician told me that it was the caring and
attaching parts of his vocation that brought
him into medicine, yet he was primarily eval-
uated on and made accountable for the aspects
of his job that dealt with managing responsi-
bilities and avoiding bad outcomes. Such a
schism in his role-performance expectations
and evaluations had forced him to hold the
caring and attaching parts of doing his job
unexpressed. Unfortunately, it was his experi-
ence that those more person-centered aspects
of his role could not be “stuffed” for too long
and that they often came hauntingly into his
consciousness at 3 a.m. His remarks left me
to wonder if the true origin of burnout is the
failure of professions and care delivery systems
to adequately value, monitor, and reward prac-
titioners whose comprehensive care embraces
caring, attaching, managing responsibilities, and
avoiding bad outcomes.
Caring for Socially At-Risk Mothers
While I was still a postdoctoral scholar,
Dr. Barnard invited me to present my research
on caring to a group of five master’s-prepared
public health nurses. They became quite
excited and claimed that the early draft of the
caring model captured what it had been like
for them to care for a group of socially at-risk
new mothers. About 4 years before our meet-
ing, these five advanced practice nurses had
participated in Dr. Barnard’s Clinical Nursing
Models Project (Barnard et al., 1988). They
had provided care to 68 socially at-risk expec-
tant mothers for approximately 18 months
(from shortly after conception until their
babies were 12 months old). The purpose of
the intervention had been to help the mothers
take care of themselves and control of their
lives so that they could ultimately take care of
their babies. As I listened to these nurses
endorsing the relevance of the caring model to
their practice, I began to wonder what the
mothers would have to say about the nurses.
Would the mothers (1) remember the nurses
and (2) describe the nurses as caring?
I was able to locate 8 of the original
68 mothers. They agreed to participate in a
study of what it had been like to receive an in-
tensive long-term advanced practice nursing
intervention. The result of this phenomeno-
logical inquiry was that the caring categories
were further refined and a definition of caring
was finally derived.
Hence, as a result of the miscarriage, NICU,
and high-risk mothers studies, I began to call the
caring model a middle-range theory of caring. I
define caring as a “nurturing way of relating to
a valued ‘other’ toward whom one feels a
personal sense of commitment and responsibil-
ity” (Swanson, 1991, p. 162). Knowing, striving
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to understand an event as it has meaning in the
life of the other, involves avoiding assumptions,
focusing on the one cared for, seeking cues,
assessing thoroughly, and engaging the self of
both the one caring and the one cared for. Being
with means being emotionally present to the
other. It includes being there, conveying avail-
ability, and sharing feelings while not burdening
the one cared for. Doing for means doing for the
other what he or she would do for himself or
herself if it were at all possible. The therapeutic
acts of doing for include anticipating needs,
comforting, performing competently and skill-
fully, and protecting the other while preserving
his or her dignity. Enabling means facilitating
the other’s passage through life transitions
and unfamiliar events. It involves focusing on the
event, informing, explaining, supporting, allow-
ing and validating feelings, generating alterna-
tives, thinking things through, and giving
feedback. The last caring category is maintaining
belief, which means sustaining faith in the other’s
capacity to get through an event or transition
and face a future with meaning. This means
believing in the other and holding him or her in
esteem, maintaining a hope-filled attitude, offer-
ing realistic optimism, helping find meaning,
and going the distance or standing by the one
cared for, no matter how his or her situation may
unfold (Swanson, 1991, 1993, 1999b, 1999c).
Developing and Testing
Theory-Guided Practice
Applications
As my postdoctoral studies were coming to an
end, Dr. Barnard challenged me and claimed,
“I think you’ve described caring long enough.
It’s time you did something with it!” We
discussed how data-gathering interviews
were often perceived by study participants as
caring. Together we realized that, at the very
least, open-ended interviews involved aspects
of knowing, being with, and maintaining belief.
We suspected that if doing-for and enabling
interventions specifically focused on common
human responses to health conditions were
added, it would be possible to transform the
techniques of phenomenological data gathering
into a caring intervention. That conversation
ultimately led to my design of a caring-based
counseling intervention for women who
miscarried.
Soon, I was writing a proposal for a Solomon
four-group randomized experimental design
(Swanson, 1999b, 1999c). It was funded by the
National Institute of Nursing Research and the
University of Washington Center for Women’s
Health Research. The primary purpose of
the study was to examine the effects of three
1-hour-long, caring-based counseling sessions
on the integration of loss (miscarriage impact)
and women’s emotional well-being (moods and
self-esteem) in the first year after miscarrying.
Additional aims of the study were (1) to exam-
ine the effects of early versus delayed measure-
ment and the passage of time on women’s
healing in the first year after loss and (2) to
develop strategies to monitor caring as the
intervention/process variable.
An assumption of the caring theory
was that the recipient’s well-being should be
enhanced by receipt of caring from a provider
informed about common human responses to
a designated health problem (Swanson, 1993).
Specifically, it was proposed that if women
were guided through in-depth discussion of
their experience and felt understood, informed,
provided for, validated, and believed in, they
would be better prepared to integrate miscar-
rying into their lives. The content for the three
counseling sessions was derived from the
miscarriage model, a phenomenologically
derived model that summarized the common
human responses to miscarriage (Swanson,
1999c; Swanson-Kauffman, 1983, 1985,
1986a, 1986b, 1988).
Women were randomly assigned to two
levels of treatment (caring-based counseling
and controls) and two levels of measurement
(early = completion of outcome measures
immediately, 6 weeks, 4 months, and 1 year
postloss; or delayed = completion of outcome
measures at 4 months and 1 year only). Coun-
seling took place at 1, 5, and 11 weeks postloss.
Analysis of variance was used to analyze
treatment effects. Outcome measures included
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self-esteem (Rosenberg, 1965), overall emo-
tional disturbance, anger, depression, anxiety,
and confusion (McNair, Lorr, & Droppleman,
1981) and overall miscarriage impact, personal
significance, devastating event, lost baby, and
feeling of isolation (investigator-developed
Impact of Miscarriage Scale).
A more detailed report of these findings is
published elsewhere (Swanson, 1999b). There
were 242 women enrolled, 185 of whom com-
pleted. Participants were within 5 weeks of loss
at enrollment: 89% were partnered, 77% were
employed, and 94% were Caucasian. Over
1 year, outcomes were as follows: (1) caring
was effective in reducing overall emotional dis-
turbance, anger, and depression and (2) with
the passage of time, women attributed less
personal significance to miscarrying and real-
ized increased self-esteem and decreased
anxiety, depression, anger, and confusion.
In summary, the Miscarriage Caring Proj-
ect provided evidence that, although time
had a healing effect on women after miscar-
rying, caring did make a difference in the
amount of anger, depression, and overall
disturbed moods that women experienced
after miscarriage. This study was unique in
that it employed a clinical research model to
determine whether or not caring made a dif-
ference. I believe that its greatest strength
lies in the fact that the intervention was
based both on an empirically derived under-
standing of what it is like to miscarry and on
a conscientious attempt to enact caring in
counseling women through their loss. The
greatest limitation of that study is that I
derived the caring theory (developed from
the intervention) and conducted most of the
counseling sessions. Hence, it is unknown
whether similar results would be derived
under different circumstances. My work is
further limited by the lack of diversity in my
research participants. Over the years, I have
predominantly worked with middle-class,
married, educated, Caucasian women. I,
as well as others, must make a concerted
effort to examine what it is like for diverse
groups of men and women to experience
both miscarriage and caring.
Monitoring caring as an intervention variable
was the second specific aim of the Miscarriage
Caring Project. Three strategies were used to
document that, as claimed, caring had occurred.
First, approximately 10% of the intervention
sessions were transcribed. Analysis was done by
research associate Katherine Klaich, RN, PhD.
As one of the counselors in the study, she found
she could not approach analysis of the transcripts
naively—that is, with no preconceived notions,
as would be expected in the conduct of phenom-
enologic analysis. Hence, she employed both
deductive and inductive content analytic tech-
niques to render the transcribed counseling
sessions meaningful. She began with the broad
question, “Is there evidence of caring as defined
by Swanson [1991] on the part of the nurse
counselors?” The unit of analysis was each emic
phrase that was used by the nurse counselor.
Phrases were coded for which (if any) of the five
caring processes were represented by the emic
utterances. Each counselor statement was then
further coded for which subcategory of the five
processes was represented by the phrase.
Twenty-nine subcategories of the five major
processes were defined. With few exceptions
(social chitchat), every therapeutic utterance of
the nurse counselor could be accounted for by
one of the subcategories.
The second way in which caring was mon-
itored was through the completion of paper-
and-pencil measures. Before each session,
the counselor completed a Profile of Mood
States (McNair et al., 1981) to document her
presession moods (thus enabling examination
of the association between counselor preses-
sion mood and self or client postsession
ratings of caring). After each session, women
were asked to complete Caring Professional
Scale (Swanson, 2002). Having been left alone
to complete the measure, women were asked
to place the evaluations in a sealed envelope.
In the meantime, in another room, the coun-
selor wrote out her counseling notes and
completed the Counselor Rating Scale, a brief
five-item rating of how well the session went.
The Caring Professional Scale originally
consisted of 18 items on a 5-point Likert-type
scale. It was developed through the Miscarriage
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Caring Project and was completed by partici-
pants in order to rate the nurse counselors who
conducted the intervention and to evaluate the
nurses, physicians, or midwives who took care
of the women at the time of their miscarriage.
The items included the following: “Was the
health-care provider that just took care of
you understanding, informative, aware of your
feelings, centered on you?” The response set
ranged from 1 (yes, definitely) to 5 (not at all).
The items were derived from the caring theory.
Three negatively worded items (abrupt, emo-
tionally distant, and insulting) were dropped
due to minimal variability across all of the data
sets. For the counselors at 1, 5, and 11 weeks
postloss, Cronbach alphas were .80, .95, and
.90 (sample sizes for the counselor reliability
estimates were 80, 87, and 76). The lower reli-
ability estimates were because the counselors’
caring professional scores were consistently
high and lacked variability (mean item scores
ranged from 4.52 to 5.0).
Noteworthy findings include the following:
1. Each counselor had a full range of presession
feelings, and those feelings/moods were, as
might be expected, highly intercorrelated.
2. For the most part, counselor presession
mood was not associated with postsession
evaluations.
3. The caring professional scores were ex-
tremely high for both counselors, indicat-
ing that, overall, the clients were pleased
with what they received and, as claimed,
caring was “delivered” and “received.”
4. One of the counselors was a psychiatric
nurse by background. She knew little about
miscarriage before participating in this study
and had recently experienced a death in her
family. The only time her presession moods
(in this case, depression and confusion) were
significantly associated (p ≤ .05) with any of
the postsession ratings (both client caring
professional score and counselor self-rating)
was in Session I. During Session I, women
discussed in-depth what the actual events of
miscarrying felt like. It is possible that the
counselor was so touched by and caught up
in the sadness of the stories that her own
vulnerabilities were a bit less veiled.
5. Session II, in which the two topics
addressed were relationship oriented
(who the woman could share her loss with
and what it felt like to go out in public as a
woman who had miscarried), was the only
session in which the other counselor’s
vulnerabilities came through. This coun-
selor had just gone through a divorce.
Her postsession self-evaluation was signifi-
cantly associated with her presession
moods: depression (p ≤ .05) and low vigor,
confusion, fatigue, and tension (all at
p ≤ .01). Also, most notably, there was
an association between this counselor’s
presession tension and clients’ postsession
Caring Professional scores (p ≤ .05).
Clarifying Caring Through
Literary Meta-analysis
I also conducted an in-depth review of the
literature. This literary meta-analysis is pub-
lished elsewhere (Swanson, 1999a). Approxi-
mately 130 data-based publications on caring
were reviewed for that state-of-the-science
paper. Through it I developed a framework for
discourse about caring knowledge in nursing.
Proposed were five domains (or levels) of
knowledge about caring in nursing. I believe
that these domains are hierarchical and that
studies conducted at any one domain (e.g.,
Level III) assume the presence of all previous
domains (e.g., Levels I and II). The first do-
main includes descriptions of the capacities or
characteristics of caring persons. Level II deals
with the concerns and/or commitments that
lead to caring actions. These are the values
nurses hold that lead them to practice in a car-
ing manner. Level III describes the conditions
(nurse, patient, and organizational factors)
that enhance or diminish the likelihood of
caring occurring. Level IV summarizes caring
actions. This summary consisted of two parts.
In the first part, a meta-analysis of 18 quanti-
tative studies of caring actions was performed.
It was demonstrated that the top five caring
behaviors valued by patients were that the
nurse (1) helps the patient to feel confident
that adequate care was provided, (2) knows
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how to give shots and manage equipment,
(3) gets to know the patient as a person,
(4) treats the patient with respect, and (5) puts
the patient first, no matter what. By contrast,
the top five caring behaviors valued by nurses
were (1) listens to the patient, (2) allows ex-
pression of feelings, (3) touches when com-
forting is needed, (4) perceives the patient’s
needs, and (5) realizes the patient knows him-
or herself best. The second part of the caring
actions summary was a review of 67 interpre-
tive studies of how caring is expressed (the
total number of participants was 2314). These
qualitative studies were fully able to be classi-
fied under Swanson’s caring processes. The
last domain was labeled “consequences.” These
are the intentional and unintentional out-
comes of caring and noncaring for patient and
provider. In summary, this literary meta-
analysis clarified what “caring” means, as the
term is used in nursing, and validated the
generalizability or transferability of Swanson’s
caring theory beyond the perinatal contexts
from which it was originally derived.
From Theory and Research
Back to Practice
In 2004, I was honored to be named a Robert
Wood Johnson Foundation (RWJF) Executive
Nurse Fellow. When I wrote the application, I
set the goal to “leave the comfort of academia”
and to make myself learn more about the world
of nursing practice. I realized that if my work
on caring was going to have relevance to nurs-
ing I needed to understand better what it was
like to practice as a nurse in today’s health-care
environment. I was delighted that Susan Grant
(at that time Vice President for Patient Care at
the University of Washington Medical Center)
agreed to mentor me. My personal mantra was
that I wanted to “help create the conditions
that enable nurses to work in accordance with
their core values of caring, healing, and keeping
their patients safe.” The journey I took as an
executive nurse fellow was extremely rewarding
and, at the same time, daunting. The world
of health care is undergoing rapid change.
The vocabulary, pace, politics, technologies,
locations, and challenges of health care are
changing at warp speed. I learned that in the
healthiest practice settings caring must take
place at the organizational level and at the point
of care. Institutional caring practices take the
form of continuous quality improvements that
strive to achieve the Institute of Medicine’s
(2001) call for health care that is delivered in a
safe, efficient, effective, timely, equitable, and
patient-centered manner. Providers experience
the rewards of knowing their work matters
when they practice in organizations that are
driven to constantly enhance safe, effective,
and compassionate care for patients, families,
and employees. As a result of lessons learned
through the RWJF fellowship, I now routinely
consult with health-care facilities where the
mission is to create and sustain a culture of
caring.
As It Progresses: Caring
and Healing
The Journey Continues: The Couple’s
Miscarriage Project
In 2009, we completed a National Institutes of
Health/National Institute of Nursing Research-
funded randomized controlled trial of the effec-
tiveness of three caring-based interventions
against a control condition in enhancing the
resolution of grief and depression for men
and women during the first year after miscar-
riage. This study included four treatment arms:
nurse caring (three nurse counseling sessions),
self-caring (three home-delivered videotapes and
journals), combined caring (one nurse counsel-
ing plus three videotapes and journals), and no
intervention (control). All intervention materials
were developed based on the Miscarriage Model
and the Swanson Caring Theory. We enrolled
and randomized 341 couples. Intervention find-
ings are reported in depth elsewhere (Swanson,
Chen, Graham, Wojnar, & Petras, 2009) and
briefly summarized here. We learned that
whereas resolution of women’s grief was en-
hanced through any of our three caring-based
interventions, resolution of men’s grief was only
helped by the combined and nurse-caring inter-
ventions. Women’s depression resolved faster
CHAPTER 31 • Kristen Swanson’s Theory of Caring 529
3312_Ch31_521-532 26/12/14 3:51 PM Page 529
when they received the nurse caring interven-
tion. Men’s depression was not affected by
receipt of three counseling sessions (there was
no significant difference from the control group)
and appeared to be slowed by receipt of the com-
bined caring or self-caring interventions (their
resolution of depression took longer than the
control group). Additional research needs to be
done to identify who is most likely to experience
depression during the first year after miscarriage
so that the right intervention may be offered.
The Connection Between Caring
and Healing
It is hard to believe that the caring model was
first proposed almost 30 years ago. There
are now scientists, practitioners, and educa-
tors around the world who are applying the
caring theory in their work. Reflecting back
on the work we did to understand how
couples evaluated our caring interventions,
considering the lessons learned through
consulting with nurses and other providers
seeking to change the culture of care, and in-
tegrating the writings and findings of others
who have explored the caring processes and
their impact, I now propose that there are
some logical links between the caring
processes and healing outcomes. Using the
language of provider to mean the one who is
practicing caring and recipient to mean the
one who is receiving caring, I offer the
following model (Fig. 31-1) and thoughts
about the connections between the caring
processes and experiences of healing.
When providers strive to understand the
recipient’s experience (e.g., knowing), the re-
cipient has the feeling of not only being under-
stood but, possibly, also understanding their
own experiences more fully. When the provider
is able to be with the recipient through times
of sorrow, frustration, suffering, and joy, the
recipient feels valued by the provider and
perceives that they and their experiences matter
to the provider. When the provider seeks to
do for the recipient what he or she would do
independently if they had the knowledge, time,
energy, capacity, or skills to do so, the recipient
feels safe and comforted. When the provider
enables the other’s capacity to manage a situa-
tion by providing information, validation, and
support, the recipient feels capable to get
through the challenge before them. Lastly,
and at the very core of caring, when the
provider maintains belief in the other’s capacity
to come through an event or transition and
face a future with meaning, the recipient feels
hopeful (as opposed to hopeless). This hope does
not mean that sickness, sorrow, fear, or loss will
not unfold as it must; rather, it is hope that
the recipient will be able to get through the
situation and find meaning and purpose in
whatever comes next. In summary, when a
provider takes the time to know, be with, do for,
enable, and maintain belief in the other, the
recipient feels a sense of wholeness - that is
they feel understood, valued, safe and comforted,
capable, and hopeful for the future. I believe
caring and healing is possible whenever a
provider acts with the recipient’s best interests
530 SECTION VI • Middle-Range Theories
Maintaing belief
Safe and
comforted
Understood
Knowing
Doing for Enabling
Being with
Valued
Hopeful
Capable
Fig 31 • 1 Swanson theory of
caring and healing. (Copyright ©
Kristen N. Swanson, 2013.)
3312_Ch31_521-532 26/12/14 3:51 PM Page 530
in mind. Caring can be enacted at the bedside,
in the community, in the boardroom, or in the
legislature. The measure of caring’s worth is
determined by whether it leads to the recipient
feeling seen and intact (or enhanced) versus
diminished and dismissed.
CHAPTER 31 • Kristen Swanson’s Theory of Caring 531
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3312_Ch31_521-532 26/12/14 3:51 PM Page 532
culture. See Theory of Culture Care Diversity and
Universality
Duffy’s model of. See Quality Caring Model
in Hall’s model of nursing, 59f, 60
in Human-to-Human Relationship Model, 76–77
Leininger’s theory of. See Theory of Culture Care
Diversity and Universality
Locsin’s theory of. See Technological Competency as
Caring
in Nightingale’s work, 49
Smith’s theory of. See Theory of Unitary Caring
Swanson’s theory of. See Theory of Caring
Watson’s theory of. See Theory of Human Caring
Caring Professional Scale, 527–528
Caring Science as Sacred Science (Watson), 322
Caritas nursing, 322, 323–324
Change, 12–13
transition triggers, 364f, 365–366, 372–373
Choice points, in Theory of Health as Expanding
Consciousness, 288–290, 289f, 290f
Christian feminist, 47
Client, 5
Client-nurse encounter, 5. See also Dynamic Nurse-
Patient Relationship Theory; Nurse-
patient/client relationship; Nurse-Patient
Relationship Theory
Clinical Nursing: A Helping Art (Wiedenbach), 61–62
Collaborative care, 312–313
Collected Works of Florence Nightingale, 37, 49
Comfort Theory, 382–390
application of, 385–389
best policy in, 385, 388–389
best practices in, 385, 388
care plans in, 385
coaching in, 385
Comfort Contract in, 392
comfort definition in, 384
comfort interventions in, 384
concepts of, 383–384, 384f
contexts in, 382
ease in, 382
electronic data base in, 388–389
health care needs in, 384–385
health-seeking behaviors in, 384–385
institutional advocacy in, 386–387
institutional awards in, 387
institutional integrity in, 385
intention in, 386
intervening variables in, 384
nursing practice in, 386, 388
practice exemplar of, 389–390
relief in, 382
A
Adaptation
Johnson Behavioral System Model, 91–92
Roy model of. See Roy Adaptation Model
Adaptive potential, in Modeling and Role-Modeling
theory, 191–192, 192f
Administration
Johnson Behavioral System Model application to,
99–100
Neuman Systems Model application to, 176
Aesthetic knowing, 29, 214–215
Affiliation, 190–191
Aging
in Theory of Accelerating Evolution, 240–241
in Theory of Goal Attainment, 142
American Holistic Nurses Association, 210
Anger, in morbid grief, 194
Anti-coagulants, 45
Arousal, stress-related, 192, 192f
Assessing and Measuring Caring in Nursing and Health
Sciences (Watson), 322
Attending Caring Team, 334–337
Attending Nurse Caring Model, 332–334
Awareness
in nursing theory selection, 28
in Quality Caring Model, 398
in Theory of Health as Expanding Consciousness, 283
B
Barrett, Elizabeth Ann Manhart, 497–498. See also Theory
of Power as Knowing Participation in Change
Barry, Charlotte D., 435–436. See also Community
Nursing Practice Model
Basic Principles of Nursing Care (Henderson), 62
Bearing witness, 223
Behavioral System Model. See Johnson Behavioral
System Model
Beliefs, 6, 24. See also Values
Bentov, Itzhak, 281, 282, 284
Boykin, Anne, 341–342. See also Nursing as Caring
Theory
Bureaucracy, 466–468. See also Theory of Bureaucratic
Caring
C
Care, Cure, and Core Model, 59–61, 59f
practice application of, 63
Care/caring, 5
Boykin and Schoenhofer’s theory of. See Nursing as
Caring Theory
bureaucratic. See Theory of Bureaucratic Caring
Index
Note: Page numbers followed by f refer to figures; page numbers followed by t refer to tables; page numbers followed by
b refer to boxes.
533
3312_Index_533-544 26/12/14 11:04 AM Page 533
D
Death
grieving response to, 192–194, 194t
in Theory of Integral Nursing, 222
Debriefing, 369
Developmental processes
in Modeling and Role-Modeling theory, 194–195,
195t
in Theory of Integral Nursing, 211, 217–218, 220f
Disease, origin of, 45
Dissipative structures, theory of, 288, 289f
Diversity of Human Field Pattern Scale, 251
Domain, 4–5
Dossey, Barbara, 207–208. See also Theory of Integral
Nursing
Dream Experience Scale, 251
Drives, 189–190, 190t
Duffy, Joanne, 393–394. See also Quality Caring Model
Dying
conscious, 222
in Theory of Integral Nursing, 222
Dynamic Nurse-Patient Relationship: Function, Process and
Principles, The (Orlando), 82
Dynamic Nurse-Patient Relationship Theory, 82
practice applications of, 82–84
E
Education, 6
Community Nursing Practice Model, 441–442
of Florence Nightingale, 38–39
Humanbecoming Paradigm and, 273
Johnson Behavioral System Model and, 99
Neuman Systems Model and, 175–176
on nurse-patient relationship, 69
Nursing as Caring Theory and, 350
theory-guided nursing practice and, 33
Theory of Bureaucratic Caring and, 477
Theory of Culture Care Diversity and Universality
and, 313
Theory of Goal Attainment and, 140
Theory of Human Caring and, 335
Theory of Integral Nursing and, 225
Transitions Theory and, 371
Emancipation, of women, 47
Emancipatory knowing, 29–30
Empathy, in Human-to-Human Relationship Model,
78
Energyspirit, 244
Environment, 5
Community Nursing Practice Model, 438
Johnson Behavioral System Model, 93, 95–96
Modeling and Role-Modeling Theory, 189–191
Neuman Systems Model, 171–172, 171f
Nightingale model, 45–46
Quality Caring Model, 439
Roy Adaptation Model, 158
Theory of Integral Nursing, 213–214, 213f, 220f, 224
Epigenesis, in Modeling and Role-Modeling theory,
195
taxonomic structure of, 382–383, 383f
technical interventions in, 385
transcendence in, 382
value-added outcomes in, 386
wow moments in, 386
Comfort Theory and Practice (Kolcaba), 381
Communication
integral, 224
nonverbal, 198
nursing discipline, 6
Community
Community Nursing Practice Model, 437–438,
439
Humanbecoming Paradigm, 271–273
Self-Care Deficit Theory, 117
Theory of Health as Expanding Consciousness,
294–295
Community Nursing Practice Model, 436–446
application of, 441–442, 442t–445t
community in, 437–438, 439
core services in, 439, 440
development of, 436
in education, 441–442
environment in, 438
evaluation and, 440
first circle services in, 439, 440
foundations of, 436
nursing in, 437
person in, 437, 439
policy development and, 439–440
practice exemplar of, 445
second circle services in, 439–440
services in, 438–440, 439f
third circle services in, 440
Compassion, 223
Complexity theory, 468–469
Concept development, 135–136
Conceptual models, 13
analysis of, 31
evaluation of, 31
Conceptual structures, of nursing discipline, 5–6
Conscious dying, 222
Consciousness. See Theory of Health as Expanding
Consciousness
Contagionism, 45
Couple’s Miscarriage Project, 529–530
Creating a Caring Science Curriculum: Emancipatory
Pedagogies (Hills and Watson), 322
Crimean War, 40–44, 41f, 43f
Critical points, 368
Cultural feminism, 47
Culture. See also Theory of Culture Care Diversity and
Universality
nursing theory and, 15–16
organization, 466–468
in Theory of Goal Attainment, 141
in Theory of Health as Expanding Consciousness,
291
Curiosity, 20
534 Index
3312_Index_533-544 26/12/14 11:04 AM Page 534
Index 535
Neuman Systems Model, 172
Roy Adaptation Model, 158–159
Theory of Goal Attainment, 143
Theory of Integral Nursing, 213, 213f, 220f, 224
Health Goal Attainment instrument, 139
Health patterning, 500–501
modalities, 501–503
Henderson, Virginia, 56
basic nursing care components of, 58–59, 63–64
nursing definition of, 58–59, 62–63
Hierarchy, 92
Holistic person, in Modeling and Role-Modeling
theory, 190–191, 197
Home, family, 46–48
Homeorrhesis, 91
Homo pandimensionalis, 244
Honesty, 20
Hope, 77
Humanbecoming Paradigm, 264–274
art of, 269–273
change in, 268
community settings of, 271–273
eighty/twenty (80/20) model of, 272
language in, 268
in nursing education, 285
nursing in, 264–265
nursing practice in, 270, 271–273
parish nursing in, 272–273
philosophical assumptions of, 266–267
postulates of, 267–268
principles of, 267–268
reality construction in, 268
relating in, 268
research in, 268–269
resources on, 273
true presence in, 269–270
Human Becoming School of Thought, The (Parse), 266
Human Field Image Metaphor Scale, 252
Human Field Motion Test, 251
Human-to-Human Relationship Model, 76–79
practice applications of, 79
Humanuniverse, 266
Hygiene, Nightingale on, 47
Hypnotherapeutic techniques, 198
I
Imagination, 4
Impoverishment, stress-related, 192, 192f
Individuation, 190–191
Instincts, 189–190, 190t
Integral Nursing. See Theory of Integral Nursing
Intention
Comfort Theory, 386
Nursing as Caring Theory, 343
Technological Competency as Caring, 455–456
Theory of Integral Nursing, 211, 224
Theory of Unitary Caring, 511, 515
Intentional dialogue, in Story Theory, 424
Intentionality, in Science of Unitary Human Beings, 244
Equanimity, 223
Equilibrium, 192, 192f
Erickson, Helen, 185–186. See also Modeling and
Role-Modeling Theory
Ethical knowing, 29
Ethnonursing, 304. See also Theory of Culture Care
Diversity and Universality
Evidence-based practice, 144
F
Family Health Theory, 139
Feminism
cultural, 47
in Nightingale’s caring, 46–48
in Transitions Theory, 363
Fermentation, 45
Florence Nightingale Today: Healing, Leadership, Global
Action (ANA), 37
Four-quadrants perspective, 215–220, 215f, 216f, 220f
collective exterior (“Its”), 216f, 217, 219, 220f, 224
collective interior (“We”), 216f, 217, 219, 220f,
222–224
individual exterior (“It”), 216f, 217, 219, 220f, 224
individual interior (“I”), 216, 216f, 219, 220f, 222
Functional performance mechanisms, 485–486, 486f
G
General System Theory, 134
Generating Middle Range Theory: Evidence for Practice
(Roy), 154
Geotranscendance change, 486f, 489–491
Goal attainment. See Theory of Goal Attainment
Goal Attainment Scale, 137
Grand theories, 13
analysis of, 31
evaluation of, 31
interactive-integrative. See Johnson Behavioral System
Model; Modeling and Role-Modeling Theory;
Neuman Systems Model; Roy Adaptation
Model; Self-Care Deficit Theory; Theory of Goal
Attainment; Theory of Integral Nursing
unitary-transformative. See Paradigm Science of
Unitary Human Beings; Theory of Health as
Expanding
Grieving response, 192–194, 193f, 194t
Growth needs, 192
H
Hall, Lydia, 56–57. See also Care, Cure, and Core Model
Healing
Quality Caring Model, 399
Science of Unitary Human Beings, 243
Theory of Caring, 530–531, 530f
Theory of Human Caring, 328
Theory of Integral Nursing, 212, 212f, 213f, 221
Health, 5
Johnson Behavioral System Model, 96–97
Modeling and Role-Modeling theory, 191
3312_Index_533-544 26/12/14 11:04 AM Page 535
K
King, Imogene M., 133–134. See also Theory of Goal
Attainment
Knowing, 29
aesthetic, 29, 214–215, 214f
emancipatory, 29
empirical, 214, 214f
ethical, 29, 214f, 215
paranormal, 241–242
personal, 29, 214, 214f
sociopolitical, 214f, 215
Technological Competency as Caring, 450–457,
454f
Theory of Integral Nursing, 214–215, 214f, 220,
220f
Knowledge, structure of, 11–14
Kolcaba, Katherine, 381–382. See also Comfort Theory
Kuhn, Thomas , 12
L
Language, 6
grammatical persons of, 215–216
Legitimate nursing, 108, 114
Leininger, Madeleine, 303–304. See also Theory of
Culture Care Diversity and Universality
Liehr, Patricia, 423. See also Story Theory
Life orientation, need satisfaction and, 194
Listening, deep, 223
Literature, 6. See also Research
meta-analysis of, 528–529
Living a Caring-based Program (Boykin), 341
Locsin, Rozzano C., 449–450. See also Technological
Competency as Caring
Loeb Center for Nursing and Rehabilitation, 63
M
Man-Living-Health: A Theory of Nursing (Parse), 266
Marriage, 46
Meaning, 222–224
grasping of, 248
in Nursing as Caring Theory, 344–346
philosophical, 222
psychological, 222
in Quality Caring Model, 401
spiritual, 222
in Theory of Health as Expanding Consciousness,
286–288
Medical model, 25
Meeting the Realities in Clinical Teaching (Wiedenbach),
57
Meleis, Afaf I., 50, 361–362. See also Transitions
Theory
Metaparadigm, 5
in Theory of Integral Nursing, 213–214, 213f
Middle-range theories, 13, 31–32, 138. See also Comfort
Theory; Community Nursing Practice Model;
Quality Caring Model; Story Theory;
Technological Competency as Caring; Theory of
Bureaucratic Caring; Theory of Caring; Theory of
Interactive-integrative paradigm, 12
Interdisciplinary practice, 20
International Caritas Consortium, 330
International Research on Caritas as Healing (Nelson and
Watson), 322
Interpersonal Relations in Nursing (Peplau), 67
Interpretation, in Human-to-Human Relationship
Model, 78
Intervention in Psychiatric Nursing (Travelbee), 78
Interventions
Comfort Theory, 385–386
Johnson Behavioral System Model, 97–98
Modeling and Role-Modeling theory, 186, 187t
Neuman Systems Model, 173–174
Theory of Health as Expanding Consciousness,
292
Transitions Theory, 364f, 367–369, 377
Intrapsychic factors, 486
Intuition, 190, 224
J
Johnson, Dorothy, 89–90. See also Johnson Behavioral
System Model
Johnson Behavioral System Model, 90–98
achievement subsystem in, 93t
action in, 95
in administration, 99–100
affiliative subsystem in, 93t
aggressive/protective subsystem in, 93t
applications of, 98–102
behavioral set in, 95
choice in, 95
concepts of, 92–98
conceptual set in, 95
core principles of, 90–92
dependency subsystem in, 93t
diagnostic classifications in, 97
dialectical contradiction principle of, 92
in education, 99
eliminative subsystem in, 93t
environment in, 95–96
functional requirements in, 95
goal in, 95
health in, 96–97
hierarchic interaction principle of, 92
imbalance and instability in, 96
ingestive subsystem in, 94t
nursing interventions in, 97–98
nursing process in, 97–98
person in, 92, 94
practice exemplar of, 100–102
reorganization principle of, 91–92
research on, 98–99, 99b
restorative system in, 94t
set point in, 91
sexual system in, 94t
stabilization principle of, 91
subsystems in, 94–95, 108t–109t
wholeness and order principle of, 90–91
Justice-making, 38
536 Index
3312_Index_533-544 26/12/14 11:04 AM Page 536
Index 537
concepts of, 167
created environment in, 172
in education, 175–176
environment in, 171–172, 171f
flexible line of defense in, 168f, 169, 169f, 171f
health in, 172
lines of resistance in, 168f, 169–170, 169f, 171f
normal line of defense in, 168f, 169, 169f, 171f
nursing process in, 172–174, 173f
practice applications of, 174–175, 178–179
practice exemplar of, 179–181
prevention intervention in, 173–174
spirituality in, 170–171
website for, 179
Newman, Margaret, 279–281. See also Theory of Health
as Expanding Consciousness
NICU study, 524–525
Nightingale, Florence, 37–53, 38f, 44f
assumptions of, 50
biographies of, 37
Crimean War nursing of, 40–44, 41f, 43f
early life of, 38–39
education of, 38–39, 44–45
feminist context of, 46–48
medical milieu of, 44–46
nurse definition for, 51
nursing definition for, 4, 51, 52f
nursing ideas of, 48–52
nursing’s goal for, 50–51
patient for, 51
spirituality of, 39–40, 43
Theory of Integral Nursing and, 209
travel by, 39
21st century legacy of, 52–53
Non-nursing functions, 62
Notes on Nursing: What It Is and What It Is Not
(Nightingale), 4, 38, 46, 49
Not knowing, 214f, 215
Nurse-patient/client relationship. See also Nurse-Patient
Relationship Theory
Nursing as Caring Theory, 344
Orlando’s theory of, 82–84
Quality Caring Model, 397–399, 397f
Theory of Goal Attainment, 140
Theory of Health as Expanding Consciousness,
290–292
Theory of Human Caring, 326–327
Travelbee’s theory of, 76–79
Nurse-Patient Relationship Theory, 67–74
communication skills in, 70
components of, 69
listening skills in, 69–70
orientation phase of, 70–71
phases of, 70–71
practice exemplar on, 73–74
research on, 71–72
resolution phase of, 71
self-awareness in, 69
supervisory education for, 69
working phase of, 71
Power as Knowing Participation in Change;
Theory of Self-Transcendence; Theory of
Successful Aging; Theory of Unitary Caring;
Transitions Theory
analysis of, 31
development of, 138
evaluation of, 31–32
Mindfulness, 222
Miscarriage Caring Project, 526–528
Modeling and Role-Modeling Theory, 186–204
adaptive potential in, 191–192, 192f
data collection in, 187, 188t
data interpretation in, 197–198
data processing in, 197–198
developmental processes in, 194–195, 195t
drives in, 189–190, 190t
environment in, 189–191
epigenesis in, 195
health in, 191
human needs in, 192–194, 193f
hypnotherapeutic techniques in, 198
instincts in, 189–190, 190t
intervention aims and goals in, 186, 187t
modeling process in, 187, 188t
nursing in, 191
person in, 189–191, 190t, 197
philosophical assumptions in, 188–191
practice applications of, 198–201, 199t–201t
practice exemplars of, 202–204
proactive nursing care in, 198
role-modeling process in, 187–188
sequential development in, 195
social justice in, 191
theoretical constructs in, 191–196, 192f, 193f
theoretical linkages in, 195–196
theoretical propositions in, 187–188, 188t
trusting-functional relationship in, 190, 196–197,
196t
Morbid grief, 194
N
Narrative. See Story Theory
Narrative means to sober ends (Diamond), 423
Narrative Medicine: The Use of History and Story in the
Healing Process (Mehl-Madrona), 423
Nature of Nursing, The (Henderson), 62
Needs
Comfort Theory, 384–385
growth, 192
life orientation and, 194
Modeling and Role-Modeling theory, 192–194, 193f
Quality Caring Model, 399–400
Neuman, Betty, 165–166. See also Neuman Systems
Model
Neuman Systems Model, 166–181, 168f
in administration, 176
archive for, 179
client-client system in, 168f, 169–171, 169f
client variables in, 169f, 170–171
3312_Index_533-544 26/12/14 11:04 AM Page 537
middle-range theories in, 13, 31–32, 138
paradigms of, 11–13
practice-level theories in, 13–14
relationship in, 5
structure of knowledge in, 11–14
symbols of, 6
syntactical structures of, 6
tradition of, 6
values and beliefs of, 6
Nursing education. See Education
Nursing Knowledge Development and Clinical Practice
(Roy), 154
Nursing practice. See also Practice applications; Practice
exemplar
Humanbecoming School of Thought, 270, 271–273
Johnson Behavioral System Model, 99–100
Nursing as Caring Theory, 347–349
Science of Unitary Human Beings, 244–249
scope of, 20
theory-guided, 7–9, 14, 23–25, 32–33
administrative support for, 32
education for, 33
feedback for, 33
practice evaluation for, 33
practice implementation for, 32
theory selection for, 32
Theory of Bureaucratic Caring, 464–468, 473–475
Theory of Integral Nursing, 221–224
Theory of Power as Knowing Participation in Change,
500–503
Transitions Theory, 370–371
Nursing process
Johnson Behavioral System Model, 97–98
Neuman Systems Model, 172–174, 173f
Roy Adaptation Model, 160
Self-Care Deficit Theory, 114–116, 116f
Technological Competency as Caring, 453–454
Theory of Goal Attainment, 139–140
Nursing science, evolution of, 9–11
Nursing theory, 3–16. See also specific theories and models
communication of, 6
complexity and, 472–474
conceptual structure and, 6
contextual development of, 21
culture and, 15–16
definitions of, 6–7
domain of, 4–5
education and, 6
evaluation of, 19–22, 25–27, 30–32
criteria for, 30
frameworks for, 31–32
guidelines for, 31
questions for, 21–22, 25–27, 31–32
functional components of, 31
future development of, 14–16
grand. See Grand Theories
imagination and, 4
implementation of, 32–33
language and symbols of, 6
middle-range. See Middle-Range theories
Nurse Performance Goal Attainment, 139
Nurse presence
Humanbecoming Paradigm, 269–270
Nursing as Caring Theory, 344
Theory of Health as Expanding Consciousness,
285–286
Theory of Integral Nursing, 222
Nursing, 5. See also Nursing discipline; Nursing theory
and specific nursing theories
caring in, 5
in Community Nursing Practice Model, 437
genderization of, 47–48
Hall’s conceptualization of, 59–61, 59f
Henderson’s definition of, 58–59, 62–63
in Humanbecoming Paradigm, 264–265
legitimate, 108, 114
in Modeling and Role-Modeling theory, 191
Nightingale’s definition of, 4, 51
Peplau’s definition of, 69
relationship in, 5
in Self-Care Deficit Theory, 115–116
task-based, 3–4
Wiedenbach’s conceptualization of, 57–58
Nursing: Concepts of Practice (Orem), 107
Nursing: Human Science and Human Care (Watson), 321
Nursing: The Philosophy and Science of Caring, Revised
New Edition (Watson), 322
Nursing agency, 108, 116–117
Nursing and Anthropology (Leininger), 304
Nursing as Caring: A Model for Transforming Practice
(Boykin and Schoenhofer), 341, 343
Nursing as Caring Theory, 342–355
in administration, 349–350
applications of, 347–351
assumptions of, 343–347
call for nursing in, 344, 346
caring in, 343
in education, 350
historical perspective on, 342–343
intention in, 343
lived meaning in, 344–346
nurse-client relationship in, 344
nursing focus in, 343
nursing practice in, 347–349
nursing response in, 344
nursing situation in, 343–344
person in, 344, 346
practice exemplar of, 351–355
research in, 351
Nursing discipline, 4–6. See also Nursing theory and
specific nursing theories
communication networks of, 6
conceptual models in, 13
conceptual structures of, 6
domain of, 4–5
education of, 6
grand theories in, 13. See also Grand Theories
imagination in, 4
language of, 6
literature of, 6
538 Index
3312_Index_533-544 26/12/14 11:04 AM Page 538
Index 539
Power as Knowing Participation in Change Tool, 251,
495, 498–499. See also Theory of Power as
Knowing Participation in Change
Power-imaginary process, 503
Power Prescriptions, 503
Practice, 5. See also Nursing practice; Practice
applications; Practice exemplar
Practice applications. See also Practice exemplar;
Research
Care, Cure, and Core Model, 63
Comfort Theory, 385–389
Community Nursing Practice Model, 441–442
Dynamic Nurse-Patient Relationship Theory, 82–84
Henderson’s conceptualization of nursing, 62–63
Human-to-Human Relationship Model, 79
Modeling and Role-Modeling Theory, 198–201,
199t–201t
Neuman Systems Model, 174–175, 178–179
Nurse-Patient Relationship Model, 71–73
Prescriptive Theory, 61–62, 61f
Roy Adaptation Model, 160
Science of Unitary Human Beings, 242–255
Self-Care Deficit Theory, 118–125, 119t–122t
Technological Competency as Caring, 458
Theory of Bureaucratic Caring, 472–475
Theory of Caring, 526–528
Theory of Culture Care Diversity and Universality,
313–315
Theory of Goal Attainment, 138–144
Theory of Health as Expanding Consciousness,
292–295
Theory of Human Caring, 329–332
Theory of Integral Nursing, 225
Theory of Power as Knowing Participation in Change,
499–503
Theory of Self-transcendence, 414–415
Theory of Successful Aging, 491
Theory of Unitary Caring, 515–516
Transitions Theory, 369–371
Wiedenbach’s conception of nursing, 61–62, 61f
Practice exemplar
Care, Cure, and Core Model, 64–65
Comfort Theory, 389–390
Community Nursing Practice Model, 445
Dynamic Nurse-Patient Relationship Theory, 84–85
Henderson’s conceptualization of nursing, 63–64
Human-to-Human Relationship Model Theory,
80–81
Johnson Behavioral System Model, 100–102
Modeling and Role-Modeling theory, 202–204
Neuman Systems Model, 179–181
Nurse-Patient Relationship Theory, 73–74
Nursing as Caring Theory, 351–355
Quality Caring Model, 403–407
Roy Adaptation Model, 160–163
Science of Unitary Human Beings, 270–271
Self-Care Deficit Theory, 126–129
Story Theory, 427–431, 430t
Technological Competency as Caring, 459
Theory of Bureaucratic Caring, 475–477
nursing conceptualization in, 21
practice and, 7–9, 14, 23–24. See also Nursing practice;
Practice applications; Practice exemplar
practice-level, 13–14
purpose of, 7–9
questions for, 21–22
research and, 8. See also Research
selection of, 23–33
evaluation and, 30–32
implementation and, 32–33
practice and, 24–25
questions about, 25–27
reflective exercise for, 28–30
significance of, 22, 24–25
sources for, 21–22
structural components of, 31
study guide for, 19–22
syntactical structure and, 6
tradition and, 6
values and beliefs and, 6
O
Object attachment, 192–194, 193f
Observation, in Human-to-Human Relationship
Model, 78
Occupations, for women, 47, 48
Ordered to Care: The Dilemma of American Nursing
(Reverby), 46
Orem, Dorothea E., 105–106. See also Self-Care Deficit
Theory
Organization-disorganization paradigm, 12
Orlando, Ida Jean, 82. See also Dynamic Nurse-Patient
Relationship Theory
P
Paradigm, 11–13
Paranormal phenomena, 241–242
Parker, Marilyn E., 437. See also Community Nursing
Practice Model
Parse, Rosemarie Rizzo, 263–264. See also
Humanbecoming Paradigm
Particulate-deterministic paradigm, 12
Peplau, Hildegard, 67–69. See also Nurse-Patient
Relationship Theory
Person, 5
Community Nursing Practice Model, 437, 439
Humanbecoming Paradigm, 270–271
Johnson Behavioral System Model, 92, 94
Modeling and Role-Modeling theory, 189–191, 190t,
197
Nursing as Caring Theory, 344, 346
Self-Care Deficit Theory, 108
Technological Competency as Caring, 450–451,
454f
Theory of Integral Nursing, 213, 213f, 220f,
222–224
Personal control, 487–488
Personal knowing, 29
Postmodern Nursing and Beyond (Watson), 321–322
3312_Index_533-544 26/12/14 11:04 AM Page 539
Quality Caring Model, 397–399, 397f
Theory of Human Caring, 326–327
Theory of Integral Nursing, 220–221
Religion, 223. See also Spirituality
Research. See also Practice applications
Humanbecoming Paradigm, 268–269
Johnson Behavioral System Model, 98–99, 99b
Neuman Systems Model, 176–178, 178–179
nurse-patient relationship, 71–72
Nursing as Caring Theory, 351
Science of Unitary Human Beings, 242–255, 249–255
Syrian Muslim ethnonursing, 314–315
Technological Competency as Caring, 458f
theory-based, 8
Theory of Culture Care Diversity and Universality,
310–313, 311f, 314
Theory of Goal Attainment, 141–143
Theory of Health as Expanding Consciousness,
291–295
Theory of Integral Nursing, 225
Theory of Power as Knowing Participation in Change,
499–500
Theory of Self-transcendence, 414–415
traditions of, 14
Transitions Theory, 369–370
Rhythmical Correlates of Change, 242
Rogers, Martha E., 237–238, 281–282, 283. See also
Science of Unitary Human Beings
Role modeling. See Modeling and Role-Modeling Theory
Roy, Sister Callista, 153–154. See also Roy Adaptation
Model
Roy Adaptation Model, 154–163
assumptions of, 155, 156t
cognator-regulator processes in, 156
concepts of, 155–159
environment in, 158
health in, 158–159
historical development of, 154–155
interdependence mode in, 157, 158
modes in, 157–158
nursing process in, 160
people in, 155–158
physiologic-physical mode in, 157
practice applications of, 160
practice exemplar of, 160–163
role function mode in, 157, 158
self-concept-group identity mode in, 157–158
stabilizer-innovator processes in, 156
Theory of Successful Aging and, 484–485
Roy Adaptation Model, The (Roy), 154
Roy Adaptation Model-based Research: Twenty-five Years
of Contributions to Nursing Science, 154
S
Schoenhofer, Savina, 342. See also Nursing as Caring
Theory
Science, evolution of nursing as a, 9–11
Science of Unitary Human Beings, 238–258
applications of, 242–255
Barrett’s practice method and, 245
Theory of Culture Care Diversity and Universality,
315–316
Theory of Goal Attainment, 145–147
Theory of Health as Expanding Consciousness,
295–297
Theory of Human Caring, 332–337
Theory of Integral Nursing, 226–230
Theory of Power as Knowing Participation in Change,
504–507
Theory of Self-transcendence, 416–417
Theory of Successful Aging, 491–492
Theory of Unitary Caring, 516–518
Transitions Theory, 371–378
Unitary Pattern-Based Praxis method, 255–258
Wiedenbach’s conceptualization of nursing, 63
Prescriptive theory, 57–58, 61–62
practice applications of, 61–62, 61f
Prevention in Neuman Systems Model, 173–174, 173f
Prigogine, Ilya, 288, 289f
Q
Qualitative Research Methods in Nursing (Leininger), 304
Quality Caring Model, 394–407
affiliation needs in, 399–400
applications of, 400–403
assumptions of, 396–397
attentive reassurance in, 399
caring factors in, 399–400
caring relationships in, 397–399, 397f
collaborative relationships in, 398, 400
concepts of, 396
development of, 394–3957, 395f
encouraging manner in, 399
feeling cared for emotion in, 397, 400
healing environment in, 399
human needs in, 400
institutional use of, 407
meaning in, 399
mutual problem-solving in, 399
nurse’s role in, 397
practice exemplar of, 403–407
propositions of, 396
relationship-centered professional encounters in, 396
self-caring in, 396
Quarantine, 45
Queen Victoria, 48
R
Rapport, in Human-to-Human Relationship Model, 78
Ray, Marilyn Anne, 461–462. See also Theory of
Bureaucratic Caring
Reaction paradigm, 12
Reciprocal interaction paradigm, 12
Reed, Pamela, 411–412. See also Theory of Self-
transcendence
Relationship, 5. See also Nurse-Patient Relationship Theory
Hall’s model of nursing, 60–61
Modeling and Role-Modeling Theory, 189–191,
196–197, 196t
540 Index
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Index 541
Self-care knowledge, 190
Self-care resources, 190
Self-Care Theory in Nursing: Selected Papers of Dorothea
Orem, 106
Simultaneity paradigm, 12
Simultaneous action paradigm, 12
Skills, 25
Smith, Marlaine C., 511–512. See also Theory of Unitary
Caring
Smith, Mary Jane, 421. See also Story Theory
Social justice, in Modeling and Role-Modeling theory,
191
Spinsterhood, 46, 48
Spirituality
Florence Nightingale, 39–40, 43
Modeling and Role-Modeling theory, 191
Neuman Systems Model, 170–171
Reed’s studies of, 413. See also Theory of Self-
transcendence
Science of Unitary Human Beings, 244
Theory of Integral Nursing, 223
Theory of Successful Aging, 486f, 488–489
Standardized nursing languages, 139–140
Story. See also Story Theory
in Modeling and Role-Modeling theory, 196t, 197
Story path, 425–426, 425f
Story Theory, 421–431
assumptions of, 423
concepts of, 423, 423f
ease in, 426
emergence of, 422–423
foundations of, 423–424, 423f
intentional dialogue in, 424
practice exemplar of, 427–431, 430t
self-in-relation in, 424–426, 425f
story path in, 425–426, 425f
Stress response, in Modeling and Role-Modeling
theory, 191–192, 192f
Study guide, 19–22
Suffering, 77
in Theory of Integral Nursing, 222–224
Suggestions for Thought (Nightingale), 43
Sunrise enabler, in Theory of Culture Care Diversity and
Universality, 310–312, 311f
Swain, Mary Ann, 186. See also Modeling and Role-
Modeling Theory
Swanson, Kristen M., 521–522. See also Theory of
Caring
Sympathy, in Human-to-Human Relationship Model,
78
Syntactical structures, of nursing discipline, 5–6
Syrian Muslims, ethnonursing study of, 314–315
T
Technological Competency as Caring, 450–459
applications of, 458
calls for nursing in, 457–458
change in, 458
continuous knowing in, 455–456
definition of, 450
Butcher’s practice method and, 245–249
Cowling’s practice constituents and, 245
energy fields in, 238–239
healing in, 243
helicy in, 240
homeodynamics in, 239–240
integrality in, 240
intentionality in, 244
nursing practice and, 243b
openness in, 239
pandimensionality in, 239
pattern in, 239
postulates of, 238–239
practice exemplar of, 270–271
practice methods and, 244–249
research applications of, 249–255
resonancy in, 240
spirituality in, 244
theories from, 240–242
Theory of Accelerating Evolution from, 240–241
Theory of Emergence of Paranormal Phenomena
from, 241–242
Theory of Rhythmical Correlates of Change from, 242
therapeutic touch in, 243, 244
Unitary Pattern-Based Praxis method and, 245–249
website for, 243b
worldview of, 238
Self-care, 190
integral, 222
for nurse, 221
Self-Care Deficit Theory, 107–130
agent in, 109
basic conditioning factors in, 109–110, 109f
caregiver in, 109
community groups in, 117
concepts of, 109
deliberate action in, 111
dependent-care theory in, 107–108
developmental self-care requisites in, 113
estimative capabilities in, 111–112
family in, 117
foundational capabilities and dispositions in, 111
health deviation self-care requisites in, 113
multiperson situations and units in, 117
nursing agency in, 108, 116–117
nursing system definition in, 114–116, 116f
nursing systems theory in, 108–109
power components in, 111
practice applications of, 118–125, 119t–122t
practice exemplar of, 126–129
productive operation capabilities in, 111–112
self-care agency in, 111, 111f
self-care deficit theory in, 107
self-care definition in, 110–111
self-care requisites in, 112–113
self-management in, 125
structure of, 109f
therapeutic self-care demand in, 112
transitional capabilities in, 111–112
universal self-care requisites in, 112–113
3312_Index_533-544 26/12/14 11:04 AM Page 541
goal of, 309
health in, 310
in nurse education, 313
orientational definitions in, 309–310
practice applications of, 313–315
practice exemplar of, 315–316
professional care in, 307, 309
purpose of, 308
rationale for, 306
research in, 310–313, 311f, 314
sunrise enabler in, 310–312, 311f
Syrian Muslim ethnonursing research in, 314–315
theoretical assumptions of, 308–310
theoretical tenets of, 306–308
worldview in, 307, 310
Theory of Dependent Care, 107–108
Theory of Dissipative Structures, 288, 289f
Theory of Emergence of Paranormal Phenomena,
241–242
Theory of Goal Attainment, 133–147
conceptual framework of, 135–136, 135f
documentation system in, 137
Goal Attainment Scale in, 137
multicultural applications of, 141
nursing process in, 139–140
philosophical foundation of, 134
practice applications of, 138–144
client perspective and, 143
in client systems, 140, 142–143
with clients across life span, 142
evidence-based, 144
in multicultural settings, 141
in multidisciplinary settings, 140–141
recommendations for, 144
in work settings, 143–144
practice exemplar of, 145–147
research applications of, 141–143
standardized nursing languages in, 139–140
transaction process model in, 136–137, 136f
Theory of Group Power within Organizations, 139
Theory of Health as Expanding Consciousness
applications of, 284–291
assumptions underlying, 282
community-level application of, 294–295
consciousness stages in, 290f
cross-culture relevance of, 291
development of, 282–284
disruption-related choice points in, 288–290, 289f,
290f
expanding consciousness in, 284–285
focusing process in, 291–292
insights in, 288–290, 289f
levels of awareness in, 283
meaning in, 286–288
nurse-client interaction in, 290–292
nurse-family interaction in, 291–292
nursing practice and, 292–295
pattern in, 286–288, 292
philosophical influences on, 281–282
future research in, 458f
intention in, 455–456
knowing persons in, 450–457, 454f
nursing process in, 453–454
nursing response in, 457–458
practice exemplar of, 459
purpose of, 450
situation of care in, 452–457
technological knowing in, 457, 457f
trust in, 452, 453
wholeness ideal in, 453
Temporal Experience Scale, 252
Textbook of the Principles and Practice of Nursing
(Henderson), 58, 62
Theoretical Nursing: Development and Progress (Meleis),
362
Theory. See Nursing theory and specific nursing theories
Theory for Nursing: Systems, Concepts, Process, A (King),
133
Theory of Accelerating Evolution, 240–241
Theory of Bureaucratic Caring, 462–477
application of, 472–475
caring in, 468
description of, 469–470
development of, 468–472
generation of, 462–463, 463f
holographic emergence in, 463–464, 463f
as holographic theory, 470–472
leadership models in, 467–468
in nursing education, 475
nursing practice in, 464–468, 473–475
organizational cultures in, 466–468
organizational transformation in, 470–472
practice exemplar of, 475–477
Theory of Caring, 521–531, 530f
at-risk mothers study and, 525–526
caring knowledge in, 528–529
Caring Professional Scale in, 527–528
Couple’s Miscarriage Project study and, 529–530
evolution of, 524
healing, connection to, 530–531, 530f
literature meta-analysis in, 528–529
Miscarriage Caring Project study and, 526–528
NICU study and, 524–525
practice applications of, 526–528
refinements of, 524–526
Theory of Culture Care Diversity and Universality,
304–317
care modalities in, 307–308
collaborative care in, 312–313
cultural care diversities in, 306–307
cultural commonalities in, 306–307
culture care accommodation/negotiation in, 307–308,
310
culture care preservation/maintenance in, 307–308, 310
culture care restructuring/repatterning in, 308
development of, 304–305
domain of inquiry in, 311–312
generic care in, 307, 309, 312
542 Index
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Index 543
structure of, 220, 220f
transpersonal dimension in, 223
Theory of Integral Nursing (Dossey), 225
Theory of Nursing Systems, 108–109. See also Self-Care
Deficit Theory
Theory of Power as Knowing Participation in Change,
495–507, 497f
applications of, 499–503
concepts of, 496–499
control, power as, 498
freedom, power as, 498, 504–507
practice exemplar of, 504–507
practice methodology for, 500–503
research on, 499–500
underlying basis of, 496
Theory of Rhythmical Correlates of Change, 242
Theory of Self-Care, 107. See also Self-Care Deficit
Theory
Theory of Self-transcendence, 412–418
applications of, 414–415
concepts of, 413–414, 414f
personal factors in, 416–417
practice exemplar of, 416–417
research in, 414–415
self-transcendence in, 413, 414f, 417
vulnerability in, 413, 414f
well-being in, 413–414, 414f
Theory of Successful Aging, 483–492, 486f
applications of, 491
creativity in, 486
development of, 483–485
functional performance mechanisms in, 485–486, 486f
geotranscendance and, 486f, 489–491
intrapsychic factors in, 486, 486f
model for, 486f
negative affect and, 487
personal control and, 487–488
positive affect and, 487
practice exemplar of, 491–492
Roy Adaptation Model and, 484–485
spirituality in, 486f, 488–489
Theory of Unitary Caring, 510–518
applications of, 515–516
appreciating pattern in, 511–512, 514–515
assumptions of, 511
caring concept in, 510
concepts of, 511–513
creative emergence in, 515
development of, 510–511
dynamic flow attunement in, 512, 515
empirical indicators in, 513–515
Infinity in, 512–513, 515
manifesting intentions in, 511, 514
practice exemplar of, 516–518
propositions of, 513
Therapeutic touch, 244
Tomlin, Evelyn, 186
Totality paradigm, 12
Touch, therapeutic, 244
practice exemplar of, 295–297
presence in, 285–286
research as praxis, 291–295
resonance in, 285–286
Toward a Theory of Health presentation and, 282
unitary-transformative paradigm in, 283–284
Theory of Human Caring, 322–337
Attending Nurse Caring Model and, 332–334
carative factors in, 323–324
caring (healing) consciousness in, 328
Caring Moment in, 326
caring occasion in, 328
Caring Science orientation in, 323
clinical caritas processes in, 324–325
conceptual elements of, 323
in customer service, 335–336
development of, 322–323
in education, 335
in hospitals, 331
implications of, 328–329
International Caritas Consortium and, 330
practice applications of, 329–332
practice exemplar of, 332–337
reading of, 325–326
transpersonal caring relationship in, 326–327
Watson Caring Science Institute and, 329–330
Theory of Integral Nursing, 208–230
application of, 225
AQAL (all quadrants, all levels) in, 217–220, 220f
communication in, 224
content components of, 212–220
context in, 220–221
development in, 211, 217–218, 220f
development of, 210
in education, 225
environment in, 213–214, 213f, 220f, 224
four-quadrants perspective in, 215–220, 215f, 216f,
220f, 222–224
in global health, 226
healing in, 212, 212f, 213f, 221
health in, 213, 213f, 220f, 224
integral dialogues in, 208–209
integral process in, 208
integral worldview in, 208
intentions of, 211, 224
meaning in, 222–224
metaparadigm in, 213–214, 213f
nurse in, 213, 213f, 220–221, 220f, 222
nursing practice and, 221–224
patterns of knowing in, 214–215, 214f, 220, 220f
person in, 213, 213f, 220f, 222–224
philosophical assumptions of, 211–212
philosophical foundation of, 208, 209
in policy guidance, 225–226
practice exemplar in, 226–230
questions in, 208
relationship-based care in, 220–221
relationship-centered case in, 220
research on, 225
3312_Index_533-544 26/12/14 11:04 AM Page 543
Trusting-functional relationship, 190–191
mind-set establishment for, 196, 196t
nurturing space creation for, 196–197, 196t
story facilitation for, 196t, 197
Turkel, Marian C., 464
U
Unitary field pattern portrait research method, 253–255,
254f
Unitary Pattern-Based Praxis method, 245–249
pattern manifestation knowing and appreciation in,
245–248
practice exemplar of, 255–258
voluntary mutual patterning in, 248–249
Unitary-transformative paradigm, 12
V
Values, 6, 24
Johnson Behavioral System Model, 97
Veritivity, 155
Visions of Rogers’ Science-Based Nursing (Barrett),
495–496
W
Watson, Jean, 321–322. See also Theory of Human
Caring
Ways of knowing, 29
Wholeness
Johnson Behavioral System Model, 90–91
Theory of Health as Expanding Consciousness,
285–286
Wiedenbach, Ernestine, 55–56
nursing conceptualizations of, 57–58
prescriptive theory of, 57–58, 61–62, 63
Wilber, Ken, 211
Women Founders of the Social Sciences, The (McDonald), 49
Towards a Theory for Nursing: General Concepts of Human
Behavior (King), 133
Tradition, 6
Transaction process model, 136–137, 136f
Transcultural nursing, 306. See also Theory of Culture
Care Diversity and Universality
Transcultural Nursing: Concepts, Theories, and Practices
(Leininger), 304
Transitional objects, 193
Transitions Theory, 362–378
applications of, 369–371
assumptions of, 363
change triggers, 364f, 365–366, 372–373
concepts of, 363–367, 365t
in education, 371
feminist postcolonialism and, 363
intervention within, 364f, 367–369, 377
lived experience and, 362–363
in nursing practice, 370–371
origins of, 362–363
practice exemplar of, 371–378
properties of transition, 364f, 365, 373–376
propositions of, 363–367
research involving, 369–370
responses, patterns of, 364f, 366–367, 368t,
376–377
role theory in, 362
situation-specific theories, development of, 371
triggers of transition, 363–366, 364f
Transparency, in Theory of Integral Nursing, 222
Transpersonal Caring Theory. See Theory of Human
Caring
Travelbee, Joyce, 76. See also Human-to-Human
Relationship Model
Troutman-Jordan, Meredith, 485. See also Theory of
Successful Aging
True presence, in Humanbecoming Paradigm, 269–270
544 Index
3312_Index_533-544 26/12/14 11:04 AM Page 544
Title Page
Copyright
Preface to the Fourth Edition
Nursing Theorists
Contributors
Reviewers
Contents
Section I An Introduction to Nursing Theory
Chapter 1 Nursing Theory and the Discipline of Nursing
Chapter 2 A Guide for the Study of Nursing Theories for Practice
Chapter 3 Choosing, Evaluating, and Implementing Nursing Theories for Practice
Section II Conceptual Influences on the Evolution of Nursing Theory
Chapter 5 Florence Nightingale’s Legacy of Caring and Its Applications
Chapter 5 Early Conceptualizations About Nursing
Chapter 6 Nurse–Patient Relationship Theories
Section III Conceptual Models/Grand Theories in the IntegrativeInteractive Paradigm
Chapter 7 Dorothy Johnson’s Behavioral System Model and Its Applications
Chapter 8 Dorothea Orem’s Self-Care Deficit Nursing Theory
Chapter 9 Imogene King’s Theory of Goal Attainment
Chapter 10 Sister Callista Roy’s Adaptation Model
Chapter 11 Betty Neuman’s Systems Model
Chapter 12 Helen Erickson, Evelyn Tomlin, and Mary Ann Swain’s Theory of Modeling and Role Modeling
Chapter 13 Barbara Dossey’s Theory of Integral Nursing
Section IV Conceptual Models and Grand Theories in the Unitary– Transformative Paradigm
Chapter 14 Martha E. Rogers Science of Unitary Human Beings
Chapter 15 Rosemarie Rizzo Parse’s Humanbecoming Paradigm
Chapter 16 Margaret Newman’s Theory of Health as Expanding Consciousness
Section V Grand Theories about Care or Caring
Chapter 17 Madeleine Leininger’s Theory of Culture Care Diversity and Universality
Chapter 18 Jean Watson's Theory of Human Caring
Chapter 19 Theory of Nursing as Caring
Section VI Middle-Range Theories
Chapter 20 Transitions Theory
Chapter 21 Katharine Kolcaba’s Comfort Theory
Chapter 22 Joanne Duffy’s Quality-Caring Model
Chapter 23 Pamela Reed’s Theory of Self-Transcendence
Chapter 24 Patricia Liehr and Mary Jane Smith’s Story Theory
Chapter 25 The Community Nursing Practice Model
Chapter 26 Rozzano Locsin’s Technological Competency as Caring in Nursing
Chapter 27 Marilyn Anne Ray’s Theory of Bureaucratic Caring
Chapter 28 Troutman-Jordan’s Theory of Successful Aging
Chapter 29 Barrett’s Theory of Power as Knowing Participation in Change
Chapter 30 Marlaine Smith’s Theory of Unitary Caring
Chapter 31 Kristen Swanson’s Theory of Caring
Index
Afaf Ibrahim Meleis, PhD, FAAN
Margaret Bond Simon Dean
Professor of Nursing and Sociology
University of Pennsylvania
School of Nursing
Philadelphia, Pennsylvania
THEORETICAL NURSING
Development and Progress
Fifth Edition
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Meleis, Afaf Ibrahim, author.
Theoretical nursing : development and progress / Afaf Ibrahim Meleis,
PhD, FAAN, Margaret Bond Simon Dean, Professor of Nursing and Sociology,
University of Pennsylvania, School of Nursing, Philadelphia,
Pennsylvania. — Fifth Edition.
p. ; cm.
Includes bibliographical references and indexes.
Summary: “An additional assumption was that the processes for theory development were new to nursing and
hence, nurses in graduate programs learned strategies for advancing knowledge from other disciplines. This
assumption was debunked with the knowledge that nurses were always engaged in knowledge development,
driven by their experiences in clinical practice. Because of these assumptions, most of the early writing about
theory development was about outlining strategies that should be used, rather than strategies that have already
been used in the discipline to develop theories. Theorists themselves did not uncover or adequately discuss ways
by which they developed their theories, therefore the tendency was to describe processes that were based on the-
ories developed in other disciplines, mainly the physical and social sciences. And an implicit assumption was
made that there should be a single strategy for theory development, some claiming to begin the process from
practice, and others believing it should be driven by research”—Provided by publisher.
ISBN 978-1-60547-211-9 (hardback : alk. paper) 1. Nursing—Philosophy. I. Title.
[DNLM: 1. Nursing Theory. WY 86]
RT84.5.M45 2011
610.7301—dc22
2010051628
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LWW.com
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In Memory of Soad Hussein Hassan, RN, PhD
A maverick—
for exemplifying humanism and commitment,
for encouraging feminism and autonomy,
for accepting challenge and diversity,
for tolerating rebellion,
for sponsoring inquisitiveness,
and for being my mother.
And
For teaching me about the courage
to face a life of challenges
and an end of life with Alzheimer’s.
LWBK821-FM_pi-xiv 1/8/11 1:30 AM Page iii
R E V I E W E R S
Patricia M. Burbank, RN, DNSc, MS
Professor
University of Rhode Island
Kingston, Rhode Island
J. Carolyn Graff, PhD, MN
Associate Professor
University of Tennessee Health Science Center
Memphis, Tennessee
Rebecca Otten, RN, EdD, MSN, BA Health
Administration
Assistant Professor
California State University — Fullerton
Fullerton, California
And
Mount St. Mary’s College
Los Angeles, California
Linda A. Streit, RN, DSN
Dean and Professor for the Graduate Program
Georgia Baptist College of Nursing of Mercer
University
Atlanta, Georgia
Cynthia Toman, RN, PhD, MScN, BScN
Assistant Professor
University of Ottawa
School of Nursing
Ottawa, Ontario, Canada
iv
LWBK821-FM_pi-xiv 1/8/11 1:30 AM Page iv
P R E F A C E
v
THROUGHOUT the many editions and revisions
of this book, I received a lot of feedback and
many responses about the ideas presented.
These arrived in writing, in person, in meet-
ings, and in e-mails. Many responses, from
many corners of the world, reflected a real
intellectual engagement in the book. Some
were inspired by our theoretical history, others
questioned our philosophical past, but most
thought the dialogues that evolved from dis-
cussing the ideas in the book reaffirmed their
identity in nursing and ignited their pride in
the profession and the discipline of nursing.
These comments, reviews, and suggestions for
revisions made me realize that the major role
of this book is empowering its readers. It has
given the readers a voice to engage, debate,
and to challenge sacred cows about how our
discipline evolved and ways by which we can
evaluate growth in the discipline.
The intent of this book, then, is to demys-
tify theory, to chart the different strategies to
use in developing and advancing theory, and to
provide tools and best practices in evaluating
progress in the discipline. It provides both an
open invitation to embark on a journey with-
out the many preconceived assumptions that
may have been a barrier to pursuing knowl-
edge development. Among these assumptions
were that a select few could engage in devel-
oping theory. Perhaps this is because, during
1950–1970, the construction of theory in nurs-
ing occupied only a select few members of
the discipline. The metatheoreticians and
their writings attracted another select group
of nurses, and they focused on suggestions
about formulating theories, defining types of
theories, and identifying sources for theories.
Subsequently, conceptualizing nursing phe-
nomena commanded the attention of a wider
circle of members of the discipline. Many
other assumptions shaped our history and
influenced our current progress in the disci-
pline. For example, there was the assumption
that a conceptual framework was essential for
advancing nursing knowledge. This assump-
tion changed as we entered the 21st century
because the discipline was better defined and
was replaced with another assumption: that
empirical knowledge and research programs
are the only means toward advancing knowl-
edge.
An additional assumption was that the
processes for theory development were new to
nursing and hence, nurses in graduate pro-
grams learned strategies for advancing knowl-
edge from other disciplines. This assumption
was debunked with the knowledge that nurses
were always engaged in knowledge develop-
ment, driven by their experiences in clinical
practice. Because of these assumptions, most
of the early writing about theory development
was about outlining strategies that should be
used, rather than strategies that have already
been used in the discipline to develop theories.
Theorists themselves did not uncover or ade-
quately discuss ways by which they developed
their theories, therefore the tendency was to
describe processes that were based on theories
developed in other disciplines, mainly the
physical and social sciences. And an implicit
assumption was made that there should be a
single strategy for theory development, some
claiming to begin the process from practice,
and others believing it should be driven by
research.
Another implicit assumption was that the-
ory development was an elitist activity, to be
engaged in only within the halls of academia.
Furthermore, it was assumed that what goes on
within the halls of academia had no resem-
blance to the clinical work that goes on in real
life. (Notice the many comments over the
years about nursing theory and the lack of cli-
nicians’ need for such theory.) Some believed
that nursing had always borrowed its theory
LWBK821-FM_pi-xiv 1/8/11 1:30 AM Page v
vi
and that nursing was an applied field. To them,
nursing practice theory was not needed
because theories from science and ethics were
enough to guide nursing. Therefore, theory
development was an unnecessary process.
Some critics did not consider that redevelop-
ment, resynthesis, and reintegration of find-
ings, ideas, and statistical wisdom were also
processes for knowledge development.
Different eras provided different sets of
assumptions. In many instances, biomedical
sciences dominated more than biopsychologi-
cal sciences. And, as educational programs in
nursing became more biologically and med-
ically based, theories that reflect the human
sciences tended to be neglected. Therefore,
major journals in nursing tended to capture
empirical evidence based on more medically
defined outcomes of mortality and morbidity
rates as compared to quality of life, levels of
functioning, perceived health status, adapta-
tion, and energy levels.
The reader of this book will find that it
includes many arguments that dispel many of
these preconceived assumptions and that:
• Nurses have a fine and useful theoretical
heritage that is worthy of analysis. By
understanding how and why our heritage
evolved as it did, we may be in a better
position to consciously and deliberately
drive the development of theoretical nursing
to meet the mission that we have articulated
about our discipline.
• There are sources and resources by which
nurses can conceptualize different aspects
of the nursing universe for the purpose of
facilitating understanding, increasing
autonomy in their actions, and enhancing
control over their domain. The ultimate
objective is to provide quality care utilizing
the different tools and strategies for theory
development. The reader will find support
that clinicians are as valuable in advancing
nursing knowledge as theoreticians because
they articulate their practical wisdom into
exemplars that may help to solve other clin-
ical problems.
• The scientific development of the discipline
of nursing has followed a unique path,
charted by members of the discipline to suit
its unique features and the context of its
nursing care complexities. The sociology
and the philosophy of nursing science are
legitimate and significant areas of investiga-
tion to discern the progress and develop-
ment of the discipline. As nurses questioned
the empiricist’s view of science and
embraced other more dynamic and chang-
ing conceptions of science, the behavior of
scientists and theoreticians, the processes of
selection of research and theories, the his-
torical environment, and the sociocultural
context for the development and utility of
the discipline’s theories become legitimate
and provide central questions for the
domain.
• And finally, our theoretical history, our
epistemology, and our domain are the bases
for our theoretical future. The novice should
be acquainted with them, the advanced
should explore and question the relation-
ships between the parts and, together with
the experienced, they should shape and
reshape nursing knowledge.
Demystifying theory and dispelling assump -
tions are essential but not sufficient conditions
for empowerment. The metaphors that describe
the current stage in theory development are
epistemic diversity and integrative process,
both of which are an acknowledgment and val-
uation of nursing history, heritage, and prac-
tice. Both of these metaphors reflect and accept
the central role of practice in advancing nurs-
ing knowledge and nurses’ ways of knowing
as vital in uncovering and developing knowl-
edge. Empowerment is also about believing
in one’s self, abilities, and capacities to
advance knowledge and about using these
capacities to become an agent for continuous
learning and creating. It is about being a criti-
cal thinker, an innovative advocate, and an
agent for change.
In this book, I present and provide sup-
port for our domain as we see it today. The
future progress of the discipline depends on
the extent to which members of the discipline
will embrace epistemic diversity and integra-
tive approaches to theory development, and
LWBK821-FM_pi-xiv 1/8/11 1:30 AM Page vi
vii
the extent to which evidence is translated,
utilized, and evaluated. The scholars of the
future are those who are as comfortable with
theorizing as with researching, practicing, and
teaching. They will be able to understand and
speak the languages of different disciplines,
translate their findings to the different practice
fields, and engage in changing policies.
In short, the major goals of this book are
to make a contribution to raising the con-
sciousness of the reader about the theoretical
development and progress of our discipline, to
acknowledge our theoretical history, to place
the present in the context of our history, and to
develop an awareness of the potential inherent
in members of the discipline, both men and
women. It is about the pride we must have in
the contributions our discipline makes to the
health and well-being of people.
I offer the ideas in this book as tentative
thoughts to provide an even platform to
enforce self-agency in students, faculty, clini-
cians, researchers, and theoreticians to drive
the development of new coherent frameworks
to advance nursing science. By knowing
equally, each may be empowered to leverage
their competency and use their expertise. A
democratization of the processes in developing
theory is an empowering process to you, the
reader, to believe in your own voice, to respect
and value the voices that came before you, but
to challenge and build on them.
Every time I work on a new edition, I feel
renewed, inspired, and regenerated. It has been
a privilege for me to be a nurse, and it is an
incredible privilege to write this book honoring
the past and envisioning the future. To readers
near and far, I thank you for dialoguing with the
ideas in this text. I truly value your responses
and comments, so keep sending them.
Afaf Ibrahim Meleis, PhD, FAAN
LWBK821-FM_pi-xiv 1/8/11 1:30 AM Page vii
LWBK821-FM_pi-xiv 1/8/11 1:30 AM Page viii
REVISING and updating this book and bringing
this 5th edition to you is a testament to my
unwavering passion about its subject matter, the
progress we made in advancing knowledge in
the discipline, and the incredible support this
project received from many people.
I am grateful to Lippincott Williams &
Wilkins’ project manager, Helen Kogut, who,
knowing my schedule and commitments,
planned ahead, monitored progress, provided
reminders, respected my work priorities, and
recognized that emergencies happen. Her
patience and encouragement made it possible
to complete and publish this 5th edition.
What made this project most pleasurable in
spite of its intensity and time commitment is the
partnership that I have developed with Maria
Marconi, who oversaw the typing and organiz-
ing, seeing it through beginning to end. Watch-
ing her enthusiasm and commitment to the
quality of the project, her excitement about
learning new skills, and her pride in the project
at the completion of each phase, added tremen-
dously to the pleasure we both derived in com-
pleting it. To her, I offer my heartfelt gratitude
for her commitment, and my admiration for her
professionalism, and for the quality of her work.
I also extend my deep appreciation to
members of the Dean’s Office, who allowed me
some time flexibility to devote to this project.
My responsibilities as the Dean were well man-
aged, and the many other projects in our agenda
were completed effectively, efficiently, and on
time. That I attribute to a highly functioning,
effective, productive, and committed team,
which includes Caroline Glickman and Lucia
DiNapoli, under the leadership of Ann Marie
Franco. I am indebted to them for their expert-
ise, caring, and wonderful sense of humor.
I continue to be inspired by how far our
discipline has progressed in spite of the many
barriers and obstacles its members faced due
to gender-, occupational-, and policy-driven
inequities. The resilience, the pride, and the
commitment of nurses globally are reflected in
the many mentees who challenged my thinking
while students or junior faculty, and later, as
established scholars, extended and expanded
my horizon. I am always awed by these
mentees from around the world who continue to
be in my life. They, along with the many stu-
dents and faculty who take the time to read
what I write, and whether to extend or argue
with it, continue to influence and shape the
ideas presented in each new edition. My profes-
sional, academic, and personal lives continue to
be deepened, renewed, and enriched by each
and every one of these interactions.
My partner in life, Dr. Mahmoud Meleis,
vacillates between taking pride in all that I do,
and wishing that I would slow down to enjoy
more together-time at this stage in our lives. In
spite of this time-commitment versus time-free
paradox, his support never wavers, his advice is
always authentic, his voice is always insightful,
and his dedication to our family is emulated by
our sons, Waleed and Sherief, who are now rais-
ing their own families. They all provide a foun-
dation of family support that is most inspiring.
I am indebted to all for your support.
A.I.M.
A C K N O W L E D G M E N T S
ix
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LWBK821-FM_pi-xiv 1/8/11 1:30 AM Page x
C O N T E N T S
xi
P a r t O N E
Our Theoretical Journey 1
CHAPTER 1
POSITIONING FOR THE JOURNEY 2
Our Theoretical Heritage 3
Assumption, Goals, and Organizations 3
Organization of The Book 4
On a Personal Note 6
Reflective Questions 6
CHAPTER 2
ON BEING AND BECOMING A
SCHOLAR 7
Scholarliness in Nursing 9
Nurses as Scholars 15
Revisiting Scholarship in the 21st Century 17
Conclusion 20
Reflective Questions 20
CHAPTER 3
THEORY: METAPHORS, SYMBOLS,
DEFINITIONS 23
The Destination: Theory and Theoretical
Thinking 23
Definitions 25
Types of Theories 33
Theory Components 35
Uses of Theory 35
Reflective Questions 37
P a r t T W O
Our Theoretical Heritage 39
CHAPTER 4
FROM CAN’T TO KANT: BARRIERS AND
FORCES TOWARD THEORETICAL
THINKING 40
Barriers to Theory Development 41
Resources to Theory Development 50
Conclusion 55
Reflective Questions 56
CHAPTER 5
ON THE WAY TO THEORETICAL
NURSING: STAGES AND
MILESTONES 59
Stages in Nursing Progress 59
Milestones in Theory Development 67
Conclusion 80
Reflective Questions 81
P a r t T H R E E
Our Discipline and Its
Structure 85
CHAPTER 6
THE DISCIPLINE OF NURSING:
PERSPECTIVE AND DOMAIN 87
Nursing Perspective 88
Domain of Nursing Knowledge 94
Definition of Nursing 106
Conclusion 108
Reflective Questions 108
CHAPTER 7
SOURCES, RESOURCES, AND
PARADOXES FOR THEORY 113
Spinoza on Knowledge
Development 113
Sources for Theory Development 114
Classifications of Nursing Diagnosis,
Nursing Interventions, and
Decision Making 120
Resources for Theory Development 122
Identifying Domain Paradoxes 124
Conceptual Models Versus Theory 125
Nursing Theory Versus Borrowed
Theory 128
Conclusion 132
Reflective Questions 133
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xii
CHAPTER 8
OUR SYNTAX: AN
EPISTEMOLOGICAL ANALYSIS 136
Knowing from the Received View
to Postmodernism View 136
Truth: From Correspondence to Integrative
View of Truth 150
Conclusion 155
Reflective Questions 155
P a r t F O U R
Reviewing and Evaluating:
Pioneering Theories 159
CHAPTER 9
NURSING THEORIES THROUGH
MIRRORS, MICROSCOPES, OR
TELESCOPES 160
Images of Nursing, 1950–1970 162
Theories’ Primary Focus 174
Images, Metaphors, and Roles 175
Areas of Agreement Among and
Between Theorists and Schools
of Thought 175
Conclusion 177
Reflective Questions 178
CHAPTER 10
A MODEL FOR EVALUATION OF
THEORIES: DESCRIPTION,
ANALYSIS, CRITIQUE, TESTING,
AND SUPPORT 179
Selecting Theories for Utilization 180
Framework for Evaluating Theories 185
Description 185
Analysis 189
Critique of Theory 194
Theory Testing 200
Theory Support 202
Conclusion 203
Reflective Questions 204
CHAPTER 11
ON NEEDS AND SELF-CARE 207
Dorothea Orem 207
Conclusion 224
Reflective Questions 224
CHAPTER 12
ON INTERACTIONS 229
Imogene King—A Theory of Goal
Attainment 229
Ida Orlando 241
Josephine Paterson and Loretta Zderad 251
Joyce Travelbee 258
Ernestine Wiedenbach 265
Conclusion 271
Reflective Questions 272
CHAPTER 13
ON OUTCOMES 279
Dorothy Johnson 280
Myra Levine 290
Betty Neuman 300
Martha Rogers 311
Sister Callista Roy 324
Conclusion 338
Reflective Questions 339
P a r t F I V E
Our Theoretical Future 353
CHAPTER 14
CHALLENGES AND OPPORTUNITIES
FOR A THEORETICAL FUTURE 354
Opportunities Within Paradoxes 355
Disciplinary or Interdisciplinary
Knowledge 355
Global or Local Theories 356
Marginalized or Privileged Populations 357
Technical Nursing or Expert Nursing
Practice 357
Nursing Informatics or Medical Informatics 358
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xiii
Taxonomies or Interpretations 359
Clinical, Conceptual, or Empirical Theorizing 361
Knowing Through Research and Knowing
Through Theory 362
Integration or Isolation of Theoretical
Discourses 365
Middle-Range or Situation-Specific
Theories 367
Conclusion 368
Reflective Questions 368
CHAPTER 15
CONCEPT DEVELOPMENT 371
Concept Exploration 372
Concept Clarification 374
Concept Analysis 376
An Integrated Approach to Concept
Development 380
Conclusion 387
Reflective Questions 388
CHAPTER 16
THEORY DEVELOPMENT 391
Theory Development: Existing Strategies 394
Theory to Practice to Theory Strategy 394
Practice to Theory Strategy 396
Research to Theory Strategy 398
Theory to Research to Theory Strategy 403
Conclusion 404
Reflective Questions 404
CHAPTER 17
MIDDLE-RANGE AND SITUATION-
SPECIFIC THEORIES 407
The Integrative Process for Developing
Middle-Range and Situation-Specific
Theories 407
Tools for Developing Middle-Range
or Situation-Specific Theories 409
Middle-Range Theories 410
Situation-Specific Theories 419
Conclusion 423
Reflective Questions 424
CHAPTER 18
MEASURING PROGRESS IN A
DISCIPLINE 427
A Theory of Revolution 428
A Theory of Evolution 431
A Theory of Integration 433
Conclusion 436
Reflective Questions 436
P a r t S I X
Our Historical Literature 439
CHAPTER 19
HISTORICAL WRITINGS IN
THEORY 440
Section I: Abstracts of Writings in
Metatheory, 1960–1984 440
Section II: Abstracts of Writings in Nursing
Theory, 1960–1984 469
Dorothy Johnson 469
Myra Levine 478
Dorothea Orem 482
Martha Rogers 489
Sister Callista Roy 494
Joyce Travelbee 501
CHAPTER 20
HISTORICAL AND CURRENT THEORY
BIBLIOGRAPHY 502
Theory and Theorizing in Nursing 503
Nursing Theory and Theorists 548
Paradigms That Have Influenced
Nursing 616
Middle-Range Theory 631
Situation-Specific Theory 632
Video and Audio Tapes on Theory 632
AUTHOR INDEX 637
SUBJECT INDEX 663
xiii
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LWBK821-FM_pi-xiv 1/8/11 1:30 AM Page xiv
Our Theoretical Journey
I INVITE you, in this first part of the book, to embark on a journey that will introduce
you to the rich theoretical underpinnings of our discipline. Uncovering the role that
theory plays in our daily experiences as nurses is the first step in the theoretical jour-
ney proposed in this book. In the three chapters in Part One, the theoretical journey,
along with its symbols and scholarly destinations, is described. In Chapter 1, you
will find assumptions on which the journey is planned, the organizational plan for
the journey, and some of the supporting material. Chapter 2 includes scholarly goals
and the different possible destinations for the journey. The context for the journey is
then set in Chapter 3, where the key definitions of theoretical symbols and terms
are provided.
As with any long journey, planning is essential, but it is equally important to
allow flexibility for personal goals to emerge from the experience, side trips that
may distract or enrich you, and serendipitous opportunities that may attract you. It
is the totality of these experiences that will lead to immersion, understanding, and
innovation.
P A R T O N E
LWBK821_c01_p001-006 07/01/11 6:03 PM Page 1
C H A P T E R 1
Positioning for the Journey
Disciplines should be dynamic to respond to emerging and changing needs of societies and to new
demands imposed by population movements, health care reforms, and transformation of global
order. However dynamic disciplines are, they have a core set of values, assumptions, a perspec-
tive, and a mission that maintain their stability and effectiveness. This core is what provides conti-
nuity and progress in disciplines.
Quality care for all people continues to be nursing’s top priority. In the 21st century, this goal
is even more urgent than it has been because of increasing diversity and better awareness of the
changing needs of the public, the conflicting priorities in health care systems, and the emergent
costs and reimbursement issues that patients, insurance companies, the health care industry, and
health care professionals are confronting. Theory and theoretical thinking may have been pro-
moted in the past as answers to the undefined roles of nursing or the diffused nature of the profes-
sion of nursing. However, in this new era of unequal access to health care, where disparities in
provision of health care services are becoming more recognized, where there are emerging chal-
lenges in treating chronic illnesses and infections, and where there is a proliferation of health care
professionals and many global dialogues about health care reform, the role of theory has become
even more urgent and more compelling. To fully appreciate the role of theory in shaping the future of
equitable and accessible quality health care, we must review and analyze our theoretical past and its
influence on the present and future of health care.
By uncovering and understanding a discipline’s theoretical journey, members of the discipline
learn and build on it. By unfolding the process used in developing the theoretical past, we gain insights
that improve our understanding of our current progress, and we are empowered to achieve our discipli-
nary goals. When we take a critical and reflective stance on the current theoretical discourse, or lack
thereof, as the case may be, we see shadows of past issues and accomplishments, as well as visions of
the future of our discipline and profession. Therefore, reconstructing our theoretical heritage is a
process that involves reconstructing our present reality. The intent of the historical-to-future journey
proposed in this book is to demonstrate the progress of nursing through analyses of the philosophical
assumptions, theoretical methods, and theoretical threads that have influenced the development of the
discipline. We will perform these analyses in ways that value our experiences as nurses, in ways that
support and enhance our progress, and in ways that allow us to proactively develop abstractions, exem-
plars, conceptualizations, and theories that reflect and guide our nursing assessments and actions. Syn-
thesizing insights from and about the past, considering the current reality of the health care systems,
analyzing the societal context, and considering the potential future visions of quality care can enhance
creativity in the discipline of nursing, which could further its development and progress.
Despite many crises along the path of quality care, the development of the discipline of nursing
has progressed by leaps and bounds during the last 30 years of the 20th century. The new century
brought with it many challenges, some new and some merely shadows of the past. Few would dispute
the notion that theory in general has been responsible for this development; yet, some continue to
question the specific role of theory in the development of the discipline and its effects on the disci-
pline’s scientific bases and clinical practice. The thesis of this book is that the evolution of the disci-
pline of nursing and its scholarliness is greatly intertwined with its focus on theory. The movement in
our discipline to incorporate vigorous philosophical and theoretical discourses is a credit to those who
theorized about nursing practice: thinkers who dared to conceptualize in a practice discipline and edu-
cators who pioneered theory development, all of whom were instrumental in defining and advancing
the discipline of nursing. These thinkers framed the discussions and the discourse about the mission
and the boundaries of the discipline of nursing. The discussions in this book go beyond this thesis to
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CHAPTER 1 Positioning for the Journey 3
delineate the very outer boundaries of nursing knowledge, the sources used to advance that knowl-
edge, the different approaches to knowing, the theories that guided the development of nursing’s sci-
entific base, and the criteria of truth that the discipline may or may not use. Although the dialogues in
this book intend to provide the reader with a sense of history, the process itself helps to unfold a futur-
istic course. The readers of this text are the agents who will shape the future of the discipline.
Theory is not a luxury in the discipline of nursing. Using theory as a way to develop concep-
tual frameworks to be used to guide curriculum development is part of our past. Theory has
become an integral part of the nursing lexicon in education, administration, and practice. Mem-
bers of the nursing discipline should understand its role in the development of nursing and in the
delivery of quality evidence-based nursing care.
OUR THEORETICAL HERITAGE
Like all journeys, the journey proposed for you, the reader, could be short or long, detached or
involved, superficial or profound, simple or complex, preplanned or spontaneous, or structured or dis-
covered. Like all journeys, this one has maps, destinations, lamp posts, detours, setbacks, surprises,
disappointments, and insights. Like all journeys, you will get out of it what you put into it. It has been
my experience in sharing this journey with many fellow travelers, through teaching, research, and
practice, that the insights gained and advancements in knowledge made coincide with the extent to
which there is complete openness and flexibility in the discoveries experienced and developed during
the journey, to the extent to which there is true involvement in all aspects of the journey, and to the
extent that there are opportunities to integrate this journey with personal experiences.
Therefore, you are invited to embark on a long journey that spans the theoretical past, present,
and future of our discipline. Journeys are meaningful when they become personal. Therefore, you
are also encouraged to reflect on your own theoretical journey and to compare and contrast your
experience and responses with that of other members of the discipline, as well as with the journey
of the discipline itself. All journeys will take on different meanings—the insights from one journey
will enhance the insights from another. For your journey, take some time to question your values
about theory, your own assumptions about theoretical thinking, your biases against theory, your
goals for reviewing theoretical writings, and your goals for the discipline of nursing. For the disci-
pline’s journey, ask questions about the discipline’s focus and ultimate goals, who drives these
goals, which discipline’s perspective is driving these goals, why are these the goals set in the 21st
century, and are these goals the same for all health care professionals? Questions that include “if
then,” and “so what,” could help in promoting critical thinking about the discipline.
ASSUMPTION, GOALS, AND ORGANIZATIONS
This book is designed to provide tools and strategies to unfold the thought processes inherent in
nursing, analyze the origins of nursing concepts, and contribute to the ongoing dialogue about the
role of theoretical thinking in the development of the discipline of nursing. Its intent is to provide
the reader with the knowledge base necessary to fully engage in and understand the current situa-
tion in health care, and to begin to formulate ideas about how to shape a future for nursing that is
more theoretically coherent and effective. This book is about theory, theorizing, and theoretical
thinking. Critical thinking is essential for theoretical thinking. Clinicians, theoreticians, and
researchers use different forms of theoretical activities in their work. When theory is discussed,
the discussion should include how we have been theorizing and using theory in the different com-
ponents of the discipline of nursing, perhaps without attaching the label of “theory” to these activ-
ities. It is also about how we can continue to advance the discipline of nursing through knowledge
development, enhance professional nursing through the processes that nurses use in conceptualiz-
ing their actions, and facilitate better care for clients through theory-based policies and theory-
driven practices. This book does not provide recipes for achieving these goals; instead, it provides
ideas, questions, processes, and some strategies to enable you to pursue your own goals, develop
your own action plans, and share your own insights and wisdom with your colleagues.
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4 PART ONE Our Theoretical Journey
The ideas contained in this book are articulated to compete vehemently with any work that deni-
grates the theoretical history of nursing—past, present, or future. At the same time, the ideas comple-
ment and are intended to collaborate with all other writings of colleagues on theory and metatheory.
When I provide critique, I attempt to voice it from a nursing perspective, place the critique within an
historical context, and analyze the contributions, allowing for the contextual forces and constraints.
This book is not intended to promote a certain epistemological perspective, a certain theory, or a
certain set of ontological propositions over any others. Instead, this book explores, discusses, ana-
lyzes, critiques, compares, and contrasts different epistemologies, theories of truth, and nursing theo-
ries. It delineates components of theory and criteria for theory critique. It describes different strategies
used in the development of nursing theories and the consequences of each strategy. This book is
intended to be used by those who want to understand a significant aspect of the nursing discipline that
has been dichotomized with practice and shadowed by an emphasis on education of nurses. It
attempts to promote understanding, not to dissect the discipline of nursing into separate compart-
ments, but rather to emphasize nursing as a discipline that is based on philosophy, theory, practice,
and research. Although the focus is on nursing theories, the relationships and interdependence among
research, art, philosophy, and practice are highlighted and explicated. The ultimate goals of the differ-
ent chapters are to stimulate thinking, inspire robust dialogue, and challenge the status quo.
The development of the ideas for this book is based on several assumptions:
• Understanding theory and its role is enhanced by exploring the origin of ideas and the
processes by which ideas develop into theories.
• Pluralism in nursing theories is desirable and inevitable; therefore, an exploration of
existing theories is essential for improving the utility of theory and for continuing the
development and progress of the discipline.
• A critical assessment of the history of theoretical thought will pave the way for the
development of theories that further describe and prescribe nursing practice. This
understanding will help delineate issues that could be resolved in the future.
• No evidence can exist without a coherent theoretical framework that drives the questions
and answers for practice.
ORGANIZATION OF THE BOOK
To improve the potential of achieving the goals of understanding the role of theory in the develop-
ment and progress of the discipline, and of understanding the role of members of the discipline in
developing and constructing theory, this book is organized into parts and chapters according to
potential illuminations throughout the journey. It is divided into six major parts.
Part One describes terms of the theoretical journey, assumptions to guide the journey, the
lamp posts that define key elements of the journey, and the destinations of the journey, as well as
scholarship and what it means within the context of the 21st century.
The second chapter in Part One focuses on the agents and producers of knowledge—the
scholars in the discipline. Different frameworks for scholarship are analyzed, and scholarship is
defined within the context of the practice properties of the discipline. Scholarship includes giving
careful attention to the development of nursing theories and to ways in which nursing theories are
viewed and analyzed.
Part Two presents a historical analysis of the discipline’s progress toward its present theoreti-
cal perspective. Stages of development and milestones leading to the next phase are discussed. A
pattern of progress unique to the discipline of nursing is explored. Forces and barriers that may
have influenced theory development, and therefore indirectly affected the scholarly evolution of the
discipline of nursing, are proposed and explored. Chapter 5 presents the evolution of the discipline
of nursing and the various stages that have been marked by significant turning points or milestones.
In Part Three, I provide an epistemological discussion of our discipline as it is perceived and
articulated by its thought leaders. The dialogue and analysis provided reflect the thinking about
our discipline at the end of the first decade of the 21st century. This part contains three chapters
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CHAPTER 1 Positioning for the Journey 5
focused on defining the discipline of nursing, its domain of study, and its perspective of clinical
practice as differentiated from other disciplines. Chapter 7 provides an analysis of the sources and
resources used to develop theory, and it dispels the myth that only research can be a source of the-
ory. Chapter 8 provides a proposed approach to analyzing the structural components of the disci-
pline and the different ways by which we claim knowledge. Different theories of progress are
explored, and the course of development of nursing knowledge is traced, compared, and con-
trasted with other disciplines.
Part Four focuses on the analyses of those theory pioneers who provided the tipping point for
initiating a robust theoretical and philosophical dialogue. In Chapter 9, I provide an overall per-
spective on the theories by putting them through magnifiers, telescopes, and microscopes. The
result is an integrative synthesis providing support for emerging categories. In Chapter 10, I pro-
vide a discussion of the different analysis and critique models for evaluating the quality and effec-
tiveness of theories. The model provided differentiates between strategies and processes for
describing, analyzing, critiquing, and testing theories. The remainder of Part Four is devoted to the
use of the model for theory description, analysis, critique, and testing for analyzing the selected
nursing theories. The selections, based on the theories’ central questions, are matched with domain
concepts. Therefore, the five chapters in Part Four are organized around an integrative analysis of
the theories, a proposed model, and focused analyses of needs and self-care, interactions, and out-
come theories.
Part Five is devoted to the future, without losing track of our past or the context of our disci-
pline. Frameworks and strategies for developing concepts and theories are provided as processes
and guideposts for a future of influencing health care policies. In Chapter 14, I outline the chal-
lenges and opportunities for advancing our discipline. In Chapters 15, 16, and 17, I discuss
processes and tools essential for developing different types of theories. Examples are provided to
reflect the major strategies presented. Among these examples are those specific to the development
of middle-range and situation-specific theories. And in Chapter 18, I discuss the different theories
by which we can continue to measure the progress of and developments in advancing knowledge.
Part Six contains two chapters. Chapter 19 presents an abstracted analysis of selected central
writings on metatheory and nursing theory. It is not intended as a comprehensive compilation of
abstracts of everything that has been written about metatheory and theory; rather, it is intended as a
beginning—but central—collection that you are encouraged to use as a model for your own collection
of analytical abstracts. The analyses are intended to provide a starting point for discussion and debate.
The last chapter of the book, Chapter 20, contains an extensive bibliography on metatheory,
on paradigms that have been used in nursing, and on nursing theory. Sections 1 through 12 of this
chapter contain the metatheory literature and are organized around common themes in nursing
and theory, such as philosophy and methods, theory development in nursing, forces and con-
straints in theory development, theory and science, theory and research, theory and practice, the-
ory and education, and theory analysis and critique. Sections 13 through 37 contain writings about
nursing theories by theorists or others who have used the theories for research practice, education,
or administration. You can find all the writings related to a theory—to the best of my knowledge—
by looking under the theorist’s last name in this section. In addition, there are two new sections on
middle-range and situation-specific theories, with many references reflecting both.
Asterisked citations in this chapter indicate citations that have been abstracted and analyzed in the
previous chapter under metatheory or theory. Sections 38 through 48 contain writings on several cen-
tral paradigms that have influenced the discipline of nursing, including psychoanalytical theory, sym-
bolic interaction, developmental systems, adaptation, and role theories. Sections 49 through 53 provide
a descriptive list of audiotapes and videotapes that have been created to explain the theorists’ ideas.
This book is designed to be used sequentially or nonsequentially. This free use of each chap-
ter and each part necessitates a slight repetition of ideas. The repetitions emphasize and expand
on significant themes and present the same or similar ideas with a different analytical posture.
This book ideally should be used in four teaching/learning units: the first focusing on Part One
and Part Two, the second on Part Three, the third on Part Four, and the fourth on Part Five. Part
Six provides the necessary supportive material for each of the parts.
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6 PART ONE Our Theoretical Journey
ON A PERSONAL NOTE
Writing and reading books are both existential experiences and ongoing, evolving processes. Nei-
ther the reader nor the writer is the same person after reading or writing a book, nor are their ideas
and viewpoints the same. A book is never complete because ideas are never complete. Yet, at some
point, a project needs to be abandoned so that others can explore its ideas to modify, extend,
affirm, refine, or refute their own—all of which, if shared with the author, will allow her to do the
same. When I completed the last edition, I had decided to temporarily abandon the project as an
individual endeavor. It is now our dynamic project; it belongs to the readers and to me, and
engagement in the ideas and constant discourse is the ultimate goal. These assumptions continued
to guide the current edition.
I urge you to consider this book complete as well as incomplete, a temporarily abandoned proj-
ect that represents my own thinking and analysis. It incorporates my past, present, and future, inter-
mingled with the past, present, and future of nursing and of nurse theorists. It is from all of this that
my present interpretation of theoretical nursing has evolved, but this continuous, evolving process is
presented here with temporal boundaries. Therefore, if I misinterpreted any theorists’ or metatheo-
rists’ admonitions, it was unintentional, and my critique should be viewed as an honest epistemolog-
ical interpretation bounded by cognitive, historical, and sociocultural meanings of the time.
I firmly believe that without the theorists and metatheorists and their writings, this book
would not have been written, and it would not have been necessary. Interpretations and selections
of theorists and metatheorists and their ideas were not guided by a desire for omission, but rather
by limitations imposed by time and space. The conceptualizations of all theorists and all the
analyses of the metatheorists, whether included in this text or not, provide the tapestry that depicts
the future of theoretical nursing.
Finally, I have tried to avoid language that suggests stereotypical views of the nurse, patient,
and physician, but at times comprehension, clarity, and simplicity took precedence. Because the
majority of nurses are women, I have used “she” to encompass both “she” and “he.” I have done
the same elsewhere with “he.”
Are these the same as, or different from,
those criteria used in selecting or reject-
ing nursing theories?
5. In what ways do you demonstrate your
critical assessment of progress in theo-
retical and scientific nursing? Are these
critiques illuminated by a true under-
standing of daily experiences of mem-
bers of the discipline? Are these
critiques guided by a nursing perspec-
tive? (Then respond to this question
again after reading Chapter 18.)
6. What is your own conception of a nurs-
ing perspective, and in what ways does
this conception match or not match with
your practice environment (or curricular
framework)?
REFLECTIVE QUESTIONS
The following are some questions to guide a reflective approach to your journey:
1. Comment on this statement that is often
heard: “I have practiced (or taught) nurs-
ing for many years without the need to
use theory, so why do I need theory in a
practice discipline?”
2. How did you come to define theory,
nursing, human beings, and health?
What values and assumptions do these
definitions hold, and what courses of
action are dictated by those values?
3. What theories guided you in your assess-
ment of your patients, in your research
projects, and in your teaching methods?
Why did you select these theories? How
congruent are the ontological beliefs of
these theories with your own? With those
of the discipline of nursing?
4. What criteria did you use in selecting or
rejecting theories to guide your actions?
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C H A P T E R 2
On Being and Becoming a Scholar
Theory and theoretical thinking are intricately intertwined with advancing scholarship in any dis-
cipline. Established disciplines provide an intellectual environment that nurtures and promotes
scholarly inquiry, and theory and theoretical propositions drive such inquiry. Theory development
encompasses those goals and outcomes of inquiry in the discipline that claim scholarship. When I
think of scholarship in nursing, I think of a number of renowned individuals who have made an
impact on the meaning of scholarship; some of these people are from ancient history, and others
are from recent history. Hypatia and Hatshepsut reflect very different types of scholars who con-
tinue to fascinate modern thought. Conversely, Ernest Boyer’s name is attached to more contem-
porary thoughts regarding scholarship.
Hypatia was a renowned Greek philosopher and scholar of the fifth century (Osen, 1974), and
Hatshepsut was the only ruling queen among the pharaohs of Egypt in 2500 BC (Wells, 1969).
Both demonstrated commitment, persistence, innovation, leadership, and intelligence. Both were
true scholars. Both followed similar paths in their lives—different from the universal and main-
stream paths that existed at their respective times. Both met death violently and may have been
tortured because they charted different paths for their people, were forceful in expressing their
views, and succeeded in making changes.
Hypatia left her mark on the world in the form of innovative devices to study astronomy and
to determine the specific gravity of liquids—devices that were praised highly by Socrates.
Hatshepsut left her mark in the form of architecturally beautiful temples for her people, peace
within her country and between her country and neighboring countries, and new artifacts in her
land. Both women demonstrated a unique brand of scholarship; however, scientists had to dig
deep to learn about their work and their stories. Was that because they were women? Can they be
judged by the same criteria used to evaluate and judge male mathematicians and male pharaohs?
Ernest Boyer (1990), however, inspired most disciplines to engage in robust dialogues about the
meaning of scholarship in modern times. His Carnegie Foundation publication, “Scholarship Recon-
sidered: Priorities of the Professoriate,” continues to resonate in academic institutions. Boyer dis-
cussed the origin of the most prevalent definition of scholarship, as research and discovery
corresponding with an emphasis on higher education and on increasing grant support that nurtures the
research enterprise. Increasingly, in Boyer’s opinion, scholarship was becoming synonymous with
academic work, and professors were expected to compete for grant funding and focus on research,
thereby creating a dichotomy between teaching and research. Many groups in U.S. society had begun
to question this de-emphasis on teaching in universities, and analyses such as those done by Boyer
(1990) and Glassick, Huber, and Maeroff (1997) fueled the call for a redefinition of scholarship.
Boyer proposed that there are four different categories of scholarship. The first and most
familiar is the scholarship of discovery that is tied to original research. This type of scholarship
calls for activities that enhance a deeper understanding of research processes in a quest to answer
a discipline’s pressing questions. The emphasis in this type of scholarship is on research, and
research attracts funding from such institutions as the National Institutes of Health (NIH) through
the R01 program, among other sources of similar funding. In the U.S. scientific community, the
R01 designation is considered the gold standard for research funding, denoting the significance of
the research, the credibility of the investigation, and the standing of the investigator in the aca-
demic community. However, disciplines, and students within the various disciplines, needed other
kinds of scholarship to advance and flourish (Meleis, 2001). Therefore, a second area of scholar-
ship, the scholarship of integration, was proposed. This is the quest to find connections between
different discoveries, leading to new wisdom and insights about an area of investigation or a
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8 PART ONE Our Theoretical Journey
discipline. Scholarship of integration is achieved when innovative insights are realized that are
larger than the smaller disconnected facts produced by research. The exceptional discoveries in
sciences in the late 20th century and the complexity and interrelationship between the different
disciplines makes the scholarship of integration more timely (Strober, 2006).
The third type of scholarship as defined by Boyer is the scholarship of application. This type
of scholarship builds bridges between theory, research, and practice. Scholarship of application
encompasses the translation of knowledge to solve problems for individuals, families, or societies.
This type of scholarship requires the integration of knowledge of best practices in achieving best
outcomes (Shapiro and Coleman, 2000). With the increasing acknowledgment of this interde-
pendence between academic institutions and society, there comes an expectation that relevant
knowledge must be translated to benefit societies, and, conversely, the knowledge that is devel-
oped must emanate from the needs of society.
The fourth type of scholarship is that of teaching (Hutchings and Shulman, 1999; Shulman,
1999; Glassick, 2000). Shulman suggests that good teaching should be differentiated from schol-
arly teaching and from scholarship of teaching. He states that for teaching to be scholarship, the
work must be communicated and public, should be peer reviewed critically, should be compared
to some accepted standards for quality control, must be reproduced, and must be cumulative,
building on other scholars’ work.
In what ways are these discourses about scholarship—by Hypatia, a woman philosopher
from ancient Greece and Egypt, and Boyer, a contemporary educator—relevant to nursing in gen-
eral and to theoretical nursing in particular? This is what we will discuss in the rest of this chapter;
let me begin by saying that there is no scholarship without a robust theoretical discourse. Theoret-
ical thinking and theory-driven dialogues are essential for any type of scholarship, as will be
explained throughout this book. However, developing theory, refining theory, and analyzing theo-
ries are more reflective of the scholarship of integration. The discipline of nursing continues to be
in dire need of scholars who use the tools of critical thinking (as defined on page 19 in this chapter
as well as in Chapters 3 and 14) to develop the theories and theoretical frameworks that guide
practice and research. Several questions may be posed at this point.
Is nursing scholarliness different from scholarliness in other disciplines? Do nurse scholars
have the same attributes as other scholars? Do some differences exist? What might they be, and
how is current scholarship in nursing related to Boyer’s conception of different types of scholar-
ship? In this chapter, we discuss these questions. Answers to these questions, however, are
dynamic, evolving and changing, reflecting new experiences for nurses and redefined goals for the
discipline.
There are some indications that the nature of those disciplines that are oriented to human
responses and the nature of those disciplines that focus on clinical matters may differ considerably
from other disciplines that focus on physical phenomena or that are purely theoretical in nature
(Holmes, 1990; Sarvimki, 1988; Watson, 1990). There are also historical indications that
women’s history and their lived experiences may provide them with different voices, different
cognitive styles, and different ways of knowing (Belenky, Clinchy, Goldberger, and Tarule, 1986;
Gilligan, 1984; Anderson, Reimer–Kirkham, Browne, and Lynam, 2007). The discipline of nurs-
ing is defined both by its perspective and domain, and by its historical association with women
and the propensities of most societies to assign the work and labor of caring to women. These def-
initional characteristics may be reflected in the philosophical perspectives adopted by its mem-
bers. They also drive the way in which members of the discipline approach the frameworks they
develop or use to define the curricular content and the educational strategies used. These charac-
teristics may also define the ethical decision-making frameworks that govern knowledge develop-
ment and utilization.
It is also expected that disciplines oriented to human responses may require a different set of
criteria to judge their scholarly progress and development. These criteria evolve from the people-
oriented nature of the clinical and human sciences, as well as from the struggles that women have
endured to achieve equity and to receive acknowledgment for their work and respect for their
credibility. Scholarliness in such disciplines may, by necessity, take different routes and reach
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CHAPTER 2 On Being and Becoming a Scholar 9
different destinations. Nursing falls into this category of disciplines, and nurses (women and men)
often represent a scholarliness that is more congruent with the nature of nursing and less with the
nature of other disciplines. However, the question remains: What is a scholarly discipline?
Boyer’s four types of scholarship are predicated on assumptions that a discipline is scholarly and
thus is in need of four types of scholarship. Let’s discuss the reasons why nursing may be consid-
ered a scholarly discipline.
SCHOLARLINESS IN NURSING
A scholarly discipline has a focus that is evident and significant. Scholarship in a discipline
refers to the degree to which its mission is defined and based on rigorous and credible research
and on well-developed, supported, and significant theories. Scholarship is evident in disciplines
in which knowledge and its progress are easily articulated, and in which research and philo-
sophical inquiries explore, examine, and answer significant domain questions. Theory is an
essential component of scholarly disciplines; it provides members of the discipline with the
means to articulate their focuses. Scholarliness combines theory, research, philosophy, and, in
disciplines such as nursing, practice. Scholarliness is reflected in the synthesis and integration
between a discipline’s different components. Characteristics of the stage of scholarliness in a
discipline are that the relationships among theory, research, philosophy, and practice become
more apparent; that clinical scholarship is expected and practiced; and that clinical research, as
well as fundamental research, is required (Diers, 1995). Scholarliness is also indicated by
engaging in societal issues and achieving partnerships to deal with pressing civic, moral, and
social issues (Boyer, 1990). When questions arise about how nurses are or are not engaged in
making a difference in communities, they indicate that our discipline has achieved a new mile-
stone toward becoming a scholarly discipline (Duke and Moss, 2009). We would not have been
able to reach this current stage without having gone through previous stages in which the focus
was on practice or teaching.
The scholarship of the discipline is driven by those nurse theorists who reflect the scholar-
ship of in tegration; however, this was not always true. In the early 1960s, nursing theorists
developed theories in isolation, researchers pursued questions of interest only to educators or
administrators, investigators asked isolated questions, and practitioners pursued their practices
while remaining somewhat oblivious to what the other groups were doing. Today, significant
changes have occurred in the relationships among educators, researchers, theoreticians, and
practitioners. These groups are now partnering with each other, writing for each other, and
working with each other. Note the increasing involvement of clinicians in educational pro-
grams, the increasing commitment of academics to practice, and the emerging research collabo-
ration between both groups. Clinicians and academics are crossing the boundaries to work
together and, more importantly, most of them believe that practice is the raison d’être of nurs-
ing. As a result, middle-range and situation-specific theories are being developed to answer
clinical questions that evolve from the partnerships forged between academic institutions and
academic health centers. These may encompass more inclusive questions such as: Who are our
nursing clients? When does a client need nursing care in addition to or instead of medical care?
And, when do we discharge a client from our care? Or, they may include more specific ques-
tions pertaining to ways in which we make our patients comfortable, strategies for pain relief,
symptom management, care of wounds, culturally competent nursing therapeutics, and transi-
tions and health promotion.
These questions should be compared with those related to teaching strategies (such as
those related to modular or individualized instruction) or with questions about leadership
styles (such as those related to developmental or transformational styles of leadership). Both
of these sets of questions were the forms of inquiry pursued the past; the answers they pro-
vided led to knowledge that was not as central to clinicians’ concerns about providing quality
nursing care but were more congruent with nursing management and teaching missions. How-
ever, these types of questions also can be related to scholarship in practice if they include
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10 PART ONE Our Theoretical Journey
outcomes, such as the discovery of the effects of teaching strategies and leadership styles on
patients, families, or communities. The current generation of scholars in nursing ask questions
central to practice and explore phenomena emanating from and influencing practice outcomes.
New generations of scholars are being educated to provide answers that could drive and shape
the future of nursing practice.
Nursing theories to describe, explain, and predict the quality and outcomes of nursing prac-
tice and nursing interventions were developed during the decades of the 1960s to the 1980s to
answer broad questions that were central to the field of nursing. Although these questions evolved
from interest in the curriculum, they nevertheless addressed practice indirectly. These questions
concerned what knowledge is essential for students, how to organize curricula, and what to
include and what not to include in a nursing curriculum. Answers were developed in the form of
theories that addressed the nursing client, environment, transitions, health, nursing process, nurs-
ing therapeutics, and strategies for nursing care. The theories attempted to describe the phenome-
non of nursing and chart a theoretical course for nursing actions. Thus, the beginnings of a
scholarly discipline were created.
There are more indications that nursing scholarliness became even more integrated in the
1980s and 1990s (Table 2-1). Theory and practice began to be interrelated. A review of nursing
practice literature demonstrated a growing awareness of a stronger relationship between theory
and practice. In clinically oriented national meetings, there was an outgrowth of presentations that
were theory based, and there were discussions of questions that lent themselves to theory and the-
ory development. We moved away from “how to” to “why,” “what if,” and “when” in an attempt
to generalize, document, and verify phenomena in nursing practice.
Nursing theories tended to address imaginative and ideal nursing practice. These theories
were visions of what nursing ought to be and what care should be; they were necessary visions of
how nursing should move forward to establish its identity and its boundaries. Once the ideal goals
were established, these theories were modified as nurses described and documented real-world
results and what goals and outcomes are attainable. Nurses became more comfortable with look-
ing at their own practice, describing it, and allowing theoretical formulations to emanate from it
(Benner, 1984). Acknowledging and valuing practice as a source of theory, and nurses as agents
for developing integrated and coherent theoretical descriptions of nursing practice, resonates in
some ways with Boyer’s definition of scholarship of practice.
There are also many indications that professional organizations speak a language congru-
ent with that spoken by theorists and clinicians. One example is the social policy statement
issued by the American Nurses Association (ANA) in the 1980s, revised in the 1990s, and
updated in 2003. The statement provided the profession of nursing with a national definition of
nursing and a direction for practice, and was another indication of agreement on nursing con-
cepts and issues. Nursing was defined as “the diagnosis and treatment of human responses to
actual or potential health problems,” which is congruent with the focus that emerged on human
responses (versus nurses’ functions, interactions, or relationships, and versus symptoms, signs,
and behavior) (American Nurses Association [ANA], 1980, p. 9). This definition was reviewed,
affirmed, and supplemented by an ANA task force (ANA, 1995). The policy statement affirmed
that, “The nursing profession remains committed to the care and nurturing of both healthy and ill
people, individually or in groups and communities” (ANA, 2003, p. 6); however, this definition
TABLE 2-1 CHARACTERISTICS OF THE STAGE OF SCHOLARLINESS
• Relationships among theory, research, practice, and philosophy become more apparent.
• Pluralism in paradigms is encouraged.
• Boundaries of domain become more identified.
• Domain guides nursing practice, research, and theory.
• Knowledge is developed that makes a difference in health care.
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CHAPTER 2 On Being and Becoming a Scholar 11
was expanded in 2003. The new definition has maintained the essence of the earlier definitions
but is more specific:
Nursing is the protection, promotion, and optimization of health and abilities; prevention of illness
and injury; alleviation of suffering through the diagnosis and treatment of human response; and
advocacy in the care of individuals, families, communities, and populations. (ANA, 2003, p. 6)
The definition of nursing provided in the policy statement acknowledges several essential
features of nursing practice. These are that nursing: focuses on the full range of human responses;
places less emphasis on problem-focused evaluation; emphasizes the integration of knowledge
based on objective data, as well as on knowledge that reflects subjective experiences; stresses the
application of knowledge related to diagnostic and interventional processes, caring relations, and
the goal of facilitating and promoting health and healing. This document also defines the nurse’s
function as incorporating a responsibility to develop theories from evidence provided through
research. These theories are expected to guide nursing practice (Hobbs, 2009).
The definition of human responses to health and illness includes need, condition, concern,
event, dilemma, difficulty, occurrence, and fact—as well as lived human experiences that can be
described within the target area of nursing. It considers the diversity of human responses in the
health/illness situation. In the social policy statement (ANA, 1995), one can see the influence of a
number of theories from the 1960s and 1970s on the concepts selected for inclusion, such as inter-
action, self-care, and affiliation, as well as on the inclusion of the goals for advancing nursing the-
ories. Human responses to health and illness provide us with phenomena on which to base further
research and theory development.
A positive relationship between theory and research is not as foreign and unattainable as it
was in previous stages of nursing scholarship. More specifically, up until the late 1970s, only a
limited relationship existed between research and theory. Later, more links were established
(Batey, 1977), with links between theory and research preceding links between theory and prac-
tice. The literature is replete with suggestions of how nurses can use theory to guide research and
how they can use research to build theories (Fawcett and Downs, 1986).
Different philosophical premises infiltrated nursing beginning in the 1960s and continuing
throughout the 1990s. Questions about truth drew on the writings of such diverse philosophers as
Popper and Kaplan, and spanned the gamut of empiricists, rationalists, pragmatists, existentialists,
feminists, and critical theorists. Some questioned the received view as a guiding framework; others
proposed the incorporation of intuitive thinking, combining it with the more traditional Baconian
approach to nursing science. Silva (1977) and Benoliel (1977) supported the idea that nursing
should not lose sight of the significant notion that truths gained from intuition are as important as
truths gained through more traditional research methods.
In the late 1980s, writing in nursing demonstrated a passion for knowledge, a search for the
meaning of truth, and an exploration of values guiding practice as well as knowledge; it also indi-
cated that changes occurred in the outlooks of nursing’s pacesetters. As a result, areas of nursing
that, during a prior generation, were not deemed worthy of investigation enticed a new generation
of scholars. An example of this is comfort (Arruda-Neves, Larson, and Meleis, 1992; Morse, 1983)
and spirituality (Schwartz and Campesino, 2006; Lewis, 2008) as areas worthy of investigation.
Norms of Scholarliness
An analytical view of the normative structure of nursing supports the notion of scholarliness
in nursing. Education and practice came back together during the 1970s and 1980s. Some institu-
tions tried and succeeded in having their faculty maintain joint appointments. Theory infiltrated
practice, and, from practice, theories evolved. Instead of occurring within the curriculum, tests of
theories were done in practice. Research findings demonstrated significant outcomes of nursing
care through changes in morbidities, mortalities, and quality of life (Fagin, 1981). There was not
only tolerance for multiple theories in nursing but there was, in addition, an evolving view that
pluralism in nursing theory is essential (Newman, 1983).
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12 PART ONE Our Theoretical Journey
The use of many theories and the acceptance of pluralism were accompanied by an attempt to
derive meaning from their relationship to nursing practice. Representative examples of excellent
theoretical frameworks of nursing phenomena appeared increasingly in the nursing literature
(Mercer, 1981; Millor, 1981; Mischel, 1990; Norbeck, 1981; Tilden, 1980; Weiss, 1979; Younger,
1991). These conceptualizations represented openness to multiple approaches (Armiger, 1974;
Schlotfeldt, 1981); they comprised a pluralism that was neither addressed nor advocated during
the previous stages.
Authors of these new conceptualizations combined the traditional view that concepts were
not accessible to empirical testing with the view that concepts did, however, generate variables
that were testable. Other nursing concepts, such as maternal role attainment, touch, and tempera-
ment in battered children, were based on research and premises from interactionist and develop-
mental models, and were drawn from natural and physical science. These new propositions
allowed for the divergence of thought and approach that was essential for the development of fur-
ther testable propositions and, eventually, the development of theories.
This process was analogous to other processes in the history of science. Johannes Kepler, for
example, developed the four laws of planetary motion by using careful observations painstakingly
collected by Tycho Brahe (Bernstein, 1978). By doing so, Kepler opened up new avenues and
brought up new questions. Therefore, he used a convergence of Brahe’s data and his own ideas to
evolve his laws and to allow for more questions and propositions to develop. Extensions and
refinements of early data produced refined and usable laws.
Another property of scholarliness in nursing is that of collaboration. The essence of collabo-
ration is that each member of the team has a major contribution to make and that, without that con-
tribution, the collaborative act has no meaning (Gortner, 1980). All established disciplines require
collaboration within and between disciplines. Our discipline demonstrated increased collabora-
tion by leaps and bounds at the turn of the 21st century, in both research and publications. The
establishment of research centers such as the Women’s Health Research Center at the University
of Washington, and the Center for Health Outcomes and Policy, the Center for Research in Health
Equities, and the Center for Integrative Science in Aging at the University of Pennsylvania are
examples of a critical mass of scholars united to collaborate on developing knowledge that is con-
nected by theoretical assumptions, values, and goals.
Increasingly there has also been a movement toward a synthesis of the different modalities of
what constitutes truth. Criteria for establishing truth include considering evidence and truth as cor-
roboration through verification and falsification, as in the Popperian tradition, as well as the logical
coherence of arguments in the Aristotelian sense. Truth is also established when clinical evidence is
given in narrative stories by expert clinicians. The prestige and power of those who provide the evi-
dence that may prompt members of the discipline to accept and agree on concepts—the units of
analysis that are focal in the discipline—were advanced by Kuhn. Concepts and derivations of their
meanings are also accepted as truth through processes of introspection and derivation of meaning in
the Kantian sense. (See Chapter 8 for a fuller discussion of truth.)
Nurses used all these meanings to constitute multiple truths, combining subjectivity and
objectivity. Because nurses deal with complex phenomena, with human beings, with behaviors,
cognitions, and perceptions, the discipline cannot use one meaning of truth to the exclusion of
others. Because of the consideration of the relationship between science and humanity during the
1980s, and because of the close relationships between philosophy and science and science and
ethics, nurses realized that a singular theory of truth was inadequate and would defy the essence
and purpose of nursing as a human science. Theories and research in nursing considered the prob-
lems that have motivated the construction of the intellectual systems of nursing, such as the use of
self in caring and the need for the total involvement of clients in their care.
As we increasingly accepted the shifts from received to perceived views (see Chapter 8), and
as we began to acknowledge the uniqueness of our progress (the integrative processes discussed in
Chapter 8), we looked at questions of truth as archaic, traditional, and useless. Questions of truth
are being replaced by questions about the degree to which theories are able to solve scientific
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CHAPTER 2 On Being and Becoming a Scholar 13
problems. The basic unit of analysis for progress became “the solved problems” in nursing (Laudan,
1981; Silva and Rothbart, 1984), rather than confirmation and verification only.
Tools of Scholarliness
Over the decades, different approaches have been used to support the scholarly develop-
ment of nurses. Among them are higher education and mentorship. These tools purport to fos-
ter innovation and creativity and develop nurses as agents for advancing knowledge. Creativity
in nursing is manifested in many ways. Rogers, in the late 1960s and early 1970s, used electro-
magnetic concepts to explain human reactions to health and illness and to give philosophical
guidelines to nurses’ interventions. She talked about holism before holism became part of our
health care language (Rogers, 1970). Orem (1971) spoke of self-care before the initiation of
the self-care movement. Travelbee (1966) pioneered the role of a nurse as the explorer of per-
ceived meanings of suffering, and she discussed the significance of spirituality in nursing care.
The humanists in the discipline articulated the meaning of the experience of loss and death
before it became part of our media lexicon, and clinicians used creative therapeutics such as
touch, imagery, and acupressure as alternative health care interventions before the National
Institute of Complementary and Alternative Health Practices was instituted to legitimize these
practices.
Creativity is the ability to link seemingly unrelated concepts and variables (Bronowski,
1956), just as Einstein linked time with space and mass with energy. Creativity is the discovery of
hidden likenesses. Bronowski (1956) said that the act of creation is original but does not stop with
the originator. Kepler’s laws, which describe the movements of the planets, were not arrived at by
mounds of corresponding facts that he collected himself or by corresponding readings, although
both are significant. He speculated, dreamed, used metaphors, and made analogies (e.g., with
music), all of which helped to give conceptual order to the data. In the same fashion, Rogers
(1970) used the analogy of symphonic harmony to describe a human being’s relations with his
environment. Creativity is a leap of imagination, and scholarliness is characterized by leaps that
enhance the explanation and understanding of phenomena.
Communities also enhance scholarship. Cash and Tate (2008) used a community develop-
ment approach to build scholarship capacity among faculty by creating a community of scholars.
By using a nursing practice approach (community development) as a tool, they demonstrated the
connection between strategies for nursing practice and their use for nursing scholarship. Scholar-
liness is a process and a state that encompasses the norms and tools of science and the norms and
tools of theorizing and philosophizing. It includes not only creativity but also the communication
of ideas through teaching to enhance the scholarly socialization of its members. Over the decades,
nursing added the necessary pieces to the puzzle of scholarliness. Nursing continues to have a
high commitment to improve its curricula, its teaching and learning strategies, its methods of eval-
uation, and its administrative styles. It is one of the few disciplines that isolates the components of
research design and methodology and helps students to develop necessary skills to undertake a
research career.
Scholarliness is a hallmark of nursing in the 1990s because research and theory help explicate
major agreed-on nursing phenomena; because nursing is able to articulate its mission in theoretical
terms and with scientific data (Fagin, 1981); because nursing has well-established organizations,
scientific journals, and scientific arenas in which to express its views, using both scientific and
philosophical methods; because it has authoritative reference groups, all of which helped in estab-
lishing agreed-on, well-defined intellectual goals; because it believes in the autonomy of its clients;
because it has a pluralistic view of truth that encompasses internal coherence of premises and
propositions, external correspondence of truth through sense, and pragmatic truth through meta-
physical processes; because it deals with significant problems; because it deals with humanity and
is therefore a stage for humanity; because its constituents have both a passion for knowledge and a
flair for practice; and, finally, because it offers cumulative wisdom. Nursing goals are generally
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14 PART ONE Our Theoretical Journey
congruent with those of the recipients of its care; nursing operates from a health and holistic
approach and purports to enhance coping and harmony with one’s environment.
Indicators of Scholarliness in Nursing
Several indicators serve as examples of the scholarly maturity of nursing. First, scholarliness
is demonstrated through continuity. Continuity is manifested by those important and fundamental
questions in the field that are addressed within a conceptual or theoretical scheme to refine and
modify ideas over generations of scholars (Gortner, 1980). Answers are not the isolated incidents
with which nursing is confronted (National Institute of Nursing Research [NINR], 2006). The
relationship of mechanostimulation on primary or secondary pain; therapeutic touch as a modality
for communication, assessment, and intervention; or the consequences of reality testing on the
elderly are linked to other answers to form a whole that belongs to a theory of stimulation or
person–environment interaction.
Scholarliness is the ability to delineate the premises on which one’s decisions and questions
are based; the ability to engage in, complete, and communicate the results of research projects that
are supported and documented; the ability to critically assess the objective and subjective compo-
nents in their inquiry; and the ability to relate the results to existing theory and to participate in the
development of theories. Our scholarly efforts are concentrated on sharpening and refining our
knowledge of the theory-making process identified as central to the discipline and on using the
frameworks that define a nursing perspective.
Scholars in nursing use quantitative and qualitative analyses to define, refine, and sharpen con-
cepts, and to test basic propositions for the purpose of adding to substantive knowledge. We must
not forget, however, that a significant mission of the discipline is not only the better care of patients,
but the emergence of our clients from transition situations equipped with the tools to cope with sim-
ilar or different transitions in life, with the ways to promote their health, with the means to prevent
further illness episodes, and with the techniques to deal with stress in life. In doing so, we help to
merge research, theory, and practice—the concatenation realized as we handle clinical problems
more and more with the same ease as we handle theoretical and research problems (Barnard, 1980).
The second indicator, concatenation, therefore, is demonstrated through nursing theories that
evolve from practice and are used in education. As practice joins with education (Schlotfeldt,
1981), the distance between creation of knowledge, corroboration, and translation of knowledge
in practice is diminishing. I call this process concatenation, which is the condition under which
that shortening of distances is occurring. Joint appointments for nursing faculty that bridge prac-
tice and academic systems, as well as regular clinical rounds conducted by faculty and clinicians,
are examples of achieving a collaboration that drives the translation of knowledge in practice
areas. Concatenation also involves joining with the public media to inform the public of nursing’s
mission and to modify its goals based on public needs. Our local and national media are cooperat-
ing in modifying the negative image the public had of nursing experts, and, more importantly,
nurses are speaking up, their messages are loud and clear, and they are being heard (Reemtsma,
1981). In fact, toward the end of the first decade of the 21st century, the story lines of several
prime-time television programs in the United States focused on nurses as the central figures,
depicting them in leadership and decision-making positions.
The third indicator of scholarliness is the development of the National Institute of Nursing
Research (NINR), which was authorized under the Health Research Act of 1985 and was estab-
lished in 1986. This represented a significant milestone in nursing scholarliness, and it affirmed
two significant aspects of the discipline of nursing. First, quality nursing care depended on a care-
ful and systematic program of investigation; and second, nursing defined its domain and its the-
matic characteristics. The Act made us hopeful of increased support and commitment to
knowledge development. However, successful funding through the NIH, which has become the
gold standard for scholarship, in and of itself is an inadequate indicator. It is merely a means to an
end, and better indicators are the quality and significance of the area of scholarship, the quality of
publications, the venue for dissemination of knowledge, and the manner by which knowledge is
translated (El-Masri and Fox-Wasylyshyn, 2006; Meleis, 2001).
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CHAPTER 2 On Being and Becoming a Scholar 15
The fourth indicator of nursing’s growing scholarly maturity is the cumulative work through
research and theory that is being done on the central concepts in nursing. For example, when con-
sidering the environment’s impact on health, environment is considered to be the patients’ envi-
ronment, the sociopolitical environment, the administrative environment, and the environment for
students. The growing interest in considering the roots of violence and the connection between
violence and the environment—at home, at school, in public places, and at work—and how vio-
lence, injury, and human safety are related and are the business of nursing, further demonstrates a
disciplinary maturity leading to more effective programs of research (Chinn, 2008). Studies also
were developed to explain different components of environment that add to our understanding of a
safe environment. The concept may be the same, but the different settings help in the development
of all components and all properties of the concepts of environment, violence, and safety. For
example, in an innovative study related to environment, Holzemer and Chambers (1986) found a
significant relationship between faculty perceptions of the environment’s scholarly excellence,
available resources, student commitment, and motivation and faculty productivity. They helped us
conceptualize properties of healthy environments for students in the same way that we conceptu-
alize healthy environments for patients. Similarly, a whole issue of Advances in Nursing Science
was devoted to violence, injury, and human safety in schools, homes, workplace, global war, and
military areas, as well as in different age groups (Chinn, 2008).
The fifth indicator is the development of centers of research that house scholars with expert-
ise, interest, and research methodologies focused on a particular area for knowledge development.
These research centers have been the force for advancing knowledge related to central problems in
the field of nursing. Examples are women’s health, vulnerable populations, disparities in health
care, care for elder adults, symptom management, and transitions and health. These centers also
train and mentor future scholars, as well as provide continuity in training postdoctoral scholars.
The sixth indicator of scholarship in the 21st century is the movement toward the valuation
and respect accorded to clinical scholars, who integrate clinical and academic goals and who are
offered joint clinical and faculty appointments (Bauer-Wu, Epshtein, and Ponte, 2006).
NURSES AS SCHOLARS
Although nursing is a field of study open to men and women, the predominance of women in nurs-
ing must not be ignored when considering nursing scholarship. Scholarship is based on knowl-
edge, and women are agents of knowledge whose characteristic activities provide a grounding that
is different from and in some respects (in some disciplines based on human science) preferable to
men’s grounding (Harding, 1988). Harding makes this argument:
What it means to be scientific is to be dispassionate, disinterested, impartial, concerned with-
out abstract principles and rules, but what it means to be a woman is to be emotional (passion-
ate), interested in and partial to the welfare of family and friends, concerned with concrete
practices and contextual relations. (Harding, 1988, p. 83)
The question that forms the basis for this section is: Are nurses’ approaches to knowing,
understanding, and formulating conceptualizations unique? There are indications in the literature
of the 1980s and 1990s, and continuing into the 21st century, of the uniqueness of women’s devel-
opmental processes and women’s ways of describing their experiences, and the unique ways by
which experts tend to make decisions.
The unique ways by which experts in general analyze, judge, and make decisions about situ-
ations were discussed and defined by Dreyfus and Dreyfus (1985). In using this framework, Benner
and Tanner (1987) demonstrated how nurses use intuition in expert clinical judgment. Six key
aspects of intuitive judgment were identified and discussed in a study that included 21 nurses who
were defined by their colleagues as experts. Nurses demonstrated their ability to make judgments
by using their intuitive expertise to recognize patterns of relationships in situations that are not
readily recognizable to others, by detecting similarities between situations through common-sense
understanding, by “knowing how” in a way that is not definable in common scientific terms, by
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16 PART ONE Our Theoretical Journey
having a “sense of salience” (i.e., recognizing priorities), and by using “deliberative rationality”
(shifting perspectives for better understanding) (Benner and Tanner, 1987). These processes
involved a level of intuition that has been devalued by nurses for its lack of scientific bases. Are
any of these characteristics for caring congruent with those needed for knowing and understand-
ing? The uniqueness of nurses’ capacity to know and the unique ways by which they demonstrate
that knowing and understanding are proposals that should be seriously considered.
That there are different processes of knowing is a proposal that has been supported by a num-
ber of key publications from the 1980s. For example, Belenky, Clinchy, Goldberger, and Tarule
(1986) identified five different types of knowers. Schultz and Meleis (1988) theorized that these
types could be found in nursing. Types of theories and levels of theory development may be influ-
enced by the ability of nursing theorists to uncover knowledge of the different types, to be able to
hear and reflect the voices of the different knowers in theoretical development.
If the five types of knowers identified by Belenky and colleagues (1986) are defined from a
nursing perspective, the following is what we might find:
1. Silent knowers are nurses who tend to accept the voices of authority and thus learn to be
silent. These nurses know their practice, their teaching, or their administrative practice,
but they may not be able to articulate what they know through abstract thought for theo-
retical development and may not have the language to express their analysis or interpreta-
tion of the phenomenon. Their work, insights, and wisdom are invisible because they are
not represented or because theorists have not been able to retrieve them for further theo-
retical development. Could these silent knowers conceptualize their understanding of
phenomena in ways that are more congruent with their propensity to develop theories?
2. Received knowers believe others are capable of producing knowledge that they can fol-
low and reproduce. They believe in external authorities’ abilities to generate knowledge,
but not in their own or their peers’ abilities to do the same. These people depend on and
value the expertise of others. Many nurses have contented themselves with using the
works of others, believing those works to be far superior to anything they themselves
could create. Examples are the different theories and paradigms that we have bought into
and used for years without questioning.
3. Subjective knowers depend on their personal experiences. These knowers believe and
depend on their own inner voices and inner feelings. Knowledge to them is “personal,
private, and subjectively known and intuited,” and truth “is an intuitive reaction—some-
thing experienced, not thought out, something felt rather than actively pursued or con-
structed” (Belenky, Clinchy, Goldberger, and Tarule, 1986, p. 69). Although these
knowers find it difficult to articulate the processes used to arrive at knowledge, they have
the wisdom to look holistically and explain complete situations. Knowledge from nursing
practice as articulated by subjective knowers could inform the discipline of nursing in
ways that no other knowledge could. This is the knowledge that Carper (1978) referred to
as personal knowledge and Benner (1984) as expert knowledge.
4. Procedural knowers depend on careful observations and procedures. They are the ratio-
nalists among us. These are the people who communicate procedures, rules, and regula-
tions, and thus may be best suited for developing empirical or procedural theories.
5. Constructed knowers view all “knowledge as contextual, they experience themselves as cre-
ators of knowledge and value both subjective and objective strategies of knowing (Belenky,
Clinchy, Goldberger, and Tarule, 1986, p.15).” These knowers integrate the different ways of
knowing and the different voices (including the silent voice). To them, “all knowledge is con-
structed, and the knower is an intimate part of the known” (Belenky, Clinchy, Goldberger, and
Tarule, 1986, p.137). To subscribe to this view is to accept the never-ending process of knowl-
edge development, to accept that theories are always in process, to accept that frames of refer-
ence are constructed and reconstructed, and to accept that situations, as well as knowledge,
are contextual and subject to different interpretations (Schultz and Meleis, 1988).
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CHAPTER 2 On Being and Becoming a Scholar 17
Scholarship of Integration
Are there different types of scholars in nursing? In considering the major theoretical and
research literature from the 1970s through 2006, patterns of scholarship emerge. These patterns
are tentative and are continuously evolving; however, I think they represent definite patterns of
scholarship in nursing. Here, I propose some concepts intended to reflect the nature of the differ-
ent patterns used by nurses to arrive at the integration of knowledge. These are intended to gener-
ate discussion and debate.
The synthesizers are conceptualizers who are able to connect already developed ideas, ana-
lyze them, and arrive at new “wholes.” These new wholes make for a more effective
explanation and interpretation of already existing knowledge.
The leap theorizers are those who amass research or clinical data and reduce these data to
abstract ideas. They are the conceptualizers who are able to make leaps to generaliza-
tions, to create challenging theoretical questions and answers.
The bush describers are those who know how to describe relationships that have been
empirically identified and verified. They usually are reluctant to go beyond these specific
findings.
The out-of-discipline theorizers are those who see the world of nursing through glasses
tinted by other disciplines. Therefore, when engaging in conceptualizing and answering
questions, they select those that are more accepted and more central to other disciplines.
At the same time, however, their findings and conceptualizations shed some light on
nursing problems, however minor those problems are to the core of nursing.
The conceptualizers are those who are discovering, identifying, and exploring the disci-
pline’s concepts. These concepts may be central or tangential.
The integrated theorizers are those who are as comfortable with theorizing as with
researching or practicing. More importantly, these are individuals who have synthesized
the different aspects of their problem of interest and have been able to develop conceptu-
alizations in which clinical, research, and theoretical insights are contained.
REVISITING SCHOLARSHIP IN THE 21ST CENTURY
Now, let’s see how scholarship in nursing may be defined based on the redefinitions provided in
the preceding text. Scholarliness has been described by many writers, with some slight variations
in the definition. The common themes are that a scholar is a person who has a high intellectual
ability, is an independent thinker and an independent actor, has ideas that stand apart from others,
is persistent in her quest for developing knowledge, is systematic, has unconditional integrity, has
intellectual honesty, has some convictions, and stands alone to support these convictions. A
scholar is a person who is flexible and who respects all divergent opinions (Armiger, 1974; Diers,
1995; Meleis, Wilson, and Chater, 1980; Parse, 1994; Roe, 1951). In addition, of course, a scholar
is a person who is deeply engaged in the development of knowledge in the field (Johnson,
Moorhead, and Daly, 1992). Not all scientists are scholars, and not all scholars are scientists.
Scholarliness concerns having a sense of history about a discipline and knowing how one’s work
fits within the larger framework and goals of the discipline.
The definition of scholarship has changed. Rules once were clear. Scholarship meant
research, and research meant one type of research. As discussed previously in the chapter, Boyer
changed how scholars are viewed. Scholars were defined as:
academics who conduct research, publish and then perhaps convey their knowledge to
students or apply what they have learned. (Boyer, 1990, p. 15, Carnegie Foundation)
Let’s now revisit Boyer’s different classifications from a nursing perspective. Scholar-
ship was confined only to those involved in the discovery of knowledge and was limited to
innovative discoveries that made contributions to knowledge development and progress.
Scholarship in nursing, within this prevailing framework, was defined as having an academic
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18 PART ONE Our Theoretical Journey
rank and as being engaged in basic research and in publication (Hofmeyer, Newton, and
Scott, 2007). Furthermore, the sentiment prevailed that those who applied knowledge were
not scholars; rather, they were practice-oriented folks who must leave scholarship aside and
focus on their own practice.
Nurses who value practice as the essence of the discipline have always known something is
missing in this definition. It robbed nurses of their rich clinical heritage, and it stifled the
processes needed to integrate knowledge and relate it to practice. And practice, we suspected,
was the heart and the soul of the discipline. As nurses, we were, however, afraid to rock the
“ivory towers” in an attempt to change these definitions. After all, we were just the new kids on
the block, with no clout and with a lot of vulnerability. Beginning rumblings were manifested in
the writings of many nurses who questioned this status quo. But these rumblings became louder
in the Carnegie Foundation report described previously (Boyer, 1990), which urged that schol-
arship be redefined. The proposal of this document was the acceptance of other types of schol-
arship, such as the scholarship of integration, as well as the scholarship of application.
Scholars who excel more at the integration of knowledge rather than at the discovery of knowl-
edge tend to focus on conceptualizing and theorizing; they not only describe findings, but also
interpret and ascribe meanings to these findings within the context of the discipline. Their
scholarship is thus manifested in presenting thoughtful analyses of profound, philosophical,
and theoretical changes in the discipline. This form of scholarship is manifested but continues
to be overshadowed by the scholarship of discovery. The language of integration increasingly
penetrated academia and practice, and there are indications that it is being accepted and valued
as an acceptable form of scholarship (Hofmeyer, Newton, and Scott, 2007). Scholarship of
application, on the other hand, has gained more support. Scholarship of application is defined
by Palmer (1986) as:
a complex activity and synthesis of observations of clients and patients . . . a complex activity
that has as its purpose, the discovery, organization, analysis, synthesis, and transmission of
knowledge resulting from client-centered nursing practice. (p. 318)
Diers (1995) also defines clinical scholarship (or scholarship of application in Boyer’s report) as:
certain habits of mind. Clinical scholarship modifies the noun only by focusing on observa-
tions in and of the work, including the perception of one’s own participation in it. To these
observations are applied disciplined habits of analysis (including careful attention to sources)
and analogy, that are carefully described and even more carefully edited so that, when written,
the activity produces new understanding, new knowledge. (p. 25)
Clinical scholarship is reflected in the careful analyses of situations and critical assessment of
responses; it requires a certain intellectual maturity that comes from expertise and repeated expe-
riences. The explanations and reflections offered by the clinical scholar are contexted in her per-
sonal history and are enhanced by her well-supported interpretations. Scholarship of application is
honored in institutions of higher education through professional appointments in the clinical and
practice ladders.
The Carnegie report also acknowledged an area of scholarship that nurses long suspected
should be included. That is the scholarship of teaching. Teaching was traditionally set aside as an
application of knowledge, and accepted as secondary to knowledge discovery. We all spent hours
developing innovative curricula, creative teaching strategies, and learning modules, and we dis-
covered new ways to help students understand their practice roles, defined ways by which we
could create synthesis and integration in student’s knowledge, and watched with admiration how
seasoned clinicians assisted the inexperienced to become transformed. We wished there were
some ways in which we could articulate how productive researchers managed to inspire and guide
beginning researchers. But we were reluctant to consider all this as scholarship.
I believe that what began in nursing decades ago, what nurses have attempted to demonstrate
as scholarship, is now acknowledged as such. The question before us today is: In what ways will
these redefinitions of scholarship reshape scholarship in nursing?
LWBK821_c02_p007-022 07/01/11 6:06 PM Page 18
CHAPTER 2 On Being and Becoming a Scholar 19
These redefinitions of scholarship, which are more friendly to the nature of the discipline, the
practice of nursing, and the mission of nursing, have affirmed what nurses believed was essential
to a human science but reluctantly ignored for many decades. These new acknowledged
approaches to nursing as a discipline value the need for nurses to have a “group of fields” that are
related to nursing but are outside of nursing (Diers, 1995).
Our discipline is scholarly if members of the discipline engage in the development of knowl-
edge that has some significance to humanity and to human beings, if they open doors for those
who have the most difficulty in accessing the health care system, and if they encompass and
include the underserved population. Nursing scholars deal with human beings, and they not only
pursue explanation and prediction, they also address an understanding of clinical phenomena that
may result from clinical as well as theoretical knowledge.
Unlike other disciplines that may have promoted competition and distancing as hallmarks of
their scientific development, the nature of nursing, with its gender orientation, respect, and use of
feminist approaches in viewing the discipline (see Chapters 4 and 8), necessitates the promotion
of cooperation and collaboration over competition and separation. Scholarliness in the discipline
means flexibility regarding its theoretical base. Finally, a scholarly discipline is predicated on the
soundness of its theoretical base.
Scholarliness in nursing includes the collaborative efforts of all the resources within nursing,
working together to develop critical and reflective thinking in students, academicians, and clini-
cians. According to Dewey (1922), critical thinking is defined as the ability to suspend judgment
on matters of interest. Critical thinking should be fostered by cognitive and affective approaches
in the educational and clinical arenas. The cognitive approach is enhanced by the provision of
frameworks for teaching, discussion, and clinical practice. The affective approach is enhanced by
providing frameworks that allow for dialogue, analysis, and reflection on experience.
Examples of critical thinking in nursing include the awareness and inclusion of a focus on
systems of patriarchy and domination and their influence on knowledge development (Thompson,
1987). Scholarship in nursing must reflect the type of critical thinking that generates awareness of
unequal resources, of relationships that are distorted because of domination, and of the influence
of marginalization on members of the discipline and on those who are the recipients of care (Hall,
Stevens, and Meleis, 1994; Thompson, 1987). A scholar in nursing demonstrates a passion for
making a difference, for dismantling old patterns that are based on unequal power and reconstruct-
ing patterns that are based on equity, resources, shared power, and on collaboration in decision
making.
A balance should be struck between providing a framework that enhances critical thinking
and one that may lead to other created frameworks. If only one framework is provided, it could be
a stifling act that prevents a person from seeing other potential avenues to understanding the situa-
tion. Critical thinking lies in the balance between framework thinking and the flexible viewing of
a situation. Critical thinking can also be enhanced by using effective approaches—for example,
through the creation of dialogues about patient care situations that are open to debates and cri-
tiques. Critiquing existing theories or research is also appropriate for developing critical thinking.
Scholarship includes the creativity needed to consider ways to develop knowledge in a human sci-
ence, ways that do not stifle the richness of its phenomena.
Scholarliness necessitates the use of local models of excellence and the promotion of spon-
sorship of novices by experts or mentors and mentorees as essential. To preach scholarship with-
out demonstrating it in a close working relationship between mentor and mentoree leaves a lot to
the imagination of the mentoree that may not be tangible and attainable (Meleis, Hall, and
Stevens, 1994). Participation in a mentoring relationship with a person who is pursuing scholar-
ship in practice, theory, or research tends to promote the potential development of the same char-
acteristics in the mentorees. Scholarliness in a discipline not only depends on the definition of the
discipline by those who are inside it; it also depends on how the discipline is viewed by those out-
side it. We need to make our discipline more public—demonstrate its significance to the health
and care of the public. We also need to become involved in the political and policy-making
processes and to make a point of speaking to the public directly.
LWBK821_c02_p007-022 07/01/11 6:06 PM Page 19
20 PART ONE Our Theoretical Journey
CONCLUSION
One does not develop knowledge to gain scholarliness in a discipline. Being a scholar is a means
toward an end and not an end in itself; it is a means toward the empowerment of nursing as a pro-
fession, and of nurses as scientists, clinicians, educators, and policy-makers. The end goal is
patient care based on socially relevant knowledge that is developed with social consciousness. It is
to provide, enable, and empower nurses to make the changes they want to make in the quality of
patient care. It is to participate in the development of policies that affect the care that is given. That
influence is possible only if it comes from a socially relevant knowledge base. Such a knowledge
base can be developed only if reflective attention is given to patterns of knowing in nursing, and to
the phenomena relevant to nursing, within a values system that accepts and respects a nursing per-
spective.
4. What are the advantages and disadvan-
tages of utilizing norms of scholarship
that reflect scholarship of integration in
advancing the discipline of nursing?
5. Give examples of the different types of
scholarship within your field of interest.
6. Identify key scholars in your field of
interest who represent each type of
scholarship as discussed in this chapter.
7. In what ways is theoretical thinking
related to scholarship?
8. What criteria, milestones, and outcomes
should be used in nursing to evaluate
progress for scholars who are engaged in
the scholarship of application and the
scholarship of integration? What strate-
gies would you use to influence the gold
standard criteria for scholarship that are
embodied in academic institutions?
REFLECTIVE QUESTIONS
1. After you review the chapter, reflect on
this statement: “A scholarly discipline
must engage in societal concerns, in dia-
logues about pressing issues, and in
shaping health care reform.” Consider-
ing the above as conditions for scholar-
ship, what would be your assessment of
the level of scholarship in nursing?
2. Scholarship is defined in terms of sci-
ence, discovery of knowledge, verifica-
tion of knowledge, empirically and by
the extent to which these processes ren-
der the research competitive for funding.
Discuss the aforementioned within the
context of nursing as a human science.
3. If you think the definition of scholarship
in question 1 is the best in reflecting the
discipline of nursing, discuss the out-
comes on nursing science of using such a
definition.
Acknowledgments
This section, dealing with scholarliness, norms of scholarliness, and tools of scholarliness, was adapted, with extensive
revisions, from the Helen Nahm Lecture I delivered at the University of California, San Francisco, in 1981; and from (by per-
mission) Meleis, A.I. (1983). The evolving nursing scholarliness. In Chinn, P.L. (Ed.), Advances in Nursing. Rockville, MD:
Aspen Systems.
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C H A P T E R 3
Theory: Metaphors, Symbols, Definitions
THE DESTINATION: THEORY AND THEORETICAL THINKING
Every journey has its own symbols and metaphors that shape the experience process and destina-
tions. Students of theory, as well as of the discipline’s history, should clarify the metaphors, sym-
bols, and definitions of the theory language. Metaphors reflect how valued or devalued certain
events or concepts are. A number of metaphors have been attributed to theory in nursing, and these
metaphors have shaped the development, progress, and the use of theory in the discipline.
Metaphors that have promoted or hampered the theoretical progress of the discipline are numer-
ous. Among the metaphors that have constrained progress are theory and ivory towers; theory as
an academic exercise; theory for curriculum; conceptual frameworks that are not theories; theories
that are too esoteric; borrowed theories that should be eliminated from our discipline; and theories
used to frame research questions. When metaphors reflect curricula or ivory towers, they tend to
derail theoretical discourse and progress. When metaphors reflect practice and research, they
move the discipline forward, refining and building on its theoretical progress. Metaphors that help
to advance theoretical discourse are theories and interpretations of responses or results; shared
theories; integrated theoretical frameworks; theories in nursing and for nursing; practice theories;
and theories from practice.
New anti-theory metaphors within the discipline are related to nurses progressing from being
novices to becoming experts, a progress that is erroneously perceived by some to be based solely
on a nurse’s own personal and clinical experiences and insights. The wisdom gained in the process
of moving to expert status is reflected in articulating clinical exemplars, and these exemplars are
then used to guide the novice’s work in the future. Other metaphors that tend to substitute for the-
ories are evidence-based practice (with evidence being equated with research), best practices
(defined as based on research), and inductive reasoning as far more effective than deductive rea-
soning. In fact, theory may be either the driving force or the outcome of all these metaphors. One
metaphor that could shape the discipline of nursing during the 21st century is the cyclical integra-
tion of theory, research, and practice. Evidence for practice then becomes viewed as being based
on a set of principles and assumptions, as well as on research processes and outcomes. Interpreta-
tions of the findings are as driven by the theory that framed the research questions as by the data
analysis of the study and the meanings imputed on the data by the researcher’s own wisdom and
views. Therefore, whether the agent of knowledge or the agent of practice is aware of theory, some
level of theory shapes the questions and the interpretations that the agent uses in research or prac-
tice. Metaphors shape how students, faculty, and clinicians tend to accept, reject, use, or refuse to
acknowledge the use of theory in their work.
A metaphor that could be adopted is that of a painting that requires a coherent vision of an
end result, the right canvas to translate that vision, the painter to execute his or her vision, the tools
to make the painting happen, the viewer who perceives the painting based on his or her context,
the public who may or may not value the painting, and the media that may make or break the artist
or the painting. Theory is the coherent vision of the context, process, and outcome. Theory is the
goal of all scientific work; theorizing is a central process in all scientific endeavors, and theoreti-
cal thinking is essential to all professional undertakings. However, the painter (the nurse/theoreti-
cian), the viewer (the student of theory and the translating clinician), the public (including the
patient, other professions, the public at large, and the researchers) have their own perspectives and
interpretations of the theory. The media (all constituencies) may promote or obstruct the use of
theory.
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24 PART ONE Our Theoretical Journey
Think of all components that make up a painting or a school of thought in art as you read
about theory and theoretical thinking in the next few pages. Despite the tremendous progress
made in the theoretical development of the discipline of nursing, as demonstrated in the explosion
of theoretical writing, some confusion remains regarding the role of theory in the development of
knowledge and the role of researchers and clinicians as theorists (creator of a painting school of
thought, interpretation and translation of art). More recently, the explosion in programs that pre-
pare nurses as nurse practitioners is matched by a decline in theoretical and philosophical dia-
logue. It is natural and expected for some nurses to declare themselves only clinicians, only
theoreticians, or only researchers. However, it should be of great concern to nurses when theoriza-
tion, theory development, and theory utilization are seen as “ivory tower” activities, removed from
other scientific and professional processes. It is of concern and should be alarming because, with-
out a coherent view of what nursing is, what goals are to be accomplished, and how to evaluate
consequences, how do we expect to provide lifestyle changes, maintenance of health, and healing
and recovery to occur? Activities that clinicians and researchers perform and should perform in
some form or other, with varying degrees of intensity throughout their careers, are dependent on
coherent views of outcomes. Without a vigorous theoretical discourse about our profession and its
outcomes, we would not be able to build a cumulative knowledge base, which is the basis for
established disciplines and expert knowledge. Claiming expert and advanced clinical practice is
predicated on a coherent body of knowledge and evidence of outcomes of quality care—the mark-
ers for established disciplines and expert knowledge. None of it would be possible without theo-
retical dialogues and coherent theories that reflect existing evidence and lead to the development
of more evidence for practice.
On one level, nurses have demonstrated more commitment to the activities associated with
theory, as manifested in the language nurses use to describe the activities that occupy them. One
example is the use of criteria-based adjectives to describe theory utilization (Cormack and
Reynolds, 1992) in nursing, such as scope, usefulness, or goodness-of-fit of theory, with one’s
own values or with clients’ clinical problems. Skepticism and non–criteria-based critiques
founded on limited knowledge and a paucity of criteria are not helpful in making changes or in
developing knowledge. However, healthy skepticism and criteria-based critiques that are based on
knowledge are essential to the development of knowledge.
Theory and theoretical thinking are not limited to theoreticians in the discipline. Theoretical
thinking is integral to all the roles played by nurses, including those of researcher, clinician, con-
sultant, and administrator. In research, for example, theoretical thinking could be demonstrated in
all aspects of the research process, from conceptualizing the research questions to interpreting the
meaning of data. First, it is demonstrated in identifying the phenomenon within the domain of
nursing, in differentiating between relevant and irrelevant phenomenon, and in deciding how the
research questions are related to the theoretical domain of nursing and to the focus of nursing
practice. In a human science, theoretical thinking is also demonstrated when and if the researcher
attempts to determine the importance of the research questions to the discipline of nursing, as well
as to society at large. Theoretical thinking helps to raise questions about the investigator as an
agent of the research and to determine the meaning of the investigation to the researcher person-
ally. Theory provides a framework from which to consider those personal meanings that drive the
research, as well as from the researcher’s personal commitment to the research process. When
these questions are asked, discussed, and answered, a process of theoretical thinking has already
occurred.
Second, theoretical analyses guide the process of phenomenon definition, as well as the
research process (Quinn, 1986). The researcher seeks theories that can help in describing the phe-
nomenon or its relationships to other phenomena, or that can prescribe a nursing action for it. If
theories are available, then the researcher evaluates them to determine the most useful theory for
the research process—one that will expand knowledge. Theory evaluation is as much the business
of the theoretician as it is the business of the researcher and clinician. The researcher evaluates
whether a theory should be tested as well as whether, and in which ways, the findings of the
research can help refine and extend the theory. The clinician evaluates theories for use in practice.
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CHAPTER 3 Theory: Metaphors, Symbols, Definitions 25
Therefore, even the process of theory evaluation for use in research or practice demonstrates
another component of theoretical thinking.
Third, after a theory is evaluated, a hunch may evolve and propositions may be developed to
guide the research process or to test the theory. Fourth, after testing a theory or the propositions of
a theory, the researcher may complete the task by simply describing the findings or by interpreting
those findings in relationship to the original theory, perhaps choosing to refine, extend, or modify
the original theory. Each of these activities is theoretical in nature and represents a vital compo-
nent of theoretical thinking and theory building; each of these activities should be acknowledged
as an aspect of engaging in the work needed to develop theoretical nursing.
The professional clinician goes through a similar process in deciding what to assess in clients,
the timing of assessment, how to define the needed actions, and what interventions are best for the
situation. He or she develops hunches, pursues some, accepts others, and refutes others. The clini-
cian develops priorities, modifies them, and reorders them in the process, making some “auto-
matic” decisions and others that require careful consideration and deliberation. Some of these
decisions are based on theory; others could be the impetus for theoretical development. These
processes reflect those activities of theoretical analysis and development that are described in this
book. In engaging in any or all of these processes, a clinician is experiencing theoretical thinking,
but may not be aware of the process, may not label it as such, or may not allow the theoretical
process to progress enough to culminate in knowledge development. To understand these processes
and to use them to the fullest, definitions of some key concepts are first proposed as a baseline.
DEFINITIONS
Concepts used in developing, evaluating, and operationalizing theories can be defined in a number
of different ways. Definitions are influenced by one’s world view, as well as by the particular the-
oretical heritage of the concept. Language tends to shape the discourse about a particular problem
or a specific care situation. Kramer (2002) demonstrated how informal caregiving for patients
with dementia was described in terms of burden, and thus questions raised about such care tended
to be built on assumptions of passivity in patients with dementia and oppression by caregivers. It
is significant for theory students to be critical of any definitions provided and to recognize that
they are based on a variety of frameworks and a number of different truths.
With that caveat, I encourage you to familiarize yourselves with the definitions provided in the
subsequent text. Recognize that a variety of options exist, and perhaps one of them will be most
congruent with your own philosophical values. The following definitions (Meleis, 1997) are influ-
enced by a feminist perspective, which shapes the fabric of tentative realities (Bleier, 1990).
Another major influence on my thinking and writing about theory is the tradition of symbolic inter-
actionism (Mead, 1934). The definitions that I provide here are given as guidelines and are, there-
fore, limited in depth and scope. Your extensions and refinements of these definitions are expected.
Assumptions
Assumptions are statements that form the bases for defining concepts and framing proposi-
tions. Assumptions provide the context for a theory. They are accepted as truths, and they repre-
sent values and beliefs. These statements represent the thread that holds different aspects of
knowledge together. Assumptions are the taken-for-granted statements of the theory, the concept,
or the research that preceded the subsequent investigation. When assumptions are challenged,
they become propositions. Assumptions emanate from philosophy; they may or may not represent
the shared beliefs of the discipline. The values in a theory and/or about the profession and disci-
pline of nursing are reflected in the theory’s explicit or implicit assumptions.
Concept
Concept is a term used to describe a phenomenon or a group of phenomena. A concept
denotes some degree of classification or categorization. A concept provides us with a concise
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26 PART ONE Our Theoretical Journey
summary of thoughts related to a phenomenon or a group of phenomena; without such concise
labeling, we would have to go into great detail to describe them. Notice the difference between
describing the phenomena of what happens to individuals who travel from one time zone to
another through detailing their sleep disturbances, and the changes in their moods, eating habits,
bowel movements, and routines, and summarizing all those details through the concept of “jet
lag.” The latter is a more concise and a more efficient way of communicating the ideas contained
in, and related to, jet lag. Labeling a concept may make it more feasible to analyze and to develop
it further. A labeled phenomenon or set of phenomena is a concept, and a concept could be opera-
tionalized further and is more amenable to be translated into a research tool.
Domain
Domain is the territory of the discipline. It contains the subject matter of a discipline, the
main agreed-on values and beliefs, the central concepts, the phenomenon of interest, the central
problems of the discipline, and the methods used to provide some answers in the discipline. A
domain includes the players and actors who help to ask and answer the questions. The actors in
the domain of nursing are clinicians, researchers, theorists, metatheorists, philosophers, teachers,
consultants, and ethicists. Domains are discussed further in Chapter 6.
Epistemology
Epistemology is a branch of philosophy that focuses on reflection on and investigations about
the nature and foundation of knowledge. Questions about how knowledge is defined, developed,
verified, believed, or became certain are epistemological questions (Przylebski, 1997). Epistemol-
ogy also addresses notions about the extent to which knowledge is limited or expansive. Episte-
mology is the theory of and about knowledge, and it is also about the methods by which
knowledge is developed (White, 1999).
Evidence-Based Practice
Evidence-based practice is a concept that was initially developed in Canada, in the 1980s, for
medical education with the intent of using and valuing research findings over data-generated
dichotomy and opinion. The Cochrane Collaboration, an organization with global influence,
helped sustain the momentum by developing and propagating meta-analyses. Evidence-based
practice is based on the comprehensive review of research findings, with emphases on interven-
tion, randomized clinical trials as a gold standard, the integration of statistical findings, and mak-
ing critical decisions about the findings based on evidence hierarchies, tools used in studies and in
meta-analysis, and cost (Jennings, 2000; Jennings and Loan, 2001).
Evidence-based practice is based on research data that suggests a basis for the choice of a
particular practice and the consequences and outcomes that are likely to occur. It is the implemen-
tation of findings from the most recent investigations for the purpose of providing quality care.
Decisions that a nurse makes in caring for her patients may depend on the best solutions derived
from her experiences or from the best research findings that are substantiated through publication
in public or academically peer-reviewed forums. The latter choice reflects evidence-based prac-
tice (Ervin, 2002).
What guides the nature of the questions and the evidence must not be forgotten. Similar
meta-analysis of theories that drive the questions, analysis, and interpretation should become part
of the meta-analysis (Fawcett, Watson, Neuman, Walker, and Fitzpatrick, 2001). Therefore,
although evidence-based practice rarely refers to theoretical underpinnings, evidence based on
research that is not theoretically driven limits the utility of that evidence to limited sets of vari-
ables that may lack a coherent framework.
Ontology
Ontology is the fundamental assumptions about the nature of beings, the relationships between
the parts as they exist. It is a theory of “what there is” (Lejewski, 1984). Ontology provides the basis
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CHAPTER 3 Theory: Metaphors, Symbols, Definitions 27
for analyzing and understanding nature and the relationship between human beings and nature
(Rawnsley, 1998), as well as the laws that are behind these categories (Burkhardt and Smith, 1991).
It is the discipline that provides the logical tools to analyze the nature of basic and fundamental cat-
egories (Grossman, 1983). An ontological analysis of a conceptualization is an analysis of the
nature of its existence, the categories it encompasses, and the relationship between those categories
and what they mean. Ontology has been referred to as a science, a theory, and/or a specific concep-
tualization (Gracia, 1999; Jacquette, 2002). It is a concept used in the philosophical tradition, as
formalized ontology. It is a branch of metaphysics, and it has a variety of meanings (Hartmann,
1953). Among them are describing the nature of theoretical formulations as they exist, an analysis
of the qualities of beings, and postulations about relationships (Burkhardt and Smith, 1991). Gen-
eral ontology focuses on the study of such concepts as space, time, and event, and special ontology
studies social systems and structures (Dictionary of Philosophy, 1999, pp. 200–201).
However, in nursing we use ontology to mean a study and critical analysis of the very
nature—the core—of beings, relations, and concepts. It is an internal analysis of the core of an
entity. The analyses utilize logic as a tool. Ontology as a concept has been used to describe the
nature of development and analysis of theories (Rawnsley, 1998), and it has been used to dialogue
about the nature of nursing (Reed, 1997) and the differences between viewing nursing as an innate
human process of well-being and its service orientation (Bryant, 1998).
Paradigm
The definition of paradigm is closely associated with Kuhn (1970), who introduced the concept
to those members of the scientific community who were interested in philosophical analyses of dis-
ciplines and their development. Critics and supporters of Kuhn’s work have created a multitude of
meanings for paradigm, which were further confused by the many uses of the term that Kuhn
demonstrated in his own writings. Kuhn reported a critic’s finding of “twenty-two different” uses of
paradigm in his writings (Kuhn, 1977, p. 294). Paradigm is defined as those aspects of a discipline
that are shared by its scientific community. To dispose of the confusion created by his multiple use of
paradigm, Kuhn (1977, p. 297) proposed to replace it with disciplinary matrix. A disciplinary matrix
includes the shared commitments of the community of scholars, its shared symbolic generalizations,
and its exemplars, which are the shared problems and solutions in the discipline. The varied, and at
times conflicting, definitions of paradigm within and among disciplines makes its use in nursing
problematic. (See Chapter 18 for further discussion of paradigms.)
Parsimony
Parsimony is the presenting of ideas succinctly, under the premise that explanations should be
clearest when made using the fewest statements. Parsimony requires the elimination of redundan-
cies. Parsimony is also known as the “principle of economy of thought” (Marenbon, 1999, p. 411).
Phenomenon
A phenomenon is an aspect of reality that can be consciously sensed or experienced. Phenomena
within a discipline are those aspects that reflect the domain or the territory of the discipline. A phe-
nomenon is the term, description, or label given to describe an idea about an event, a situation, a
process, a group of events, or a group of situations. A phenomenon may be temporally and geograph-
ically bound. Phenomena can be described from sense-based evidence (e.g., something seen, heard,
smelled, or felt) or from evidence that is grouped together through thought connections (e.g., the
observation that more children die in pediatric intensive care units during the 3:00 p.m. to 11:00 p.m.
shift than on other shifts). In this example, simply observing the deaths does not make the phenome-
non; it is grouping them and considering a connection between them—considering a connection
between the deaths and the specific staff shift—that makes it a phenomenon. As another example, tak-
ing a certain amount of time to adjust to new time zones, having trouble remembering, experiencing
foggy thinking, and being indecisive may all be part of the phenomenon related to flying, or flying
across time zones. Another discussion of phenomena appears in Chapter 15.
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28 PART ONE Our Theoretical Journey
Philosophy
Philosophy is a distinct discipline in its own right, and all disciplines can claim their own philo-
sophical bases that form guidelines for their goals. Philosophy is concerned with the values and
beliefs of a discipline and with the values and beliefs held by members of that discipline. An individ-
ual’s values and beliefs may or may not be congruent with those of the discipline. Philosophy
focuses on providing a framework and worldview for asking both ontological and epistemological
questions about central values, assumptions, concepts, propositions, and actions of the discipline.
Philosophy also provides the assumptions inherent in the discipline’s theoretical structure.
The philosophy of a science deals with those values that govern the scientific development
and justification of a discipline. It helps in defining or questioning priorities and goals. Philosoph-
ical inquiries help members of the discipline to uncover issues surrounding priorities and to evalu-
ate these priorities against societal and humanistic priorities.
Praxis
Action theory or action research was introduced with more frequency to the nursing lexicon
in the 1980s, as critical inquiry based on social criticism and nursing practice. Actions are predi-
cated on interactions between the theorist or the researcher, and knowledge and action are intri-
cately connected. Feminist praxis is based on the premises of mutual interaction: nurses working
on changing situations while developing knowledge, and incorporating emotions and reciprocity
in the knowledge that is being developed. Theories based on praxis allow for action, activity,
development, and constant dynamic changes, but, most importantly, on the dialectic relationship
between theory, action, and critical reflection (Powers and Knapp, 2006, p. 135). Perhaps a purist
view of praxis may negate the development of theoretical thoughts (O’Toole, 2003, p. 1421),
which is more ordered and could be viewed as more structured and static. Purist praxis followers,
the creators of emancipatory knowledge through a dynamic process of critical reflection and prac-
tice changes, would argue vehemently against what they view as the more static nature of theory
and theory development.
Science
Science is a unified body of knowledge about phenomena that is supported by agreed-on evi-
dence. Science includes disciplinary questions and provides answers to questions that are central
to the discipline. These answers represent wisdom based on the results of data that have been
obtained through different designs and methodological approaches. These answers are also the
seeds from which science evolves and develops. There are different approaches to evaluating and
judging scientific findings: support of truth through repeated findings, tentative consensus among
a community of scholars supporting aspects of evidence, tentative consensus among other sub-
communities attesting to descriptions of reality, and the use of objective criteria by members of
the community (Brown, 1977; Kuhn, 1962; Popper, 1962).
Tautology
Redundancies, repetitions, and circular statements are described as tautological (Mautner, 1999).
Teleology
This is the branch of philosophy that deals with ends or consequences. It postulates that the
purpose of any action must be understood in terms of final causes. It is an inquiry into the conse-
quences of the phenomenon being studied. Phenomenon could only be studied in terms of pur-
pose. There is an element of predetermination and determinism. Teleology allows for looking at
the effect of a phenomenon as the cause (Collins English Dictionary, 2000).
Theoretical Frameworks
A theoretical frameworks is a basic structure developed to organize a number of concepts that
are focused on a particular set of questions (O’Toole, 2003).
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CHAPTER 3 Theory: Metaphors, Symbols, Definitions 29
The terms theoretical frameworks, conceptual frameworks, conceptual models, and theo-
ries have been used interchangeably in the literature. The distinction between them occupied
much of the discourse and debates of the mid-1980s. Theories are developed to answer spe-
cific questions. Frameworks and models are developed to provide direction for research proj-
ects. Models are developed to represent theories and to provide direction for research
projects. Theoretical and conceptual frameworks evolve from theory, theories, or research.
Theories differ from frameworks in coherence, a connection between concepts, and the
nature of propositions.
Theory
A theory is an organized, coherent, and systematic articulation of a set of statements related
to significant questions in a discipline and communicated as a meaningful whole. It is a symbolic
depiction of those aspects of reality that are discovered or invented for describing, explaining, pre-
dicting, or prescribing responses, events, situations, conditions, or relationships. Theories have
concepts that are related to the discipline’s phenomena. These concepts relate to each other to
form theoretical statements.
Nursing Theory
Nursing theory is defined as a conceptualization of some aspect of nursing reality com-
municated for the purpose of describing phenomena, explaining relationships between phe-
nomena, predicting consequences, or prescribing nursing care. Nursing theories are reservoirs
in which are stored those findings that are related to nursing concepts, such as comfort, healing,
recovering, mobility, rest, caring, enabling, fatigue, and family care. They are also reservoirs for
answers related to significant nursing phenomena, such as levels of cognition after a stroke,
process of recovery, refusing a rehabilitation regimen for myocardial infarction patients, and
revolving admissions.
The definition of nursing theory has been most problematic, as demonstrated by many
exchanges in the nursing literature. Many concepts have been used interchangeably with the term
theory, such as conceptual framework, conceptual model, paradigm, metaparadigm, theorem, and
perspective. The multiple use of concepts to describe the same set of relationships has resulted in
more confusion and perhaps in less use of nursing theory.
Several types of theory definitions (Table 3-1) are identified by Chinn and Jacobs (1987),
Chinn and Kramer (2004), and Fawcett (2005):
1. The first type of definition focuses on the structure of theory, as exemplified by McKay
(1969), who defined theory as “logically interrelated sets of confirmed hypotheses”
(p. 394). This definition incorporates research as a significant step in theory development
TABLE 3-1 TYPES OF THEORY DEFINITIONS
Chinn and Jacobs (1987) identify four types:
1. Definitions focusing on structure
2. Definitions focusing on practice goals
3. Definitions focusing on tentativeness
4. Definitions focusing on research
From these, Chinn and Kramer (2004) present a fifth type:
5. Definitions focusing on creativity in developing and connecting concepts and the use of theory in practice as
well as research
Fawcett (2005) provides a sixth type:
6. Definitions focusing on progression from conceptual framework to theory
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30 PART ONE Our Theoretical Journey
and discounts conceptualizations that are based only on mental processes. Therefore,
using this definition would not allow the consideration of any of the current nursing theo-
ries as theories.
2. The second type of definition focuses on the goals on which the theory is based. Different
theorists, such as Dickoff and James (1968), define nursing theory as “a conceptual sys-
tem or framework invented for some purpose” (p. 198). Not only do they focus on out-
comes and consequences because of their premise that prescriptive theory should be the
ultimate goal for all theory activities in nursing, but they also do not distinguish between
conceptual framework and theory. Indeed, theory is defined in terms of a conceptual
framework. This definition also brings to our attention the potential for inventing nursing
reality (Chinn and Jacobs, 1987); mental images are therefore not restricted to the discov-
ery of reality but to the construction of reality.
3. The third type of definition alludes to the tentative nature of theory, as exemplified by
Barnum (1998). Barnum defines theory as “a construct that accounts for or organizes
some phenomena” (p. 1). Barnum emphasizes that the source of nursing theory is not
“what is” but “what ought to be,” and that existing conceptualizations are indeed nursing
theories because, she asserts, quibbling over labels of theory, concept, framework, and so
forth are “mere splitting of hairs” (p. 1). Barnum’s definition is significant in a number of
ways: It acknowledges that theories are always in the process of development (Chinn and
Jacobs, 1987), that existing conceptualizations are theories, and that invention is as much
an arena for theory development in nursing as is discovery.
4. The fourth type of definition focuses on research and is exemplified by Ellis (1968). Ellis
defines theory as “a coherent set of hypothetical, conceptual, and pragmatic principles
forming a general frame of reference for a field of inquiry” (p. 217). Ellis’ definition
reminds us that theory is developed for the purpose of guiding research. This definition
assumes that practice guides theory development, theory guides research, and research
guides theory.
5. A fifth definition emerged from the previous four and was articulated by Chinn and
Kramer (2004). They define theory as “a creative and rigorous structuring of ideas that
projects a tentative, purposeful, and a systematic view of phenomena” (p. 58).
According to this definition, imagination and a coherent vision are important, but a
rigorous process of ordering of these imaginative ideas is essential. Tentativeness in put-
ting these ideas together is essential.
Also according to this definition, when concepts are defined and interrelated in
some coherent whole for some purpose, we have a theory. The definition leaves the
door wide open for using theory in practice and research, and it does not restrict the-
ory to research-verified propositions. This definition exemplifies the multiple usages
of theory.
6. A sixth definition of theory is exemplified by Fawcett (2005), who differentiates
between conceptual models and theories, indicating that few nurses present their ideas
as theories. For example, Newman (1994) and Parse (1996) did present their ideas in
the form of a theory, whereas others such as Orlando (1987), Peplau (1992), and
Watson (1989) are a few, according to Fawcett, who spoke about their ideas as theories,
whether grand or middle-range. She defines theory as “one or more relatively concrete
and specific concepts that are derived from a conceptual model, the propositions that
narrowly describe these concepts, and the propositions that state relatively concrete and
specific relations between two or more of the concepts” (Fawcett, 2005, p. 18). This def-
inition and differentiation adds another dimension to how theories are viewed in nursing.
The definition of nursing theory adopted in this text was based on the work and definitions of
previous theorists. I have considered the common themes that evolved from these definitions and
incorporated them into the definition offered here. Theorists and utilizers of theory used labels
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CHAPTER 3 Theory: Metaphors, Symbols, Definitions 31
interchangeably to describe their conceptualizations, and sometimes different labels were used to
describe the same structures. The criteria for the selection of the different labels (model, para-
digm, science, theory, and framework) are not always entirely clear. For example, the utilizers of
theory have used models and theories interchangeably; and, although some usage differentiated
between models and theories, such differentiation was not completely clear. For some, models are
considered structures of concepts that precede the development of theory. They are also used as
structures of concepts evolving from theories. (Refer to Chapter 20, wherein a cursory review of
the section titles will document this multiple usage.)
A deliberate decision was made to avoid fine-line debates about how to label existing con-
ceptualizations about nursing. These differences are tentative at best, and hair-splitting, unclear,
and confusing at worst. Some theorists who differentiate between theory, metaparadigm, con-
ceptual framework, and model have provided analyses that tend to overlap the properties of
each of these concepts. If, indeed, conceptual models are more abstract, less specific, and con-
tain fewer defined concepts and testable propositions, then their linkages with research and
practice should not be expected. Because the utility of these models in practice and research has
in fact been evaluated, and the linkages between theory and practice, research, education, and
administration have been addressed by the utilizers, the properties of the existing conceptual-
izations do not lend themselves to the label “conceptual models.” (See Chapter 7 for further dis-
cussion.) Therefore, the differences between the different labels (theory, metaparadigm,
conceptual frameworks, and so forth) are differences in emphasis rather than substance and may
not be worth continued debate or the creation of new esoteric entities to describe the mental
images of nurse theorists. There is limited support that the use of one label over another has
helped in the differentiation of the type of knowledge developed, and it may have managed to
create more ambiguity for the novice and the experienced alike. Perhaps we need to debate
more substance and less form!
When comparing nursing theories with theories in other fields, such as role theory in sociol-
ogy or psychoanalytical theory in psychology, we often find that some of our nursing theories may
be as specific or as nonspecific as those theories, or as abstract or as concrete. That being said,
why did we continue to unwittingly downgrade nursing theory by relegating it to a conceptual
framework status when other conceptualizations have been called theory? The early reluctance of
nurses to designate their work or the work of others as theories changed in the mid-1990s (Lenz,
Suppe, Gift, Pugh, and Milligan, 1995).
Theories are always in the process of development. Therefore, a theory in process should not
be considered a conceptual framework just because it is in progress or in process. It is simply in an
expected stage in the process of development, and, in a human science, it will always be in process
and in progress.
Some theorists and theory utilizers may prefer the use of one particular label over another;
however, they may find that they use the same conceptualization differently and for different pur-
poses. Theories could be used as conceptual frameworks when concepts from different theories
are linked together to form a new whole. They could be used as theoretical frameworks when con-
cepts from one theory are given new meanings or when they are linked with another theory to
form a new structure that will be tested. They could be labeled a conceptual model when a theory
is used as a prototype and is modeled in form or structure.
Nurse theorists (such as Rogers, Johnson, and Henderson) developed coherent, systematic,
and organized visions of what nursing is and what the nursing mission ought to be. To consider
these conceptualizations as models and frameworks for nursing as a whole is to convey the idea
that nursing is conceptualized in one way and according to one model. Therefore, other conceptu-
alizations may be excluded prematurely by the one-particular-model advocate. Proponents may
ask: How can we see the world through different pairs of glasses simultaneously?
The position taken in this book is that existing nursing conceptualizations are theories that
could be used to describe and explain different aspects of nursing care. They are not competing
models; they are complementary theories that may provide a conceptualization of different
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32 PART ONE Our Theoretical Journey
aspects, components, or concepts of the domain. They reflect and represent different realities.
They also address different aspects of nursing. Nursing theory is then defined as a conceptual-
ization of some aspect of reality (invented or discovered) that pertains to nursing. The con-
ceptualization is articulated for the purpose of describing, explaining, predicting, or
prescribing nursing care. Therefore, not only is nursing theory an articulation of phenomena and
their relationships, but it is an articulation that has to be communicated to colleagues in ways that
make it possible to test, evaluate, interpret, and use these articulations.
Nursing theories evolve from extant nursing reality, as seen through the mind of a theorist
who is influenced by certain historical and philosophical processes or events. These theories also
may evolve from a perception of ideal nursing practice, tinted by one’s history (personal, profes-
sional, and disciplinary) and philosophy. Furthermore, they may reflect a coherent representation
of nurses’ daily work. Theory is a tool for the development of research propositions (see the left
side of Fig. 3-1). Theory is also a goal, a reservoir in which findings (both quantitative and quali-
tative) become more coherent and meaningful. The cyclical nature of theory, practice, philosophy,
history, research, and science is depicted in Figure 3-1. Taken together, and in relationship to each
other, theories constitute the knowledge base for the discipline of nursing.
Examples of the phenomena and relationships depicted in nursing theories are:
• A nursing client is conceptualized as a self-care agent.
• A nursing client is a biopsychosocial and cultural being.
• A nursing client is a system with a number of behavioral subsystems.
Knowledge Base: Truth, Evidence, Perception, and Belief
FIGURE 3-1 ◆ Knowledge base for nursing theory (H, health; C, client; T, transitions; E,
environment; , interactions and process).
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CHAPTER 3 Theory: Metaphors, Symbols, Definitions 33
• A nursing client is conceptualized as a conglomerate of needs.
• A nursing client is a system of such modes as interdependence, self-concept, roles, and
psyche, among others.
• Person–environment interactions are the focus of nursing care.
• Health and illness behavior is a product of person–environment interactions.
• Communication is a tool for diagnosis and intervention in nursing.
• An efficient, functional, productive interaction has several components: sensing, perceiv-
ing, and conceiving.
• A goal of interaction is to develop rapport, which in turn enhances patient care.
• The focus of intervention is the client’s environment.
• Environment is a composite of energy fields.
• Nursing care deals with manipulation of environment.
• Nursing provides self-care needs only until the client or a significant other is capable of
providing self-care.
• A nurse is conceptualized as performing a number of functions designed to meet the
patient’s needs.
• Nurses deliver care that focuses on patients’ outcomes; these outcomes reflect medical
and/or nursing perspectives.
• Nurse–patient interactions are a framework for assessment or intervention.
TYPES OF THEORIES
Theories are reservoirs in which related knowledge is articulated and organized into meaningful
wholes. Theories answer significant questions and help investigators and clinicians to focus on
raising questions in a systematic and a coherent way. Tentative theories reflect growth in disci-
plines. They reflect the wisdom of articulating disparate facts in a meaningful whole and the chal-
lenge of answering new questions as they arise. To accomplish its goals of optimum health for its
clients, the discipline of nursing must have theories to describe its phenomena, to explain rela-
tions, to provide a framework for interventions, and to predict outcomes. Theories may be
described in terms of their levels of abstraction or in terms of their goals.
Definition of Theories by Level of Abstraction
When considered in terms of their levels of abstraction, three types of theories emerge in
nursing: grand theories, middle-range theories, and situation-specific theories. Each is described
in the subsequent text.
Grand Theories
Grand theories are systematic constructions of the nature of nursing, the mission of nursing,
and the goals of nursing care. Grand theories are constructed from a synthesis of experiences,
observations, insights, and research findings. Grand theories reflect the broadest scope and pro-
vide relationships between a large number of abstract concepts. Grand theories are the highest in
abstraction and do not lend themselves to empirical testing. Early theorizations in nursing are con-
sidered grand theories. Examples are Roger’s theory of energy fields and King’s theory of goal
attainment.
Middle-Range Theories
Theories that have more limited scope, less abstraction, address specific phenomena or con-
cepts, and reflect practice (administrative, clinical, or teaching) are considered middle-range theo-
ries. The phenomena or concepts tend to cross different nursing fields and reflect a wide variety of
nursing care situations. Middle-range theories lend themselves to empirical testing because the
concepts are more specific and can be readily operationalized. Examples of middle-range theories
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34 PART ONE Our Theoretical Journey
are uncertainty, incontinence, social support, quality of life, community empowerment, comfort,
social support, and unpleasant symptoms.
Situation-Specific Theories
Situation-specific theories focus on specific nursing phenomena that reflect clinical practice
and that are limited to specific populations or to a particular field of practice. These theories are
socially and historically contexted; they are developed to incorporate, not transcend time, or social
or political structures. Therefore, their scope and the questions driven by them are limited and
encompassing of the context. Examples are menopausal experiences of Korean immigrants, lived
experiences of Asian American women caring for their elderly relatives, and preventive models
for HIV among adolescents.
Definition of Theories by Goal Orientation
Theories can also be classified in terms of their goals. As such, there are descriptive and pre-
scriptive theories. Descriptive theories describe relationships between phenomena, describe
nurses’ and patients’ relationships, and describe guidelines for interventions. Processes of assess-
ing, diagnosing, and intervening must be considered in the development of nursing theories
(Kritek, 1978). To accomplish their goals of supporting and promoting optimum health and well-
being, nurses also need theories to capture efficient and effective clinical therapeutics to use in
achieving health care outcomes for their patients.
Descriptive Theories
Descriptive theories are those that describe a phenomenon, an event, a situation, or a rela-
tionship; they identify its properties and its components; and they identify some of the circum-
stances under which it occurs. Although descriptive theories have an element of prediction (e.g.,
predicting when a phenomenon may occur and when it may not occur), their contribution to
knowledge is mainly to help sort out observations and meanings regarding the phenomenon.
Descriptive theories describe a phenomenon, speculate on why a phenomenon occurs, and
describe the consequences of that phenomenon; therefore, they have explanatory, relating, and
predicting utility. Descriptive theories are complete theories and have the potential to guide
research.
There are two types of descriptive theories. The first type is the factor-isolating, category-
formulating, or labeling theory. This theory describes the properties and dimensions of phe-
nomena. The second type is the explanatory theory, which describes and explains the nature of
relationships of certain phenomena to other phenomena. Examples of descriptive theories are
the descriptions of the life processes of a nursing client, person–environment interactions in
health and illness, health status, ways of assessment, types of diagnosing, disruptions of life
processes, and outcomes and interventions. Descriptive nursing theories are those that
help describe, explain, and predict nursing phenomena and relationships between nursing phe-
nomena. Descriptive theories are not action oriented and do not attempt to produce or change a
situation.
Prescriptive Theories
Prescriptive theories are those that address nursing therapeutics and the outcomes of inter-
ventions. A prescriptive theory includes propositions that call for change and predict the conse-
quences of a certain strategy for a nursing intervention. A prescriptive theory should designate the
prescription and its components, the type of client to receive the prescription, the conditions under
which the prescription should occur, and the consequences. It articulates the conditions in the life
process, person–environment interactions, and health status that need the prescription and the
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CHAPTER 3 Theory: Metaphors, Symbols, Definitions 35
effect on the client’s life process, health status, and interaction with the environment. Prescrip-
tions may also be focused on the environment.
In summary, all theories used in nursing to understand, explain, predict, or change nursing
phenomena are nursing theories, whether they evolved out of other theories, other paradigms,
other disciplines, nursing experiences, diagnoses, nursing processes, or nursing practices, and
whether they were developed by nurses. If we must differentiate between different types of theory,
then such differentiation is meaningful only in terms of levels and goals, not in terms of the source
of the theory. Theories that are developed to understand and explain human processes in health
and illness are pure or basic theories. In other words, they are theories with a descriptive focus.
Theories that are developed to control, promote, and change are nursing practice theories or pre-
scriptive theories (Crowley, 1968).
THEORY COMPONENTS
Theories are structures that include assumptions, concepts, narrative descriptions, propositions,
and exemplars. The structural components of descriptive and prescriptive theories are somewhat
different.
Structural components of descriptive theories include:
Client’s state or condition
Patterns of responses to conditions, situations, or events
Analyses of contexts of conditions, situations, or events and patterns of responses
Analyses of conditions that promote and inhibit contexts
Structural components of prescriptive theories include:
Definition of client’s situation
Nursing therapeutics
Process by which therapeutics are implemented
Patterns of responses for desired status or outcomes
Context for desired/undesired responses and outcomes
USES OF THEORY
Theory and Research
The objective of theory is to formulate a minimum set of generalizations that allow one to
explain a maximum number of observable relationships among the variables in a given field of
inquiry. Theories set limits on what questions to ask and what methods to use to pursue answers to
the questions. Relationships between theories and research are cyclical in nature; the results of the
research can then be used to verify, modify, disprove, or support a theoretical proposition. Nursing
theories have provided nurse researchers with new propositions for nursing research that could not
have been as well articulated if theories from other disciplines were used. Nursing research has
been driven in the past by educational, sociological, and psychological theories and less by nursing
thought. Nursing theories stimulate nurse scientists to explore significant responses in the field of
nursing such as eating, feeding, pain monitoring, sleeping, and resting. In doing so, the potential for
the development of knowledge that informs daily activities of patients and nurses increases.
Theory and Practice
The primary uses of theory are to provide insights about nursing practice situations and to
guide research. Through interaction with practice, theory is shaped and guidelines for practice
evolve. Research validates, refutes, and/or modifies theory as well as generates new theory. Theory
then guides practice. Until empirical validation, modification, and support are completed, theory
can be given support through clinical utilization and validation and can therefore be allowed to give
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36 PART ONE Our Theoretical Journey
tentative direction to practice. Nurses gain wisdom from their practice experiences and formulate
theories that were generated from their experiences. However, until such theories are articulated
and communicated, they cannot be subjected to systematic tests and, therefore, do not inform the
practice of other nurses.
Theory provides nurses with the framework and the goals for assessment, diagnosis, and
intervention. Nurses working as part of health care teams focus on those aspects of care that are
described theoretically for a more effective judgment of patients’ situations and conditions. If the
goals of the care provided are health maintenance, promotion of self-care, and enhancement of
stability and integrity during the illness, then a nurse has an intellectual checklist by which the
levels of health and well-being, self-care needs and abilities, and integrity and stability are
assessed. Diagnosis is related to those areas in which health and wellness are compromised, self-
care is problematic, or integrity of the human being is undermined. Evaluation of care and its con-
sequences focus on patient care outcomes.
Theory is a tool that renders practice more efficient and more effective and helps in identify-
ing outcomes. Simply by being goal-directed through a theoretical perspective, a nurse’s energies
and time spent in assessing extraneous areas are minimized. If nursing goals are not articulated
from a nursing perspective, a nurse’s time is used inefficiently, and the nature and quality of care
are compromised. By considering areas of assessment or intervention that may be handled more
efficiently and expertly by other members of the health care team, the nurse conserves her own
energy, time, and talent for those areas and phenomena for which she is well prepared, such as
processes of adherence to a regimen, mobilizing support, or monitoring pain. Patients and their
families are more likely to seek and respond more effectively to nursing care when nursing goals
driven by nursing knowledge are clearly articulated.
Theory has other uses. The language of theory provides us with common ground for commu-
nicating effectively and efficiently. More effective and efficient communication can eventually
lead to further theory development as concepts are refined, sharpened, extended, and validated.
Well-defined concepts with conceptual and construct validity enhance cyclical communication
among practitioners, theorists, clinicians, and educators. The world of nursing can become more
coherent, more goal oriented, and more effective. Building evidence depends on a common lan-
guage and symbols, and using evidence is predicated on a common language. Articulating out-
comes and linking these outcomes with nursing actions and interventions are enhanced by naming
concepts.
Professional autonomy and accountability are supported by the use of theory in practice.
Being able to practice through the use of scientific principles allows nurses the opportunity to
accurately predict those patterns of responses that are consequences of care. Articulation of
actions, goals, and consequences of actions empowers nurses and enhances their accountability. If
we can talk clearly about our purpose and what we hope to accomplish, perhaps other profession-
als and patients will also be able to describe or articulate nursing actions and goals more accu-
rately and comprehensively, and even seek and demand the type of care nurses are capable of
providing. Defining the focus and the means to achieving that focus, and being able to predict
consequences increase a nurse’s control of nursing practice and therefore increase a nurse’s
autonomy. As stated by Fuller many decades ago (1978),
The autonomy of a profession rests more firmly on the uniqueness of its knowledge, knowl-
edge gathered ever so slowly through the questioning of scientific inquiry. Nursing defined by
power does not necessarily beget knowledge. But knowledge most often results in the ascrip-
tion of power and is accompanied by autonomy. (p. 701)
In summary, theory helps to identify the focus, means, and goals of practice. Using com-
mon theories enhances communication, thereby increasing autonomy and accountability to
care. Theory helps the user gain control over subject matter (Barnum, 1998). All these in
turn help bring about further refinements of theory and better relationships among theory,
research, and practice. Figure 3-1 identifies the relationships among theory, research, practice,
and philosophy.
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CHAPTER 3 Theory: Metaphors, Symbols, Definitions 37
two opposing definitions for each and
argue for what difference this particular
definition makes in our practice profes-
sion. Ultimately, how could developed
knowledge be different, and in what
ways is the practice of nursing differ-
ently informed?
4. What difference do the different levels
and types of theory make in advancing
nursing knowledge?
REFLECTIVE QUESTIONS
1. Why does a practice-based discipline
need theories?
2. Theories seem to be such esoteric notions
for a profession that has functioned well
for decades. Could our practice history
guide our practice future without theo-
ries? Why? Why not?
3. For each definition of theory compo-
nents, there are different views on how
the component is defined and used. Find
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Our Theoretical Heritage
THE discipline of nursing has established itself as a field with both a practice and a
theoretical base. The process of the evolution of the discipline and its theoretical
base follows a unique path, a path that may not be clearly understood by those who
attempt to measure the progress and development of the discipline by the same crite-
ria used to measure the progress of the physical and natural sciences. The origins of
the developmental path for nursing can be traced through an analysis of both its
research tradition and its theory traditions. This part, which includes Chapters 4 and
5, traces the historical development of nursing theory and theoretical nursing. Forces
and constraints that nurses confronted in their quest to establish theoretical nursing
are analyzed. The course of the evolution of nursing as a theoretical discipline is
mapped and discussed.
Forces and barriers in the development of theory in nursing are identified.
The roles of nurses—as nurses, as predominantly women, and as nurse theorists in
the development of nursing theory against many odds—are explored and discussed.
The development of the discipline of nursing is conceptualized as evolving in
stages. The premise on which the discussion proceeds is that all stages preceding
the most current stage made major contributions to the maturity of the discipline.
Milestones in every stage are delineated, and the influence of each milestone on
nursing theory is explored. The relationships among theory, science, practice, and
philosophy are also explored.
P A R T T W O
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C H A P T E R 4
From Can’t to Kant: Barriers and Forces
Toward Theoretical Thinking
The journey from the days of Florence Nightingale to scholarly nursing has been long, hard, and
bumpy. Nightingale’s attempts to establish professional nursing based on nursing’s unique con-
cern with the environment for the promotion of health were preempted by an illness-oriented
training that depended on other professions for existence and on hospitals for training and suste-
nance. Nursing has traveled from apprenticeship to education, from hospital service and training
to the university, from mere implementation of doctors’ orders to accountability and autonomy,
from practical to theory- and research-based applications.
The journey has included a major detour through the land of “Can’t”: a land of perceived
inability to conceptualize or generalize; a land that espoused practice, concreteness, and practical
relevance as antithetical to some generalizations, common propositions, and theoretical state-
ments. The decades of the 1970s, 1980s, and 1990s marked our emergence from this land and, as
we move into the 21st century, we are back on course to where Nightingale began. On our return
journey, however, we are more experienced, more assured, and more trusting in our perceptions.
We are more accepting of the significance of patients’ and nurses’ experiences and of the varied
meanings of experience in the development of nursing knowledge.
We are reminded in this journey of Immanuel Kant, a dominant 19th-century philosopher,
who maintained that reality is not only a thing in and of itself but is also constructed by those who
experience it. Reality in nursing history has been a synthesis of conditions that predisposed nurses
to a nontheoretical existence and an a priori perception that helped to promote a lack of accept-
ance of theoretical themes.
Kant aptly distinguished between perception of experience and sensation of experience. Sen-
sation of experience is confounded by temporal and spatial limitations. Experience, the basis of
knowledge, has, in nursing, depended on this or that procedure as performed at a certain moment,
or on the knowledge of this or that patient occupying a certain space and existing at a certain
moment. Although knowledge begins with experience, Kant maintained that this does not mean
that all knowledge evolves from experience. To him, our experiences have two components: an a
priori impression of what may be experienced, and impressions as they are actually received.
Understanding is a synthesis of both. Therefore, a human being—a knowing, active, and experi-
encing subject, not a passive recipient—interprets and analyzes impression data in a certain way.
That certain way—the a priori form by which experiences are shaped—is a synthesis of some-
thing that is out there and something that is constructed by the person experiencing it (Copleston,
1964).
During the journey of nurses from early to modern times, experience assumed different
meanings with more profound explanations. Experience provided the impetus for describing
and explaining phenomena central to nursing and perhaps was responsible for the development
of new therapeutics to promote health, change environments, or control unwanted events related
to health care. During this journey, some nurses were more accepting of the role of clinical
experience in the development of clinical knowledge, others were reluctant to acknowledge that
experience had any role in theoretical nursing, and still others preferred to rely on the experi-
ences of scientists in other fields to shape their clinical knowledge. Some pioneering thinkers in
nursing assumed that nurses can conceptualize, and they allowed themselves the luxury to con-
sider that patients’ responses and experiences could help them, and others, better understand
clients and their health care experiences. These thinkers helped the theoretical journey move
forward. The journey is still in progress, and will continue to advance in a human and dynamic
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CHAPTER 4 From Can’t to Kant: Barriers and Forces Toward Theoretical Thinking 41
discipline such as nursing. Within the discipline of nursing, evidence suggests that this long
journey will lead to more effective and useful theorizing. In order to continue to support the
journey toward a more systematic development of nursing knowledge, it is necessary to value
our history and envision our future.
Therefore, to enhance the development of theoretical knowledge, we must pause and ask why
the journey was long and complex. Why did nursing go through such detours of seemingly non-
theoretical periods and, more importantly, why did nurses appear to reject theory and theorizing
during the journey, practically forcing the detour into a nontheoretical existence? Even when a
small handful of nurses attempted to return, to put nursing on course by providing a theoretical
view of what nursing is, it was almost two decades after the development of these conceptions that
their notions and their stance began to be accepted. Why is it that some skeptics in nursing were
still saying, at the end of the 20th century, that theory or theorizing in nursing is antithetical to the
practice of nursing, and that nursing practice is either a practically or theoretically oriented situa-
tion, but not both, and therefore choosing one standpoint leaves no room and no need for the
other? And what conditions have prompted the beginning acceptance of theoretical nursing?
This chapter considers, historically, those forces that have hindered and fostered the development
of nursing scholarship and more specifically nursing theory. Kant’s writing on the synthesis between
reality as a separate entity and reality as constructed by the subject who is experiencing it helps us
understand the dialectical meanings of these forces. Human and knowledge barriers and human and
knowledge forces are two sides of the same coin. We can analyze these as both negative and positive
forces in the development of nursing theory. The content may be the same (the sensation in Kant’s
analysis), but the form distinguishes between forces as barriers and forces as resources. Together, con-
tent and form (provided by sensation and mind) enhance the knowledge and understanding of the
dynamics of the journey from no theory to theory. As we begin to perceive constraints in a new light
and through a new lens, we can shift the negative power of constraint to a positive force, and we can
reconstruct new realities and develop new blueprints that are more congruent with the mission of
nursing and health care needs nationally and internationally. Knowing our history empowers us for a
future in which we can better deal with barriers and change them into assets.
BARRIERS TO THEORY DEVELOPMENT
Human Barriers: Nurses as Nurses
The type of student who selects a nursing career, the kind of education nursing students
receive, and the nature of nursing are all related to the paucity of developments in nursing theory or
to the rejection of the theoretical nature of nursing, particularly when nursing education was con-
fined to hospitals, before baccalaureate programs became the norm and before second-degree stu-
dents began to enter the field of nursing. Evidence of these relationships varies from speculative to
more empirical and verified. Before the 1970s, women who entered nursing may have done so
because of its service orientation, rather than its professional potential. Nursing may have attracted
non–career-oriented individuals who were looking for an occupation that allowed them to get in
and out conveniently, as their families demanded. A decision to become a nurse may have depended
on an image of nursing that was glamorized in the media but that was also paradoxically servile.
Whether nursing still attracts a unique group of individuals who are substantially different
from students entering other fields is becoming increasingly debatable. Students are becoming
attracted to nursing for its financial potential, its career possibilities, and its potential to make a
difference in society. No reported data substantiate that shift; however, it is apparent to educators
that there is an increasing applicant pool of qualified students, and that the attitudes of nursing stu-
dents are changing drastically as changes occur in other spheres of life, in other professions, and
in economic status. As we enter the second decade of the 21st century, many nursing programs
were specifically developed to attract graduates from other disciplines. Similarly, more nurses are
seeking graduate degrees, and fewer nurses are enrolling in diploma programs, although this still
differs by state.
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42 PART TWO Our Theoretical Heritage
One example of this shift in attitude is the influx of graduate students (from other fields) into
community college nursing or baccalaureate nursing programs. These students are often women
(and increasingly men) who are older and therefore more developmentally mature and more intel-
lectually sophisticated. They have already experienced academic life, they have experienced dif-
ferent occupations based on their first degree, and they knowingly and deliberately selected a
different educational path, one that has the potential to lead to financial independence and a new
career. What they expect of their education, however, may not be completely congruent with the
ideas of faculty who are used to teaching younger and less experienced students (D’Antonio,
Beal, et al., in press). More men are also changing careers and choosing nursing. These differ-
ences between nursing students of the past and present may suggest a difference in attitudes
toward nursing and its professional status, as well as its theoretical underpinnings, and are likely
to create a different future for the discipline of nursing.
Although differences between students who select nursing and those who select other profes-
sions are inconclusive because of the sparseness of research, indications are that nursing educa-
tion itself has created differences between nursing students and other students. Education plays a
major role in training the mind to think beyond immediate action, to question situations, to link
events, to generalize and, in short, to conceptualize.
Analyzing and understanding the history of nursing educational levels and the status of nurs-
ing is important in dialogues about knowledge development (D’Antonio, 2004). Nursing educa-
tion has a long history of squelching curiosity, replacing it with conformity and a nonquestioning
attitude. Nursing education in the past prepared nurses to think of themselves as the handmaidens
of physicians, the executors of doctors’ orders, and the implementers of hospital policy. It social-
ized students to roles that are not congruent with scholarship and discovery. Any independent
thinking or critical attitude was the antithesis of what was expected of a nurse. Because nursing
education was based more on apprenticeship, training, and experience than on ideas, knowledge,
and learning, the nurse graduated only to find herself far more dependent on medical and hospital
systems than on her own problem-solving abilities. The educational system in nursing did not help
nurses see themselves as sources of knowledge. The discourse that nurses engaged in was one of
techniques and skills (Canam, 2008).
Theory development is an active process, and early research characterized nurses as passive
(Cleland, 1971; Edwards, 1969). The social climate in which nurses practiced did not encourage
debate or freedom to experiment. In fact,
[T]he subculture of nursing has encouraged the perpetuation of a feminine world that has been
perceived to emphasize routine and repetition, intuition and magical thinking, respectful obe-
dience for authority, and covert rather than overt methods of control. Such a subculture does
not provide a fertile field for the growth and development of curiosity and challenge of the
status quo, both so necessary to scientific inquiry and scholarship. As a result, a number of
nurses . . . have chosen to move to other disciplines for the substantive background and the
mental stimulation so necessary to scholarly development. (Benoliel, 1975, p. 25)
In addition the functional orientation of nursing—the act of performing procedures rather
than thinking, reflecting, and solving problems—is a theme apparent in the history of our disci-
pline (Loomis, 1974). This orientation originated in the early inclusion of nursing training pro-
grams in hospital settings, in which nurses were socialized to become intellectually subordinate.
The hospital’s role was to provide service within its means; its role in education was mini-
mal. Therefore, when hospitals agreed to take on the education of nurses, they did so to improve
patient care and save money. It was acceptable to have nurses work long hours and to allow them
to attend lectures only when education did not interfere with the service they were providing.
Nursing students were the lowest on the totem pole; they were taught how to respect physicians,
how to believe in physicians, and how to totally submit to hospital routine. Essentially, nurses
were taught “intellectual subordination” (Bullough, 1975, p. 229).
Nursing students worked 12-hour shifts and were even further exhausted by being sent on
home visits to bring in more revenue, which was sorely needed by the hospital. Decisions about
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CHAPTER 4 From Can’t to Kant: Barriers and Forces Toward Theoretical Thinking 43
home care were not predicated on the goals of nursing or on the outcome of nursing care but rather
on the need for an economic boost through the use of students as cheap labor. As a result, nurses
developed an task-oriented attitude and, for the most part, did not take time to think or reflect or,
better put, were not given the necessary time to think or reflect, which maintained nursing at the
practical and immediate level of functioning. Doing and thinking are not mutually exclusive, but
they were promoted as such. And, unfortunately, the education that nurses received fostered an
unquestioning acceptance of authority and a subservient attitude.
The weight of past tradition, the subordination of nurses, the sex segregation, and the appren-
ticeship model in nursing education have left a mark on the attitudes of present-day nurses.
(Bullough, 1975, pp. 229–230)
The qualities necessary for theory development are thinking, reflecting, questioning, and per-
ceiving the self as being capable of developing knowledge, through a discourse focused on rela-
tionships, caring, and the psychosocial determinants of the nursing act. The education that nurses
received may not have nurtured the development of these qualities, and it did not reinforce critical
thinking in those who came to nursing with critical-thinking abilities.
Nursing has also suffered from the paternalism of hospital administration and medical staff
(Ashley, 1977), and remnants of that mind-set persist in different forms in the 21st century, under the
guise of economic constraints in the health care system. This paternalism has been internalized as
the rules and regulations created by others have been replaced in recent years with rules and regula-
tions created by nurses for nurses. Nurses may be following the rules unquestioningly, or they may
only be controlling their questioning because, as Street (1992) discovered in a critical ethnography
of nursing practice, nurses are aware of the negative consequences of thinking or speaking critically.
Therefore, questioning is still discouraged, rebelliousness is unthinkable, and disobedience is pun-
ished, but leaving the discipline—attrition—is a personal option and many, indeed, resort to it. Shift-
ing to other careers that feature less subordination has also been used as a coping strategy.
Early on, this patriarchal framework formed the context for the nurse’s role, equated with a
woman’s or mother’s subordinate role in the family, whereas the physician’s role was equated
with that of the father, the head of the family (D’Antonio, 2010). Therefore, just as wives and
mothers were relegated to certain prescribed roles, the nurse was also plagued by the image of the
sacrificing, altruistic, submissive placater, the fixer of all—a role detrimental to the creativity
essential for theoretical thinking. Thinking, creating, and questioning were reserved for the head
of the family. It is perhaps that same image that has helped perpetuate the duality of science and
practice. Compassion (a characteristic of nurses in practice) cannot be replaced by the rigor, cal-
culation, objectivity, and coolness of the scientist or the theoretician, although perhaps it could be
complemented by such characteristics.
Academic nurses suffered from this concept of nursing just as greatly but in a different way.
Because they were far removed from patient care, they were more interested in theorizing about
student learning or curricula than about patient environments. Being new themselves to the halls
of academia, they dissipated their energies in the struggle to prove they belonged there. They com-
peted with others in more established disciplines and shied away from those in practice who
pointed fingers at these “ivory tower” colleagues and said, “Your theories are too theoretical and
your research is too esoteric; what do you know about practice anyhow?” or “Stick to teaching
and leave practice to us.”
The reward structure of the nursing profession helped shape nurses’ attitudes about theory
development, as did the personal attributes cultivated by educational and practice environments
that were antithetical to theorizing and scientific endeavors.
Recognition for nurses was based on immediate actions, and rewards were based on expedi-
ent doing. Rewards were more easily bestowed on nurses in clinical roles or on nurses in teaching
roles than on those engaged in research or theory development. Rewards for scholarliness were
not as tangible as rewards for these other roles; they were slow to come, and the rationale for the
rewards was not as well defined, especially as the discipline was still developing and had no agreed-
on standards for reward (Gaston, 1975). In addition, the subculture of nursing had not promoted
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44 PART TWO Our Theoretical Heritage
constructive debates and competition, which could have been helpful in discussing and develop-
ing theoretical ideals. What Benoliel said in 1973 about competition in research applies to theory
development in the 21st century:
If scientific inquiry and production of knowledge are dependent on individuals who thrive on
open competition, then perhaps the slow development of research in nursing is tied to a lack of
competitive spirit among nurses in idea development. Reflecting on nursing’s origins as a form
of women’s work, I find this slow development not too surprising. Compliance with the rules
rather than challenge of authority has been an organizing theme in much of nursing’s history,
and a subculture that places high value on conforming behavior is not fertile soil for the develop-
ment of practitioners who are comfortable with the aggressive rivalry of scientific endeavors.
The subservient and self-effacing posture that nurses have traditionally held in their working
relationships with physicians is not an effective stance for nurses engaged in scientific study.
Rather, those who seek to be purveyors of new nursing knowledge can only do so when they
carry a sense of self-confidence that permits them to see and experience the positive values of
open competition in the world of ideas. (Benoliel, 1973, p. 8)
Practitioner’s orientation—the educational movement toward becoming nurse practitioners
and nurse anesthetists—also contributed to the construction of barriers in the development of the-
ory. “Why should there be other frameworks to assessing, diagnosing, treating, and evaluating dis-
ease, symptoms, and responses to illness when medical science and models of care are used?”
asked my theory students who are nurse practitioners and nurse anesthetists. “If anything,” they
continued to argue, “we should be contributing to the development of medical science,” not the
use and development of theoretical nursing and the use of nursing knowledge. Although some are
concerned about the dominant discourse of evidence-based practice, labeling it as the “colonial
patronage” of the biomedical idealogy (Holmes, Ray, Perron, 2008), a kinder view may be that a
need exists for nursing knowledge to drive the development of theories dealing with the daily
responses, activities, and lived experiences of patients—such as eating, sleeping, mobility, relat-
ing, and interacting—responses and activities that are central to nursing practice but less central to
the practice of other disciplines. The best answers, however, emerge from those who are able to
integrate nursing and medical sciences, as well as synthesize their practitioner’s role with their
nursing role (Fairman, 2008).
Human Barriers: Nurses as Women
The slow development or acceptance of theory development and utilization in and for prac-
tice can also be attributed to sex-role stereotyping. Theory development is a laborious process that
requires flexibility in time, access to leisure time, access to resources, and freedom from appre-
hensions, none of which women possessed or obtained as readily as men did in the past (Keller,
1979). Many around the world still view a woman as a hard-working, home-bound person whose
energies should be confined primarily to rearing children and caring for a family. Many women
have internalized this role ascribed to them by society, and college-age students in the 21st century
may be returning to that view. Even when women tried to break away from societal stereotypes,
they were beset by the need to both fulfill new employment roles while maintaining their function
in old roles. The result has been overload—hardly conducive to reflecting, questioning, and cumu-
latively developing theory. As Cole (1981) noted, “It is in the domain of informal activities in sci-
ence that the biggest gaps between men and women remain” (p. 388).
As we move into the second decade of the 21st century, the number of male registered nurses
has more than doubled from 57,000 in 1983 to 164,000 in 2002, representing an increase from 4%
to 7%, with a similar increase in the number of men admitted to schools of nursing in the United
States (Armour, 2003). (At the University of Pennsylvania, 16% of the freshman class in 2009 con-
sisted of men.) Although this increase is significant, approximately 93% to 95% of nurses are
women (All Nursing Schools, 2000), therefore, the sex-role identity of nurses cannot be ignored
when we discuss theory development and the potential for theoretical thinking. In addition, two
other barriers maintain this status quo. Although men have historically participated in nursing
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CHAPTER 4 From Can’t to Kant: Barriers and Forces Toward Theoretical Thinking 45
during times of war and acute shortages in some countries (e.g., Yemen and Jordan), there is a fail-
ure to recognize men’s role in nursing (Evans, 2004). This failure to acknowledge the historical
trends and geographical patterns of men in nursing is a barrier to more effective gender-balanced
recruitment in nursing. The net result of this failure is that nursing has always been an occupation
with predominantly feminine characteristics, and it is still stereotyped by the nurturing and caring
roles attributed to wife and mother. Whether the image of nursing as a feminine role evolved from
the recruitment of women into nursing or whether women were recruited into nursing because of its
feminine image is a moot question. Ever since Nightingale recruited only women to accompany her
to the Crimean War area to care for the wounded, the image of the nurse was fused with the minis-
tering, sacrificing, and altruistic image of women. The same pattern also was demonstrated in the
Eastern image of a nurse. Rofaida Al-Islamiah, considered the mother of nursing in the Middle
East, recruited other women to tend to war victims in early Islamic history (Jan, 1996). There is lit-
tle doubt that many of the issues facing nursing emanated from the feminine image of nursing and
the idea of nursing as a profession for women, particularly in societies in which women are rele-
gated to secondary status (Dachelet, 1978; Heide, 1973; Sandelowski, 2000; Wren, 1971).
Many of the characteristics of women have been considered antithetical to creativity and scien-
tific productivity. Ample evidence indicates that women are reared and socialized differently than
men from the minute they utter their first cry of life, which may lead to some differences in their cog-
nitive structures. Women are perceived by many members of different societies (including the
United States), rightly or wrongly, to be more affective, more subordinate, more emotional, less
aggressive, and less achievement oriented, and they are generally expected to apply rather than to
create. Because ours, like many others, is a patriarchal society, these differences, which could have
been considered simply as differences without any value judgments, have been judged as negative
when applied toward women. In addition to this attitude, which has been more than devastating and
an impediment to women’s progress, many women find themselves juggling multiple roles, and
many struggle to survive in career-oriented jobs with limited resources to support them (May,
Meleis, and Winstead-Fry, 1982; Meleis, 1975; Valian, 2000). Generally, women are conditioned
and expected to consider a professional career as secondary to family and home. This has not
allowed them to direct their energies toward more creative endeavors, such as theory development
and theory testing, which are considered antithetical to practice (Sonnert and Holton, 1995).
Creativity and scholarly productivity embody curiosity, intellectual objectivity, the ability to be
engaged in decision making, and independent judgment. These are socially desirable attributes—so
long as they are not adopted by women. Because nursing did not insist on independence or an active
striving for success, it has generally been perceived as a profession congruent with what is “expected
of women.” Furthermore, nursing embodies subjectivity in caregiving, dependence on others for
decision making, and expressiveness in relationships—all considered female traits. Street (1992), in
a critical ethnography of nursing practice, describes how nurses are aware of the potential negative
consequences of thinking and speaking critically. Therefore, nurses may have been socialized
against thinking critically, questioning, and changing the status quo (Group and Roberts, 2001).
Even when women broke from the mold, they suffered ambivalences. Horner (1972) demon-
strated that anxiety in many women is created by achievement-related conflicts. Those qualities
that are essential for “intellectual mastery,” such as independence and active striving, are not
female qualities. Therefore, women who defy the conventions of sex-appropriate behavior usually
pay the price in anxiety.
Until recently, the message was that, because women are biologically different, they are less
than men. Nursing is a profession for women, and the attributes that women should strive for and
maintain are epitomized in nursing. Therefore, women believed the congruence between societal
expectations of women and nurses. The self-fulfilling prophecy of what education women should
have and how they should act as women and nurses lingered. As a result, women who entered nurs-
ing, at least until the 1970s, identified strongly with the roles of wife and mother and either believed
that nursing would prepare them for the natural roles of women or that the nursing role was a way
to earn a living until a knight came along and rescued them from the drudgery of full-time work.
For most women, a career was not supposed to coexist with marriage and motherhood, so a woman
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46 PART TWO Our Theoretical Heritage
had to choose between the two. Men, however, could easily combine career, fatherhood, and mar-
riage. Career advancement for women continues to be less than for men as women fail to enter sen-
ior management positions because of gender bias. In addition, nurses who work part time, and thus
in lower nursing positions, tend to generally be women (Tracey and Nicholl, 2007).
The self-identity of nursing students lay in their womanhood rather than in their profession or
in their discipline. Women in nursing were different from women studying other professions in
other ways as well. The self-concept of women who selected nursing, teaching, and dental
hygiene included a perception of low autonomy, less chance for advancement, and less need for
intellectual stimulus. They also asserted, by selecting nursing, that they had more favorable atti-
tudes toward marriage and family. Students in nursing in the late 1960s and early 1970s ranked
home and family roles as number one and career roles as number two, with their own identity
being attached more to the former and less to the latter roles (Cleland, 1971; Olesen and Davis,
1966). The increasing demands on families of the 21st century, the continuing limited resources
for employed women, and the gender issues women encounter are not making it easier for this
pattern to change (Hochschild and Machung, 1997).
On the job, nurses’ productivity was measured by their constant doing, by their sense of
urgency, and by their appearing busy. However, their identity remained first and foremost ascribed
to simply being women. Their type of productivity was devalued because women were socialized
to believe that what they do is of less worth than what men do (Reverby, 1990). Their identity also
suffered because they were allowed to receive validation mainly through the capacity to attract a
marital partner and to bear and rear children, rather than through intellectual achievement, career
advancement, or financial gain. Male productivity was valued, and a man’s identity was measured
by his job, career, achievements, and financial gains. The male identity, therefore, was measured
by what men did in society and female identity by what women did for the family. Women learned
to play the game of being less smart, less effective, and less expert to maintain an identity congru-
ent with society (Gordon, 2005).
Other perceived differences between men and women might have constrained the develop-
ment of nursing theory. For one thing, women in science were, in general, engaged in less schol-
arly production than men (Cole, 1981). Also, because nursing was fairly new to the scholarly
arena, it was apparent that
New scholars in the field have more obstacles and ambivalence to overcome in their attempt to
integrate the scholarly role with the repertoire of other roles that constitute the self-concept.
(May et al., 1982, p. 23)
Sex-role stereotyping has also impeded the theoretical development of nursing in one more
way. Many women came to believe the stereotypes that they were unintellectual, subjective, and
emotional (Keller, 1979, 1985) and thus were less vocal in confronting those claims, preferring
invisibility and the careers that allowed them to do so (Ehrenreich and Hochschild, 2002). Women
became prejudiced against each other, reinforced the myths against each other, and perpetuated
the myth about their inability to think theoretically and to develop theories (Goldberg, 1968).
Collaboration, a hallmark of success in nursing practice and an activity about which nurses
are most familiar, has not been attached to the scholarly development of disciplines. So, even this,
which nurses can do well, was not acknowledged as a significant characteristic of development
and progress in scientific disciplines until the late 1980s, when Gilligan (1984) and others
described and explained the differences in development between men and women. Women’s
development was described in terms of connection and collaboration.
Several patterns of responses reflect barriers toward theory development:
• Slow acceptance of the acts of theorizing in nursing
• Devaluation of the work of nurse theorists
• Uncritical acceptance of theories developed by nonnurses
• Valuation of evidence-based practice (defined in terms of empirical research)
• Use of biomedical outcomes
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CHAPTER 4 From Can’t to Kant: Barriers and Forces Toward Theoretical Thinking 47
Is it possible that the slow adaptation and utilization of nursing theories may have occurred
because these were theories developed by women and nurses, as compared with other theories that
were developed by men who were not nurses? This and other questions are worthy of further
exploration by those interested in sex-role identity and perceptions and knowledge development
in nursing. These issues may present different dialogues and answers depending on the context of
the particular decade.
The influence of gender in nursing may be emerging in the populations used for research
studies in nursing. Polit and Beck (2008) reviewed research publications during 2005–2006 and
reported that about 75% of the study participants were female. Although the review is limited in
scope, they provide a different view of gender bias in nursing, one that may be attributed to the
nature of the questions that researchers ask or to the gender imbalance that has been the hallmark
of the discipline of nursing.
Human Barriers: Nurses as Theorists
Nurse theorists have sometimes acted unwittingly as barriers to the further development of
theory. In the minds of practitioners, theorists who were associated with educational institutions
were castigated for being far removed from practice. The language that theorists used separated
them from their colleagues in practice and other nursing arenas. The language of theories
appeared esoteric to the rest of the nursing world, to say nothing of the outside world. A nursing
client as an energy field, a system of behavior, or a self-care agent were all new and poorly defined
concepts. To complicate matters, educators translated nursing theory to curricula rather than to
propositions for testing. This intensified the schism between theory and practice and supported the
perceived lack of relationship between theory and practice.
Nurse theorists, easily accessible to their immediate colleagues, appeared to practitioners to
be remote and inaccessible. Academics in general are perceived to represent the “ivory tower” of
academia and are perceived far less to represent the real world. The lack of intertheory discussions
and debates added a new dimension to the many intradisciplinary schisms. Schisms also appeared
between disciples of various theorists.
Most theorists agree that the discipline of nursing needs to concur on the phenomena, per-
spectives, and problems central to the field and to the mission of nursing. But to select caring,
adaptation, homeostasis, self-care, need fulfillment, or effective nurse–patient interactions as the
mission of nursing may mean concentrating exclusively on one mission to the exclusion of others.
Defining a nursing mission, advocated by the early nurse theorists, may have been interpreted to
mean an exclusive mission. Therefore, the perception was that those who theorize tend to preach
for one binding philosophy, one theory, or one conceptual model to guide nursing’s research and
practice. To accept one theory (argued the practitioners, educators, and researchers) that has not
evolved from practice, or has not been subjected to practice application, research validation, or the
test of time (to the exclusion of others) was unacceptable. Misconceptions, such as believing it
was necessary to have only one theory, drew the few believers further from theoretical nursing.
Although there is no published documentation for this analytical posture, the lack of debate
about and among nursing theories in the 1960s and 1970s may be an indication of such a misconcep-
tion. There were numerous debates, though, among and between faculty members and clinicians
regarding which theory to use and the inadvisability of such a choice. These debates were more ide-
ological than substantive. Therefore, we can propose that nurses have been harsh in critiquing nurs-
ing theories, perhaps because (1) the theories did not appear to evolve from an empirical base; (2) the
theories were developed by women; (3) each theory in itself was not able to describe, explain, and
predict all nursing phenomena; and (4) the theories were not perceived to reflect the complexities of
nursing practice. Harshness was also apparent in criticism of the nurse theorists for taking risks,
which is another manifestation of what Ryan (1971) called “blaming the victim.”
Nurses have been admonished for contributing to their own oppression and inhibiting nursing
from achieving the status of a profession (Stein, 1972). Much energy and time has been wasted,
through intradisciplinary battles between nursing service and nursing education and over types of
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48 PART TWO Our Theoretical Heritage
educational programs and levels of entry into practice. Nurses invalidate other nurses by bringing
in “experts” from other disciplines to tell nurses how to do things that are already being done by
nursing “experts.” This blaming, self-flagellation, and infighting must be recognized by nurses as
deriving from the more general social problems of women. And, like women generally, nurses
must understand that they alone are not to blame for these problems. (Yeaworth, 1978, p. 75)
Knowledge Barriers
Knowledge barriers also inhibit development in theoretical nursing. Knowledge barriers are
manifested in the uncritical use of knowledge developed by other disciplines, the reluctance to use
nursing theory developed within the discipline by members of the discipline, and the further
development of knowledge that is more pertinent to the fields of preparation of nurses (i.e., disci-
plines from which nurses may have received their doctoral education or from where their primary
mentorship was provided).
An interesting phenomenon persisted for decades in nursing—the what is imported is superior
phenomenon—in which imported knowledge is far more meaningful than that which is domestic
and developed by nurses. By “imported” we mean theories developed by individuals other than
nurses and those developed in a field other than nursing. Sometimes this importing of theories was
done for legitimate reasons, but many times it was done with no rationale other than the obvious:
someone who was not a nurse developed it, and it emerged from a nonnursing paradigm; therefore,
it must be accepted and its effectiveness must not be questioned. Other forms of “conceptual impe-
rialism” have been described that perpetuate the institutional worldview (Smith, 1990). This is
apparent in the unquestioning use of theories from other disciplines, the lack of reluctance to attrib-
ute the label of theory to conceptualizations that evolve from a nonnursing discipline (e.g., role the-
ory, when sociologists are still debating whether role is a concept, a construct, or a theory), and the
concomitant reluctance to attribute the label of theory to nursing conceptual schemes.
Nursing has been shadowed first by the biomedical model and then by numerous other mod-
els, theories, and paradigms; therefore, theory development was left to those in different fields that
are related to nursing. Few in those related fields saw fit to support nurses’ efforts to look for their
own individualized “umbrella,” their own perspective, their own paradigm. As expected, disci-
plines that opened their academic doors to nurses perpetrated the notion that these disciplines are
best suited to provide the intellectual framework for nursing theoretical development. In addition,
what Yeaworth declared in the late 1970s continued to hold true as we began the 21st century.
Sociologists, psychologists, and physiologists are much more comfortable with the idea of pro-
viding members of their discipline to do the research for nursing than with the idea of providing
doctoral preparation for nurses who then return to nursing to apply their knowledge. (Yeaworth,
1978, p. 75)
Because nurses had few role models who combined nursing and another field in their gradu-
ate programs, and because nurses were away from nursing practice while studying theory and
research, those with doctoral education from nonnursing fields tended to explore phenomena
using their new field’s binoculars and neglected to synthesize their findings into theoretical nurs-
ing. The result has been to explore propositions from sociology, psychology, education, or physi-
ology. These explorations often have implications for nursing practice but not for nursing theory.
Many of these nurses educated in other disciplines may have believed that nursing had nothing
unique to offer and, therefore, maintained that the quest for a unique domain is a quest for separa-
tion and noncollaboration. To some, to condone nursing theories and nursing’s need to develop
theories was to support a separationist notion. This view continues to persist among some mem-
bers of the discipline in the 21st century, thus creating an ideal discourse useful in furthering the
advancement of nursing’s theoretical underpinnings (Hofrochs, 2000; Thompson, 1999).
Theory itself was a barrier. First, nurses said they needed theories to prove that nursing is a
profession, not simply an occupation. They argued that what nursing lacked in its quest for profes-
sionalism was a systematic, coherent body of knowledge with set boundaries. Theories fulfilled
this requirement. As a result, theorists were suspected of developing theories for professionally
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CHAPTER 4 From Can’t to Kant: Barriers and Forces Toward Theoretical Thinking 49
selfish reasons. This turned off practitioners, and theorists found themselves spending a great deal
of energy trying to justify their theories rather than revising, further developing, or making them
more clinically useful.
Another misguided goal evolved. Educators began to believe that theory—which was then called
“conceptual framework”—was needed to develop conceptually based curricula. In fact, the National
League for Nursing required that a curriculum should have a well-articulated conceptual framework
as a requirement for accreditation. The rationale was that if students were prepared in these programs,
they would emerge as agents of change in practice. Therefore, from 1965 to 1975, faculty members of
nursing schools tried to fit square pegs into round holes. The result was curricula that overwhelmed
students with esoteric content that was rarely used in practice after graduation. The schism that
existed between the languages of clinicians and educators convinced students of the uselessness of
the esoteric content, even before they graduated and assumed clinical positions in the workforce.
Many graduate students have tried to revive the knowledge of nursing theory they gained in
their baccalaureate years, knowledge that, to them, had not been useful in practice. Many of them
believe that a theoretically based curriculum both confined and liberated their thinking. It con-
fined it to one approach, but it liberated them to experiment with theory utilization. The decrease
in the number of nursing theory–based programs, which may have started as an exercise in intel-
lectual rebellion, may actually be a sign of progress. Curricula have become more coherent, sys-
tematic, and theoretical, and therefore do not need to be limited to one framework. The academic
need for theory may have been already established. However, when theory-based curricula were
first introduced, faculty focus on curricula may have caused them to lose sight of the reason for
theory, which is quality nursing practice and patient care. Theory-based research continued to suf-
fer, as manifested by the limited number of nursing theory–based dissertations (Spear, 2007).
Another goal was that nursing have a disciplinary status based on scientific foundations. This
required the existence of theories. Theories, then, appeared to be a means to establish nursing as
an academic discipline, one distinct from medicine and deserving of professional status. All these
are worthy goals for nursing. They will not be achieved, however, by developing theories to guide
curricula; theories must be developed through asking and answering the significant questions of
the profession and the discipline. The central goal of nursing is the provision of effective nursing
care of clients in any society. Significant questions arise from this goal, and theories help us
understand, explain, predict, and prescribe the care. Secondary gains, then, comprise a profes-
sional and disciplinary status for nursing. During the 1980s and 1990s, nurses have realized the
primacy of the goal of providing care to clients and have restructured their goals.
Conceptual Barriers
All the previously discussed barriers—considered within a context of history, culture, and
environment—contribute to the lack of conscious use of nursing theories, inhibit the potential for
developing theories, and may have created conceptual barriers for nurses. Conceptual blocks are
those closed gates that prevent nurses from perceiving or developing nursing phenomena beyond
the immediate problem-solving need. According to Adams (1974), conceptual blocks are caused
by perceptual, cultural, and environmental obstacles. Cultural and environmental blocks were dis-
cussed previously; the following section discusses perceptual blocks.
Perceptual blocks are obstacles that prevent the problem solver from clearly perceiving either
the problem itself or the information that is necessary to solve the problem. (Adams, 1974, p. 13)
When used as a framework to describe the nursing situation, perceptual blocks may appear in
the following six forms, as described by Adams (1974). First, a nurse may have difficulty delineat-
ing a phenomenon that is worthy of pursuance theoretically. She may be unable to perceive mean-
ingful clues; she may focus on tangential issues, use a priori paradigms that do not permit a
nursing perspective, or fail to see a phenomenon because of the lack of a defining framework.
Second, some nurses may put closer boundaries on a phenomenon—more acceptable bound-
aries in terms of societal expectations—to the detriment of understanding the phenomenon. For
example, suppose an immigrant was admitted to the emergency room three times in the 6 weeks
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50 PART TWO Our Theoretical Heritage
after his successful triple bypass surgery. Each time, there was a question of another myocardial
infarction, and each time the infarction was unsubstantiated. The causes of the unwarranted emer-
gency room appearances were recorded as noncompliance, diagnostic problems in the emergency
room, or inability to communicate signs and symptoms. In this case, a premature closure on the
phenomenon of repeated appearance prevented a careful exploration of the phenomenon within
the context of the immigrant’s experience and the cultural meanings attached to heart problems.
Similarly, a third perceptual block is lack of experience in considering a phenomenon from
different perspectives.
Nurses also fall prey to a fourth type of perceptual block, one related to paradigms that have
guided us for many generations and make us see what we expect to see. If we see the world
through the biomedical model, we tend to see signs, symptoms, and biomedical antecedents. Our
stereotypes of cultures and social classes, and our likes and dislikes in values, limit our percep-
tions and create blocks.
Immersion and experience are two-edged swords in theoretical development. Although both
are essential in describing theoretically clinical practice, they also tend to prevent us from seeing a
phenomenon from a fresh perspective. Anthropologists and sociologists have discussed this fifth
perceptual block, and they advise distancing to allow a return to a fresh start. Another strategy is to
consciously keep a journal of events related to the phenomenon. Putting the journal aside and pick-
ing it up again later permits distancing and diffuses what Adams calls the problems of “saturation”
(1974, p. 25).
The final perceptual block to be aware of is the nurse’s potential inability to permit and
accept all senses and intuitive inputs in delineating and developing a phenomenon theoretically.
Research Enterprise as a Barrier
As nursing moved toward definition as a research-based discipline, the movement toward evi-
dence-based practice came to be regarded as the ideal goal for nursing practice (Goode, 2000). Evi-
dence was equated with research, and research was equated with empirical investigations (Farquhar,
Stryer, and Slutsky, 2002). Speaking the language of evidence, best models of care, and practice
based on best research findings has become a substitute for the language of theory, theoretical think-
ing, and practice based on the expertise of clinicians, as if these two sets of discourse are antithetical
or a substitute for each other, rather than being intricately connected in the production of quality
practice (Doane and Varcoe, 2008). They are not. The framework for evidence-based practice did not
include questions about the origin of the questions asked or the theoretical assumptions and rationale
for interpretations. It further disconnected nursing research from nursing theory. Outcomes research
became the panacea; it did not matter whether a disconnection existed between nursing care inter-
ventions driven by nursing thought and nursing care outcomes mostly driven by biomedical, social,
and behavioral sciences, rather than by a new perspective within a nursing domain.
RESOURCES TO THEORY DEVELOPMENT
Human Resources: Nurses as Nurses
Theory is a mental image and conception of reality. Tools for theory development are similar to
those tools that nurses use in their clinical practice and with which they are most experienced. One of
the most significant tools for theorizing is the ability to observe. Nurses have ample opportunity to
learn how to observe, to sharpen their observations, and to use all their senses in collecting data.
Observation is central to nursing practice; observation comes easily to the experienced clinician.
Another significant tool for theorizing is the ability to record what actually is happening in a
nursing care situation. Nursing records offer a wealth of information. They are patient specific,
temporally limited, and have space boundaries that do not allow for generalization. With other
tools—thinking and reflecting—providing legitimization for developing theories, the observation
and recording of data could become the impetus for more general descriptions. Each one of these
nursing care situations could become an exemplar for further generalization.
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CHAPTER 4 From Can’t to Kant: Barriers and Forces Toward Theoretical Thinking 51
Examples from our theoretical history substantiate these abilities and their relationship to
theory development. Nightingale reflected on the many functions and activities that nurses per-
formed during the Crimean War. While in bed (Nightingale spent the last 30 years of her life in
bed), she had uninterrupted time and resources to collate observations, critique actions, analyze
perceptions of nursing, and arrive at the first systematic, comprehensive concept of nursing
(Nightingale, 1992).
The field of nursing itself, as a source for theory development, is a gold mine for those who
wish to articulate its many components and incorporate them into theory. On a daily basis, nurses
are dealing with many phenomena that need describing and explaining, and they are responsible
for helping clients achieve their health goals through a wide range of activities, ranging from
assessing to evaluating, from the technical to the highly abstract. A world of information exists in
nursing, which needs to be described and put into order. Clinical stories from nurses’ daily prac-
tice provide rich accounts of what nursing is about. These stories could provide the necessary data
for developing exemplars and models for practice.
Unlike other disciplines that have doubtful social significance, nursing is needed as a human
service and is sanctioned for its significance to health care. Nurses in practice settings spend a
good deal of time with patients, and because practice is one of the most significant sources of the-
ory, the central ingredient for theory development is therefore available.
In the 1960s, in the wake of nursing education and its attempt at integration, the Yale school
of thought evolved to represent developing theories by observing patients, cajoling nurses into
articulating what they had accomplished in patient care, and composing a view of nursing—its
mission, its goals, and its prescription. These nurse educators used observation and recording
skills they had mastered as nurses, and they used nursing clinicians’ abilities to do the same. The
result was an early conceptualization of nursing as an interpersonal process, a conceptualization
that remains useful to this day. One must consider, however, that federal funding at the time
allowed those nurses the free time and flexible schedules to think, reflect, and develop theories.
Whereas earlier nursing education had been a deterrent to theory development, nursing educa-
tion since the beginning of the 1980s has been a force headed toward its enhancement. When fac-
ulty of doctoral nursing programs in the United States were asked what they considered the core
content in their respective programs, highest in rank order were nursing theory, theory develop-
ment, and conceptual formulation (Beare, Gray, and Ptak, 1981). Students and recent graduates
from doctoral programs in nursing, beginning in the 1980s, were practically the first purebreds in
the science of nursing. The generation immediately preceding them had experienced a truly hybrid
education, one comprising a multitude of programs. Therefore, it is natural that these purebred indi-
viduals address the central questions in the field by engaging in the much needed processes of the-
ory development and organization of nursing knowledge. Many master’s programs in the United
States also offer nursing theory, and a few undergraduate programs are beginning to orient their stu-
dents to the need for theorizing and for using nursing theory in practice. These patterns of educa-
tion about theoretical nursing are found as well in many parts of the world. How the development
of the clinical nurse leader and the doctorate of nursing practice programs will influence theory
development and nursing knowledge remains to be seen (DeMaio and Jones, 2006).
Other quests make the nature of nursing a moving force in theory development. Theoretical
knowledge is viewed as a “basis for power” (Chinn and Jacobs, 1987). Therefore, as nurses
attempt to achieve their professional autonomy, theory becomes a most significant mechanism. As
novices recognize that they can defend ideas better when they approach the argument or debate
from a theoretical basis, they will tend to use theory more. As the experienced push to have their
services acknowledge nursing care outcomes as distinguishable from outcomes of other kinds of
care, they will use theory to articulate their mission, their goals, and their focus. A move toward
autonomy is indeed a moving force toward theory development and utilization (Fairman, 2008).
Autonomy is linked to communication about patient care among nurses and between nursing
and other health care professions. Communication is enhanced when it is in an understandable
language that is common, if not to all health care professionals, then at least among nurses them-
selves. Communication is enhanced when it evolves from some guiding framework. As nurses
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52 PART TWO Our Theoretical Heritage
value and respect each other’s observations and diagnoses, and as they search for a common lan-
guage with which to communicate, a language that represents nursing’s goals and missions more
so than immediate patient care, then theory becomes a means to achieve better communication.
Therefore, the quest for better communication about patient care and about patient care outcomes
is a quest for theory development. Nursing practice and nursing education are present-day forces
toward theorizing in nursing.
Finally, experiences of nurses as experts in nursing practice were formally acknowledged in
the 1980s as a most significant source for nursing knowledge (Benner, 1984; Benner and Wrubel,
1989). Describing expert nursing practice, as seen and practiced by nurses, was considered a val-
ued source if not the most significant source for articulating in a meaningful and coherent whole
the fundamental and practice aspects of nursing.
Human Resources: Nurses as Women
Theorists and researchers are beginning to produce evidence to refute some of the myths sur-
rounding female identity and the capacity of women to produce science. Recent empirical investiga-
tions and theories do not show sex-role differentiation in sensitivity to social cues, affiliative behavior,
or nurturing behavior. Women are neither more empathic nor more altruistic than men. Although the
myth surrounding these differences still lingers, data are increasingly refuting them (Meeker and
Weitzel-O’Neill, 1977). Therefore, some of the attributes of women that have been linked to lower
productivity and paucity in theoretical thinking are questioned by more contemporary researchers
(Bleier, 1990). These new findings, though, are still limited in distribution and in their power to refute
the earlier findings presented in this chapter. In the future, more research and more widespread distri-
bution of knowledge about productivity-oriented female attributes (both of which are occurring in the
current decade) will drastically alter socialization practices that have perpetuated these myths.
In the meantime, the feminist movement has done a great deal of consciousness raising
among women in general and among nurses in particular. It has attempted to dissipate some of the
long-held myths that have formed true barriers to the development of women. As early as the
1970s, nurses began to identify more with feminist ideals and with a view of nursing as a career
rather than merely as a stepping stone toward motherhood (Moore, Decker, and Dowd, 1978;
Stein, 1972). Research supports the presence of that shift. Graduate, baccalaureate, and associate-
degree students had self-images more in harmony with the image of professional nursing (Stromborg,
1976). The shift is toward an image of independence, competence, and intellectual achievement,
characteristics more congruent with a person who engages in idea development.
Research findings demonstrated that nursing students are not qualitatively different from
other female college students in their sex-role identity and personality constructs (Meleis and
Dagenais, 1981). These studies either dispelled earlier myths that nursing students manifest more
feminine characteristics than other women in college or demonstrated that drastic changes have
occurred for women, and particularly for nurses.
When the feminine characteristics of nursing students in programs at three educational levels
(diploma, associate, and baccalaureate) were compared with normative data of women in general,
results demonstrated that nurses are generally similar to female college and university students in a
number of personality constructs. When there were differences, they were congruent with what is
expected in practice professions; that is, they did not differ in autonomy but rather in practical aspects
(Meleis and Dagenais, 1981). Education plays a more significant role in perception of self than in sex-
role identity. Changing sex-role identities through dispelling some of the myths surrounding women’s
abilities makes the environment more receptive to women’s creativity in knowledge development.
Changing society’s expectations of women and science are other forces working in nursing
theory development. Women possess some attributes that may have been perceived in the past as
inappropriate and incongruent with creativity but that are becoming more accepted in today’s
society (Weedon, 1991). Women have been described as intuitive. Increasingly, as Eastern and
Western modes of knowledge development merge, intuition is seen in a more positive light and,
indeed, as essential in idea development, as a component in different patterns of understanding
reality, and as an accepted method for scientific inquiry (Carper, 1978; Silva, 1977). Intuition is
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CHAPTER 4 From Can’t to Kant: Barriers and Forces Toward Theoretical Thinking 53
part of the philosophical process, the mental labor central to the process of developing theories.
Intuition played a significant role in Einstein’s discoveries and in Darwin’s articulation of the evo-
lutionary theory. Intuition, the “curse” of women’s abilities, was recognized in the 1990s as a
force for women’s potential. Intuitive awareness of personal and social phenomena is a resource
for women in nursing (Adams, 1972). Intuition has also been considered from the perspective of
information-based, deliberate practice, and nursing science (Effken, 2001; Hams, 2000).
Although women may have been caught in a “compassion trap” of always being available as
helpers in the past. Adams (1972) suggests that, as a result, women possess an attribute that is sig-
nificant in today’s world: flexibility. Women, as an oppressed minority, learned to deal with diffi-
cult situations when others controlled access to resources. In the process, they learned how to be
flexible and innovative in finding alternative resources essential for their development and for
accomplishing their goals.
Persons with these sensitive capacities undoubtedly perceive reality differently from those
who occupy positions of social power and dominance, yet their perceptions have much to con-
tribute to knowledge about nurturing and the caretaking process (Benoliel, 1975, p. 26).
Women’s contextual cognitive style has been learned throughout a life of socialization. Jug-
gling roles is more congruent with the contemporary need to consider sociocultural variables in
scientific questions. Changes in sex-role identity, changes in the image of women, and a growing
respect for intuition as a pattern of knowing, flexibility, and resourcefulness are all significant
forces in theory development.
Women in nursing have an added advantage over women in other disciplines. Women scien-
tists—in physics, chemistry, and social and behavioral sciences, among others—are a minority in
their own fields. They have experienced prejudices, less support, and outright discrimination in
resource allocation, among other social ills that result from the competition with a dominant
group. In such unfair competition, men tend to win, to the detriment of women’s progress in these
disciplines (Cole, 1981; Keller, 1985; National Science Foundation [NSF], 1996; Sonnert and
Holton, 1995; Valian, 2000).
Most nurses are women; therefore, conflicts resulting from intradisciplinary sex-role competi-
tion are nonexistent. Female nurses have full citizenship within their own discipline. Moreover, we
hope that the lessons we have learned from other disciplines will not permit prejudices against male
nurses. Creative energy can be freed from the sex-role struggle for the benefit of theory development.
Women and nurses have exhibited a sense of humility as a corollary to humanity, which may
have previously prevented them from generalizing beyond the immediate situation (Dickoff,
James, and Wiedenbach, 1968). This sense of humility is now being replaced by self-assurance, as
nurses articulate their own conceptualizations of the different clinical realities they encounter
(Parker and MacFarlane, 1991).
Knowledge as a Force and a Resource
Having a knowledge-based discourse helps in further advancing knowledge; the more knowl-
edge we need, the more we are stimulated and challenged to further develop an understanding of
phenomena. Theory development in nursing is enhanced by the wealth of theoretical knowledge
we already have. The theories developed by nurse scholars provide an impetus for further refine-
ment and development. They lead to an agreed-on set of concepts that are central to nursing and
point to phenomena of interest to nursing. They have set the stage for the next steps.
Debates surrounding which theories to develop, how to develop them, and whether or not to
develop them have helped to clarify the mission of nursing. With a preliminary identification of
content and a beginning articulation of methodology, the course is now clear for smoother sailing.
All this has set the stage for shaping skills in analytical and critical thinking and has stimulated
more nurse scholars to pursue development in theoretical nursing. Nursing has the potential for
developing a feminist approach to science, or even a nonsexist science, by converting “value-free
technology” to a “humane technology” that incorporates self-care (Ardetti, 1980).
Old paradigms of knowledge are being challenged by new paradigms, prompted by two signif-
icant social movements: the feminist movement and the women’s health movement (McPherson,
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54 PART TWO Our Theoretical Heritage
1983). Essential components of the new paradigm represent a shift to include humanitarianism,
holism, the incorporation of sociocultural content, perceptions of subjects of research, subjects
and researchers collaborating in the research process, and a qualitative approach. The “new para-
digm” is not new to nursing. Its newness stems more from social acceptance, as the public
becomes more aware of ways to develop knowledge and demands participation in the process.
The newness is in the congruence, rather than in a shift in thinking. There is wider acceptance of
components of the “new paradigm” by consumers who care. That is a force that will help nurses
further develop knowledge. The energy once expended by those defending components of a para-
digm that was incongruent with a prevailing scientific perspective can now be channeled from the
creativity of reaction to the creativity of action.
A new worldview emerged, a view that had even changed physics from the mechanistic con-
ceptions advanced by Descartes and Newton to a more holistic and ecological view (Capra, 1983).
The new worldview is congruent with women’s views of science and nurses’ views of health. It is
a view that has shifted focus from the causative to the more interpretive. It is heightened by phe-
nomenology and qualitative research.
Conceptual Resources
To use all senses, experiences, and intuition requires involvement and immersion in situa-
tions as a whole, and to describe patterns of responses theoretically requires longer periods of
engagement in those situations where nursing phenomena occur. The nature of nursing, the
process of nursing care, the history of the profession, and the predominant gender orientation of
the profession enhance the conceptual resources for nurses. Nurses are trained to observe, record,
analyze, and solve problems. Whether we admit it or not, we tend to use our own and others’ expe-
riences in providing care, and in doing so, we rely on all our senses and intuitions, just as we rely
on scientific principles to guide our action.
Nurses spend long hours with patients, families, and communities; this time allows an under-
standing of patterns of behaviors rather than isolated incidents. Diversity in nurses and in their
cultural, educational, and socioeconomic backgrounds can be a resource to allow for diverse
views and a safeguard against premature closure on a phenomenon and against narrow perspec-
tives. Diversity in caregivers, in some instances considered problematic, could become a useful
resource for theoretical development. This resource could help remove perceptual blocks.
Nurses have effective interviewing skills for which they have been meticulously educated and
trained. They have mastered questioning and assessing, they know how to prioritize, and they know
how to participate in dialogue. They have opportunities to confirm observations and hunches dur-
ing clinical rounds at the end or beginning of shift reports, during impromptu meetings at the
nurses’ stations, in meetings with other members of the family, and during their many regular daily
roles and activities that involve talking, listening, questioning, answering, and writing. Each one of
these tasks enhances perception, and each is a resource and an asset for conceptualization.
Other Forces for Theory Use and Development
The journey to theoretical thinking has been a progression through self-effacing stops, self-
doubt detours, humility delays, collisions with opposing and dominating paradigms, and near
misses due to embarking into unfamiliar territory or unpaved terrain. Nursing and nurses are
emerging theoretically stronger and far better prepared to embark on a task of theoretical clarifica-
tion. The quality of the journey could be enhanced by coaching, mentorship, and sponsorship
toward the development of the theoretical insights attached to the scholarly role.
Nurses who learn about theoretical nursing, who are groomed to think conceptually, are not
resistant to the use of nursing theory in their practice or to their potential involvement in theory
development. Rather, they are asking how they can use theory, and they are looking for those they
can emulate in the process. One example of nurses’ interest in theory was several national confer-
ences held in the 1980s and 1990s by clinical specialists, in which the topic of theory development
and utilization dominated a full half-day of the 2-day conference (e.g., a Clinical Nurse Specialists
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CHAPTER 4 From Can’t to Kant: Barriers and Forces Toward Theoretical Thinking 55
Conference in 1983). Many more examples are demonstrated in the increasing numbers of nurses
who are members of organizations established for such nurse theorists as Dorothea Orem, Callista
Roy, Imogene King, and Martha Rogers (see Chapters 11–13).
Planners of one of these conferences were concerned about the responses of attendants to
what might appear as highly abstract ideas not directly related to everyday care issues. The results
were astonishing, the evaluations were heartening, and the request came for another session the
following year, focusing on how to bring acceptance to theory utilization and development in clin-
ical areas (Clinical Nurse Specialists, 1984). In short, nurses were asking for role modeling, role
clarification, and role rehearsal—all properties of mentorship.
Mentorship is an intense relationship calling for a high degree of involvement between a
novice in a discipline and a person who is knowledgeable and wise in that area. . . . In the
process of helping the beginning scholar to fit resources to her needs and capabilities, the
mentor provides options, opens up new opportunities, and helps to make corrections. This
means that, on cognitive and affective levels, the mentor is involved with the novice as a
whole person and feels a sense of responsibility for her. (May et al., 1982, p. 23)
Role modeling, which is teaching by example and emulation, then fosters the learning of
these behaviors (Bandura, 1962; Meleis, 1975). Role clarification provides an opportunity to
understand the subtle intricacies of the role to be emulated. What does it mean to have a role in the
theoretical development of nursing? What cues are needed to perform that role? Role clarification
in theory use and development may include spelling out the differences between the various theo-
ries, the different strategies in theory development, the different barriers to the use of theory, and
some strategies for handling all of these. Mentorship also includes opportunities for role rehearsal.
Use of theory in theoretical patient care studies and use of different strategies in theory develop-
ment are examples of staged situations in which to practice behaviors central to the use and devel-
opment of theory (May et al., 1982; Meleis and May, 1981).
Time and sociocultural conditions are right for the development of theoretical nursing, which
in turn is significant for patient care, and nurses are “going for it.” If, indeed, there is a woman’s
way to understand the world, and if there are areas of knowledge that are better understood when
seen through the eyes of women and through the use of feminine logic, then nursing is ready on all
of these accounts, and nurses are prepared to pursue that knowledge.
Nursing education can provide supportive conditions through programs that focus on schol-
arly productivity (Meleis and May, 1981; Meleis, Wilson, and Chater, 1980). Theory and theory
development should not be limited to graduate programs. Theoretical thinking should be the
modus operandi for conscientious patient care from day one in nursing education. Nursing prac-
tice has an equal commitment to provide avenues by which nurses can communicate their findings
in theoretical terms and can have the opportunity to translate their hunches into theoretical terms.
Within the appropriate atmosphere, nurses should be able to try using different theories in practice
for the purpose of refining and extending them.
Similar supportive environments could be provided by nurse administrators to help in the
development of a theoretical culture that allows dialogues, debates, and discussions that go
beyond immediate day-to-day problem solving and decision making. Strategies to be used by
nurse administrators and educators for the enhancement of theory development include creating a
theoretical culture, supporting critical thinking, refocusing dialogues and discussions on concepts,
defining nursing territory, exploring ambiguous ideas, allowing uncertainty about phenomena to
linger, avoiding premature closure on ideas, facing views of phenomena from different perspec-
tives, and providing such resources as library time, observation time, and writing time (Jennings
and Meleis, 1988; Meleis and Jennings, 1989; Meleis and Price, 1988).
CONCLUSION
Nurses are now in the land of Kant rather than the land of “Can’t.” Kant maintained that knowl-
edge depends on experience and experience on observation, but observations by themselves do
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56 PART TWO Our Theoretical Heritage
not form experience or give meaning to experience. Observations have to be organized a priori by
the mind to develop into knowledge. In so organizing our observations, we tend to reconstruct
reality.
Nurses may have reconstructed the meaning of theoretical constraints into forces that foster
the further development of theoretical nurses. They can use the tools of practice in theory develop-
ment, relying on the same abilities they have used for practice, research, teaching, and administer-
ing, and translating these skills into theorizing and the use of theory, perhaps thereby becoming
convinced that their experiences comprise the appropriate impetus for theory development.
The synthesis between continental rationalism and British empiricism espoused by Kant may
be helpful in increasing our knowledge of nursing realities.
Are there ways to influence the cycle of
shortage and theoretical thinking?
5. As gender, ethnic, and sociocultural
diversity increases in nursing, what might
be some implications for scholarship in
nursing? Envision and discuss outcomes.
Provide support for your arguments.
6. Discuss the current situation in the use of
theoretical nursing. How are theories
used? What are the outcomes of use or
nonuse of nursing theoretical thinking?
7. In what ways did the discourse of evi-
dence-based practice contribute to or hin-
der the development of nursing theories?
8. In your view, what are some of the current
dominant discourses in nursing? What
evidence do you have for this assertion?
In what ways did this dominant discourse
influence knowledge development?
REFLECTIVE QUESTIONS
1. Explain the barriers and forces that led to
utilizing theoretical thinking in your area
of clinical practice (or education, admin-
istration, or consultation).
2. Discuss how the changes toward
women’s and men’s roles may have
influenced nursing knowledge develop-
ment. What changes would you like to
see in the future that you believe could
make an impact on advancing theoretical
thinking in nursing? Be specific in iden-
tifying changes and influences.
3. Identify and discuss one more constraint
and one more force that may have influ-
enced the theoretical journey in the dis-
cipline.
4. In what ways did the wave of the nursing
shortage in the 1980s and in 2000 support
or constrain theoretical thinking? Why?
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C H A P T E R 5
On the Way to Theoretical Nursing:
Stages and Milestones
Despite the barriers against theoretical thinking and theorizing identified in the previous chapter,
nurses, in caring for human beings in an orderly and organized way, have always been involved in
some form of theorizing. Concepts of care, comfort, communication, protection, healing, and
health, among others, were used to guide clinical practice before they were labeled as concepts
and before they were linked together to form nursing theories. However, between 1950 and 1980,
a process of serious labeling and a more systematic communication of concepts and theories
occurred. This process continues to enrich the discipline of nursing.
First attempts in theoretical nursing were made by Florence Nightingale in the late 19th and
early 20th centuries to describe nursing focus and action in the Crimean War. Nightingale was
prompted to articulate her ideas in numerous publications, with different goals. Among these
goals were gaining support for a national need for nurses, achieving acceptance for the develop-
ment of educational programs for nurses, and exposing the unhealthy environmental conditions
that were endured by English soldiers during wars.
Subsequent attempts in theorizing were published by American nurse educators in the mid-
1950s, prompted by the need to justify different educational levels for nurses and the need to
develop curricula for each of the educational levels in nursing. To differentiate curricula, and to
enhance the quality of education in each curriculum, a few pioneer nurses combined their clinical
expertise with forward vision to answer such questions as “What are nursing goals?” and “What
ought to be the aims of nursing?” These early theorists were aware that by developing programs
that represented a nursing perspective, they would help nursing students—that is, future clini-
cians—to focus on nursing phenomena and problems rather than on medical phenomena and
problems. Groups were formed in different parts of the United States (and subsequently or simul-
taneously in other parts of the world) and committees were formed to discuss the nature of nurs-
ing, the nature of nurses’ work, and the unique aspects of nursing. The goals of these early efforts
were also focused on differentiating nursing from other health science disciplines. These dia-
logues went further to explore the nature of nursing knowledge.
Perhaps the best way to consider the history of nursing theory and to analyze nurses’ current
interest in theory in perspective is to consider dominant themes in the different stages of the devel-
opment of nursing knowledge (see discussion on Nursing Perspective in Chapter 6). The implicit
assumption here is that the themes discussed in the literature are indicative and representative of
what members of the discipline were interested in at different times during the process of its
development. In addition to delineating these themes, an analysis of the theory-literature provides
us with specific milestones that may have helped in the development of theoretical nursing. Both
approaches provide insights into how nursing evolved into its current status.
In this chapter, the themes are articulated as stages that have influenced progress in knowl-
edge development. Stages are complemented by milestones, which characterize the turning points
for moving from one stage to the next. These stages and milestones helped achieve the current
level of progress in the discipline.
STAGES IN NURSING PROGRESS
Since the time of the Crimean War, nursing has gone through many stages in its search for a pro-
fessional identity and in defining its domain. It is interesting to note that our analysis and evalua-
tion of nursing’s theoretical thought, the patriarchal societies we live in, and the view and status
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60 PART TWO Our Theoretical Heritage
accorded nurses and nursing may make it appear as if each of these stages was a deviation from
the goal of establishing the discipline of nursing. However, each of these stages has indeed sharp-
ened and clarified the dimensions needed for the establishment of the scientific aspects of the dis-
cipline, promoting or leading to a scholarly evolution of the nursing discipline. Each stage has
helped nurses come closer to identifying the domain of nursing, defining its mission, and defining
its theoretical base. Progress in the development of theoretical nursing is definable in terms of six
stages: practice, education and administration, research, theory, philosophy, and integration.
Stage of Practice
The Western version of nursing as an occupation dates from the late 19th century and the
early 20th century, a product of the Crimean War. Because of the need to care for wounded sol-
diers, Florence Nightingale organized a group of women to deliver care under her supervision and
that of the war surgeons. Nightingale focused on hygiene as her goal and environmental changes
as the means to achieve that goal.
The Eastern version of the beginning of nursing gives credit to Rufaida Bent Saad al-Aslamiya
(also referred to as Koaiba Bent Saad), who accompanied the prophet Mohammed in his Islamic
wars. She, too, organized a group of women and focused on hygiene and environment in caring for
the wounded. She established special moving tents to attend to the sick, the wounded, and the dis-
abled. She modeled first aid, emergency care, and long-term healing and caring. She cared for
patients and trained women in the arts of first aid and nursing (Fangary, 1980; S.H. Hussein, per-
sonal communication, 1990). Like Nightingale, al-Aslamiya established the first school of nursing
in the Muslim world. In addition, she conceptualized a code of ethics for nurses and inspired young
women to be educated (Jan, 1996). Like Nightingale, her role in nursing did not end with the war.
al-Asalmiya continued to advocate for health care, preventive care, and health education.
Hussein (1981) described al-Aslamiya’s devotion to nursing and her success in establishing
new rules and traditions for quality nursing care as precursors to modern nursing in the Middle
East. In both Eastern and Western versions of the beginnings of nursing, a woman saw the need
for organizing other women to care for the wounded in wars; in both, they provided emergency
care as well as long-term care. They both focused on caring, healing, promoting healthy environ-
ments, and on training other nurses. They both were driven by moral commitments to alleviate
suffering and enhance healing.
Therefore, during this stage, the mission of nursing was defined as providing care and com-
fort to enhance healing and a sense of well-being, and to create a healthy environment that helps
decrease suffering and deterioration. Nurses defined their domain to include the patient and the
environment in which the care is offered. Both Nightingale and al-Aslamiya created and moni-
tored the environment in which the care was being given. The stage of practice gave nursing its
raison d’être, its focus, and its mission. Theoretical writings by Nightingale (1946) describing the
care goals and processes are testimony to the potential for nurses to articulate practice activities
theoretically. These writings also point to the potential for nursing as a field of practice to be artic-
ulated theoretically.
Stage of Education and Administration
From that early focus on practice and the concomitant traditions of apprenticeship and serv-
ice, there was a shift to questions related to training programs and nursing curricula. The “how to”
of practice eventually was translated into what curriculum to develop to support different levels of
nursing education and how to teach it. Almost three decades were spent experimenting with dif-
ferent curricula, ways of preparing teachers, modes of educating administrators for schools of
nursing and for service, and ways of preparing nurse practitioners. During this stage, the focus
was on the development of functional roles for nurses. The dominant themes of this stage evolved
from the educational and administrative roles of nurses.
The significance of this stage in the theoretical development of the discipline lies in the impe-
tus it provided nurses to ask questions related to the domain of nursing. In developing curricula
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CHAPTER 5 On the Way to Theoretical Nursing: Stages and Milestones 61
geared toward preparing nurses for different educational levels, nurses asked: What is nursing?
How different is nursing care as provided by a diploma graduate, an associate-degree graduate, a
bachelor of science graduate, or a master’s-degree graduate? These questions prompted nurses to
articulate the core of nursing practice in more theoretical terms (Henderson, 1966). In a curious
way, it is during this stage that the theoretical ideas of the pioneering American nurse theorists
were born. A focus on teaching and education, therefore, may have paved the way for the further
development of theoretical nursing.
Stage of Research
The stage of research evolved through a series of events overlapping with the stages of prac-
tice and education. As Gortner (2000) indicated, during the 1920s, case studies were formulated
as teaching tools, but they also were used as an impetus for standardization. Systematic evaluation
of these cases triggered the need for graduate education during the post-Depression years in the
United States. The war years required data collection and analysis, necessitating the establishment
of the Division of Nursing Resources as part of the U.S. Public Health Services in 1948. The
beginnings of a research enterprise were born. In the 1970s, commissions and councils of nurse
researchers were established. Nurses increasingly were receiving graduate degrees in other disci-
plines, funds for National Research Service awards were established, and nursing research jour-
nals were initiated.
The momentum in nursing in education, curriculum development, teaching and learning
strategies, and in administration also led educators to pursue research. Experts in nursing curricula
recognized that without research and a systematic inquiry into, for example, the different teach-
ing/learning modalities and the teaching/learning milieu on outcomes, the education of nurses
could not be improved. Therefore, the research interest emerged from and focused on questions
related to educational and evaluative processes. The scholarship in teaching dominated the early
research enterprise.
How to teach, how to administer, how to lead, and which strategies would be more effective in
teaching and administering were questions that led to the development and expansion of nursing
research (Gortner and Nahm, 1977). The first nursing research journal—entitled Nursing Research—
in the world was established in 1952, in the United States, and the Southern Regional Educational
Board (SREB) and the Western Council for Higher Education in Nursing (WCHEN) were founded in
the mid-1950s and mid-1960s, respectively. Their objectives called for improving nursing education,
enhancing nursing research productivity, and raising the quality of research. The journal and the meet-
ings of the SREB and WCHEN helped nursing develop its scientific norms—that “set of cultural val-
ues and mores governing the activities termed scientific” (Merton, 1973, p. 270).
Criteria for reviewing scientific papers were established, on the basis of the assumption that
scientific inquiry must be judged by peers. Therefore, nurse researchers began to abide by Merton’s
norm of universalism, the impersonal evaluation of a research product by some objective criteria
(Merton, 1973, p. 270). Universities also held the same expectations for nursing faculty that they
held for other faculty; specifically, members of faculty in schools of nursing were required to
develop their ideas and communicate them in the scientific arena through publications in refereed
journals and scholarly presentations in meetings. Therefore, when seen in the context of science,
the “publish or perish” dogma was not unrealistic but was rather another norm governing nursing
science. Nurses were now involved in that communality—the sharing of ideas—and their research
was subjected to the scrutiny of their peers and anonymous critics (Gortner, 1980; Merton, 1973).
Nursing’s initial attempts at introducing ideas and sharing research results were met with
severe and, at times, devastating criticisms from other nursing colleagues. (Those who partici-
pated in early research conferences may remember the lengthy and severe research critiques that
traumatized researchers and audience alike. These authors of these critiques may not have consid-
ered the stage of nursing research development.) As a result, and in addition to universality and
communality, two other norms evolved: objectivity and detached scrutiny. Objective criteria for
research evaluation, which were identified and shared, provided a turning point—a scholarly
medium for research refinement and further development (Leininger, 1968).
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62 PART TWO Our Theoretical Heritage
The stage of research development made major contributions to contemporary scholarly
nursing. It was also the stage in which tools of science left a major mark on curricula through the
new offerings of research classes and statistics courses and through the several publications in
which major research tools and instruments were compiled and combined.
These stages have a global parallel. Progress in knowledge development is also influenced by
international levels of education. Some countries, such as Australia and Germany, moved nursing
education from hospital training to university training in the 1980s and 1990s, respectively. Sub-
sequently, there has been a steady increase in philosophies and theoretical dialogues, as well as a
cumulative trajectory of research productivity.
These, then, were the beginnings of nursing inquiry and science. During this stage, as in other
sciences, researchers emphasized scientific syntax—the process rather than the content of research
(Kuhn, 1970). The binding frameworks or depositories of collected facts were still lacking. Never-
theless, the syntax of the discipline had been formulated.
Stage of Theory
Eventually, the fundamental questions about the essence of nursing—its mission and its
goals—began to surface in a more organized way. An incisive group of leaders, nurses who
believed that theory should guide the practice of nursing, wrote about the need for theory, the
nature of nursing theory, philosophers’ views of theory, and how nursing theory ought to be shaped.
Although the conceptual schemata of nurse theorists for the discipline of nursing appeared during
the education and administration stages of the discipline, it was not until the emergence of the stage
of theory that they were taken seriously (Nursing Theory Think Tank, 1979).
During this stage, arguments arose about whether nursing was merely a chapter of medicine
or whether it was part of the biologic, natural, or physical sciences (analogous to the earlier Carte-
sian concept that biology is simply a chapter of physics). The Cartesian concept was rejected
(biology is indeed a distinct and autonomous science), and nursing continued to resist the implica-
tion that it was a part of medicine. It became clear to a new breed of nurse leaders—the philoso-
phers and the theorists (or conceptualists, as some referred to them)—that nursing could not be
reduced to a single science that inquires into just one aspect of man, just as biology is not
reducible to physics. Nursing is complex, necessitating its intrinsic autonomy in content and
methods.
The search for conceptual coherence evolved from a preoccupation with syntax to the disci-
plined and imaginative study of the realities of nursing and the meaning and truths that guide its
actions (Table 5-1). Its development from preoccupation with scientific method to speculation and
conceptualization is reminiscent of the development of philosophical thought in the 18th and 19th
centuries. The 18th century was greatly influenced by Newton and by Bacon, who was in turn
influenced by Descartes. The 19th century was dominated by Kant, whose hypothetical, deduc-
tive, and metaphysical approach encouraged the speculative nature of science. The speculators in
nursing began to construct realities as they saw them, and their imaginative constructs evolved
from their philosophical backgrounds and from their educational inclinations.
TABLE 5-1 CHARACTERISTICS OF THE BEGINNING STAGE OF THEORY DEVELOPMENT
• Use of external paradigms to guide theory
• Uncertainty about discipline phenomena
• Discrete and independent theories
• Separation between research, practice, and theory
• Search for conceptual coherence
• Theories used for curricula
• The goal of a single paradigm prevails
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CHAPTER 5 On the Way to Theoretical Nursing: Stages and Milestones 63
It was natural for theory development to be influenced by the paradigms of other disciplines,
by the educational background of nurse theorists, and by the philosophical underpinnings of the
time. Therefore, we find premises stemming from existentialism, analytical philosophy, and prag-
matism guiding the development of those theories, sometimes explicitly and often implicitly.
Nurses also adopted concepts and propositions from other paradigms, such as psychoanalysis,
development, adaptation, and interaction, as well as from humanism, to guide its assessment and
its action. Theories were developed in response to dissatisfaction with isolated findings in
research. The emerging theories addressed the nature of the human being in interactions and trans-
actions with the health care system, as well as the processes of problem solving and decision mak-
ing for assessment and intervention.
Although certain theoretical concepts were synthesized from diverse paradigms, most nurs-
ing theories, such as subsystems of behavior, role supplementation, therapeutic touch, and self-
help, were definable and analyzable only from the nursing perspective. Theories offered a
beginning agreement on the broad intellectual endeavors and the fundamental explanatory tasks of
nursing. This stage offered knowledge of relevant phenomena, but uncertainty continued about the
discipline of nursing and its intellectual goals. Just as in nuclear physics—when the first achieve-
ment was not one of observation or mathematical calculation but one of intellectual imagination—
conceptual schemata evolved before there was any clear recognition of nursing’s empirical scope.
In nursing, theories helped the discipline to focus on its concepts and problems.
Rogers (1970) offered a conception of nursing that focused on the constant human interac-
tion with the environment. Johnson (1980) developed the notion that a human being—a biologic
system—is also an abstract system of behavior centered on innate needs. Levine (1967) and
Orem (1971) proposed guidelines for nursing therapeutics that preserve the integrity of the
human being, the psychology, the community affiliation—in short—the entire person. Orem
(1985) reminded us that the human being is perfectly capable of self-care and should progress
toward that goal.
Because of the earlier focus on education and professional identity, because the National
League for Nursing stipulated a conceptual framework for curricula, and because the truth of a
theory had not yet been established using the empirical positivists’ criteria of corroboration, emer-
gent theories were not used to guide practice or research but were instead used to guide teaching.
Consequently, scientific energies were dissipated in developing curricula that corresponded to
these theories.
Although theories may have influenced practice through students, such influence was not doc-
umented in the literature, which focused more on theory in educational programs. As an educator
who was a member of a school that used nursing theory (also called a model) as a framework for
the curriculum, I experienced first-hand, in the mid-1960s, the conflicts that graduates of the pro-
gram encountered when they wanted to use a nursing framework, one that they studied and experi-
enced in their educational program, in practice and were unable to do so because of its novelty and
its esoteric concepts. Whether the use of nursing models in education rendered nursing care more
effective and efficient is a matter left to speculation and was evidenced only in isolated incidents
and through experiential narrative analyses that were discounted for their lack of universality and
generalization. The graduates of programs based on nursing theories in the early and mid-1960s
should be encouraged to write the stories of their experiences with these theoretically based pro-
grams and the ways by which their practice was informed or not informed by these programs.
The nagging questions continued:
• What frameworks enhance safety in nursing practice?
• What are the goals of nursing care?
• What are the desired outcomes related to nursing care?
• How do nursing interventions relate to desired outcomes?
• What are the quality care criteria by which to judge nursing practice?
These questions continued to lead to one type of answer: Let us find a guiding paradigm or
search for a universal theory with explanatory power for all dimensions of nursing and, once we
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64 PART TWO Our Theoretical Heritage
find this all-encompassing theory, we will be able to answer questions related to the discipline.
This approach reminds us that Galileo and Descartes talked of the scientist’s task as that of being
able to decipher once and for all the secrets of nature and to arrive at the “one true structure” of the
nature of the world. However, that was a Platonic ideal rather than a plain description of the task
of scientific research. Later, scientists began to discard this line of pursuit. Physicists and physiol-
ogists “now believe that . . . we shall do better in these fields by working our way toward more
general concepts progressively, as we go along, rather than insisting on complete generality from
the outset” (Toulmin, 1977, p. 387). Toulmin proposed that “human behavior in general represents
too broad a domain to be encompassed within a single body of theory” (p. 387). When scientists
accept the need for multiple theories, and when they accept the process nature of science, it will be
a “sign of maturity rather than defeatism” (p. 387) within the discipline.
Because nurse scientists searched for one theory for the entire discipline, the task was either
overwhelming and too highly abstract (Rogers, 1970), or too simplistic and reductionist (Orem,
1971). The sentiment of practitioners was to question the possibility and usefulness of an all-
encompassing theory, as evidenced by the meager literature throughout the 1960s and 1970s on
nursing practice using nursing theory. The desire for a single conceptual framework to guide the
nursing curriculum was carried to nursing practice. Nurse practitioners came to believe that they
were being asked to make a choice between theories, and then adhere to that one particular theory.
Because none of the theories addressed all aspects of nursing, nurse practitioners avoided nursing
theory, ignored it, or refused to use it. A myth was being formed. However, many nurses aban-
doned the notion of a universal theory to describe and explain nursing phenomena and units of
analysis and to guide nursing practice, just as physicists did when they abandoned the 17th-century
hope that a universal science of nature could be developed within the framework of fundamental
ideas of classical mechanics.
Three themes in nursing that evolved during this stage were acceptance of the complexity of
nursing and the inevitability of multiple theories; acceptance of the need to test and corroborate
major propositions of differing theories before dismissing any of them; and the idea that concepts
or theories remaining in the field, through a cumulative effect, become the basis for the develop-
ment of a specific perspective. Dualism and pluralism were the norms during the stage of theory.
It was also during this stage that nursing developed the boundaries necessary to focus its inquiry
and the flexibility necessary to allow expansion through creative endeavor.
Stage of Philosophy
As nurses began reflecting on the conceptual aspects of nursing practice, on defining the
domain of nursing, and on the most appropriate methods for knowledge development, they turned
to philosophical inquiries. The focus during this stage was on raising and answering questions
about the nature of nursing knowledge (Carper, 1978; Silva, 1977), the nature of inquiry (Ellis,
1983), and the congruency between the essence of nursing knowledge and research methodolo-
gies (Allen, Benner, and Diekelman, 1986). During this stage, philosophy was considered an
attempt to understand the philosophical premises underlying nursing theory and research (Sarter,
1987) and an attempt to develop philosophical inquiry as a legitimate approach to knowledge
development in nursing (Fry, 1989).
This stage influenced profoundly the intellectual discourse in nursing literature. During this
stage, epistemological diversity was accepted and the need for ethical, logical, and epistemologi-
cal inquiries was legitimized, as evidenced in the numerous philosophically based manuscripts
accepted for publication (Ellis, 1983).
This stage was also marked by a scholarly maturity in the discipline, as its members acknowl-
edged the limitation of appropriate tools to investigate fundamental and practical issues. Assump-
tions about wholeness of human beings, contextual variables, and holism of care called for
congruent investigative tools, and nurse scholars acknowledged the complexity of capturing nurs-
ing phenomenon using existing tools (Newman, 1995; Stevenson and Woods, 1986). Accepting
limitations while maintaining the reality of the contextuality and complexity of the phenomenon
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CHAPTER 5 On the Way to Theoretical Nursing: Stages and Milestones 65
represents a marked scholarly maturity and the potential to focus on the development of appropri-
ate tools.
Earlier during this stage, discussions encompassed the different “ways of knowing” in nurs-
ing and espoused a call for going beyond the empirical (Carper, 1978). These epistemological dis-
cussions focusing on the structure of knowledge, nature of theory, criteria for analysis, and
justification of particular methodologies for knowledge development significantly contributed to
the discovery and construction of an identity for the discipline of nursing. As theorists and
metatheorists discussed the philosophical bases that shaped nursing knowledge (Allen et al.,
1986; Roy, 1995), a new set of questions emerged. These questions reflected more the values and
meaning of the knowledge being developed and the consequences of this knowledge on nursing
practice, and focused less on the structure and justification of knowledge (Bradshaw, 1995; Silva,
Sorrell, and Sorrell, 1995).
The emphasis on knowing was complemented by another emphasis on “being.” The being
was not limited to the nurse, or to the patient, but to each separately and to both joined in caring
interactions (Benner, 1994; Newman, 1995). This philosophical stage, encompassing both com-
ponents of epistemology and ontology, provided nurses with the legitimacy to ask and answer
questions related to values, meanings, and realities using multiple philosophical and theoretical
bases.
This philosophical stage persists, overlapping with the following stage of integration. Dia-
logues about postcolonialism provide the philosophical canons for understanding how domina-
tion, power, and resistance influence health care encounters at all different levels, from the
individual to society (Kirkham and Anderson, 2002). The postcolonial scholarship in nursing was
informed by the discourse in the discipline on race, culture, ethnicity, diversity, and power differ-
ential. It refers to and frames the theoretical and empirical work of people’s experiences living
under the oppression of colonial control. Using this philosophical stand, we can better understand
the effects of diversity in color, religion, sexual preference, ethnicity, and class in shaping
responses to health and illness. It allows health care professionals to access the meaning of
marginalization.
Postmodernism, a reaction by philosophers to positivism, translated in nursing into a prevail-
ing sentiment described by Whall as “Let’s get rid of all nursing theory” (Whall, 1993; Whall and
Hicks, 2002). Although the context is vital to postmodernism philosophy, universal totality is not
possible. Other concepts that characterize postmodernism are relativism, deconstruction, context,
atheoretical narratives, and structural influences.
Stage of Integration
This stage has seven universal characteristics, each described in the subsequent text. They
should be used to stimulate thinking and discussions about the state of development of our disci-
pline, both nationally and internationally. This stage differs from the next stage in its internal ver-
sus external integration with other disciplines. A first characteristic of this stage is the use of
substantive dialogues and discussions focused on identifying coherent structures of the discipline
of nursing at large and of its specific areas of specialization (Schlotfeldt, 1988). The structures
include scientific, theoretical, philosophical, and clinical knowledge that is focused on the nursing
domain and its phenomena. These dialogues take place in conferences, think tanks, and themed
journal editions devoted to the development of middle-range and situation-specific theories
focused on an aspect of nursing.
A second characteristic of this stage is the development of educational programs that are
organized around substantive areas through the integration of theory, research, and practice—
such as environment and health, symptom management, or transitions and health. It is also man-
ifested in the ease by which nursing administrators, clinicians, and educators use theoretical
nursing, and in the increasing dialogue among members of the discipline regarding matters
related to knowledge, discovery, and development that is focused on and emanates from the
domain of nursing.
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66 PART TWO Our Theoretical Heritage
A third characteristic of this stage is the evaluation of different aspects of theoretical nursing
by members of the discipline—nursing clinicians, teachers, administrators, researchers, and theo-
reticians. Evaluation is not limited to theory testing; it includes description, analysis, and critiques
as well. Each of these processes is important in the development and progress of our discipline
because of its diverse philosophical bases.
A fourth characteristic of this stage is the attention that members of the discipline give to the
strategies of knowledge development that are congruent with the discipline’s shared assumptions
and that consider the conditions of holism, patterning, experience, and meaning (Newman, 1995).
A fifth characteristic is the involvement of members of specialty fields in developing theories
that are pertinent to the phenomena of that particular field. This involvement does not preclude
similar attention to theories related to phenomena of the domain of nursing at large; for example,
theories to describe and intervene in symptoms.
A sixth characteristic is the critical reappraisal of philosophical and theoretical underpin-
nings that have guided the definitions and conceptualizations of the central concepts of the nurs-
ing domain, as well as the methodologies used to generate knowledge. An example of such
discourse is the reappraisal of the definition of client in the nursing literature and the congruency
of these definitions with domain assumptions (Allen, 1987). Another example is the dialogue
about melding different methods to generate knowledge that is more congruent to the tenets of a
human science, such as grounded theory, feminist theory, and critical theory (Kushner and
Morrow, 2003).
A seventh characteristic of this stage is the creative ways by which academic institutions in
nursing become involved with patient care, either through academically run clinics (nursing clin-
ics), or by developing clinically based faculty positions.
Stage of Interdisciplinarity
The stage of integration leads and overlaps the stage of interdisciplinarity. The road map
for the National Institutes of Heath (NIH) at the beginning of the 21st century provided a
strong impetus for a different type of integration, one that challenged members of different
disciplines to build programs of research that incorporate the theories and evidence from dif-
ferent fields. Although nursing has consistently depended upon, borrowed from, and shared
the research and theories of other disciplines, the drive for interdisciplinary education and
teaching research was now being promoted at leading research institutions. A central tenet of
this stage is the forging of relationships between researchers and clinicians who are members
of different disciplines, to develop joint institutes, advance research programs, or to provide
more comprehensive education. Centers for sleep research, pain management, palliative care,
complementary and alternative practices, safe practice, and gun-shot injuries are examples of
areas that require the expertise of members of different disciplines. A similar move to reflect
the nature and complexity of science was initiated at the NIH. The question that drove these
institutes was whether they should reflect discipline or an area of science. Time will tell
whether a move away from disciplinary institutes will continue to support the development of
disciplines horizontally as well as vertically. More discussion of disciplines and interdisciplines
is provided in Chapter 14.
Stage of Technology and Information Systems
Health care records, robotic medication dispensers, tele-home care, long-distance monitor-
ing, virtual surgeries, and voice mail reminders of appointments and medications are character-
istic of this stage in the history of the development of the nursing discipline. Theories that
incorporate variables and conditions related to informatics and technological breakthroughs are
necessary drivers for this stage. Self-care practices take on different meanings for individuals
and families when they incorporate the most advanced and up-to-date information disseminated
by scientists and clinicians to the public via the internet. Self-care practices and goals also
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CHAPTER 5 On the Way to Theoretical Nursing: Stages and Milestones 67
incorporate the use of such new monitoring devices as home blood pressure apparatus, glucose
kits, self-diagnosis protocols, and self-monitoring gadgets. The ability to sort among accurate
and inaccurate information, and the alternative “if-then” scenarios that result, will need to be
guided by situation-specific theories that incorporate guidelines for clinicians and consumers (An,
Hayman, Panniers, and Carty, 2007).
MILESTONES IN THEORY DEVELOPMENT
The progress and development of theoretical nursing is marked by several milestones, which are
identified through an analysis of theoretical literature that appeared in selected nursing journals
between 1950 and 2004. These milestones substantially changed the position of theory in nursing
and profoundly influenced the further development of theoretical nursing. Each milestone is
defined and briefly described here (Table 5-2). Identifying and defining these milestones chal-
lenges others to explore the impact each milestone may have had on the progress and development
of nursing knowledge.
Prior to 1955—From Florence Nightingale to Nursing Research
The significant milestone of the period before 1955, which has influenced the subsequent
development of all nursing science, was the establishment of the journal, Nursing Research, with
the goal of reporting on scientific investigations for nursing by nurses and others (Fig. 5-1). The
journal’s most significant goal was to encourage scientific productivity. The establishment of the
journal confirmed that nursing is indeed a scientific discipline and that its progress will depend on
whether nurses pursue truth through an avenue that respectable disciplines take, namely, research.
Although Nightingale may have provided the beginning impetus for research and theory, initially,
her impact was most keenly felt in nursing education. Education of nurses had predominantly
occurred in diploma programs, but this period marked a beginning interest in providing different
routes for nurses’ education.
This period was otherwise uneventful for nursing theory, except that the establishment of
nursing research publications provided the framework for a questioning attitude that may have set
the stage for inquiries that led to more theoretical discourses in later years.
TABLE 5-2 THEORY DEVELOPMENT IN NURSING: MILESTONES
Prior to 1955 From Florence Nightingale to nursing research
1955–1960 Birth of nursing theory
1961–1965 Theory: A national goal for nursing
1966–1970 Theory development: A tangible goal for academics
1971–1975 Theory syntax
1976–1980 A time to reflect
1981–1985 Nursing theories’ revival: Emergence of the domain concepts
1986–1990 From metatheory to concept development
1991–1995 Middle-range and situational theories
1996–2000 Evidence means research, not theory
2001–2005 Diversity in thought: Linking theory and practice
2006–2010 Nurses empowered: Evidence and technology as resources
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68 PART TWO Our Theoretical Heritage
FIGURE 5-1 ◆ Chronology of the develop-
ment of theoretical nursing.
1955–1960—The Birth of Nursing Theory: The Columbia University
Teachers College Approach
Although Florence Nightingale’s ideas about nursing, focusing on the relationship between
health and environment, were developed in the early 1900s, it was not until the mid-1950s that
nurses began to articulate a theoretical view of nursing. Questions about the nature of nursing, its
mission and goals, and about nurses’ roles drove nurse educators to capture the answers to these
questions and present them in a more coherent whole. These questions grew out of an interest in
changes in the educational preparation of nurses from diploma to baccalaureate programs, out of
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CHAPTER 5 On the Way to Theoretical Nursing: Stages and Milestones 69
concerns about what to include or exclude in curricula, and about what nurses needed to learn to
function as nurses.
Columbia University’s Teachers College, where the first professor of nursing, M. Adelaide
Nutting, was appointed, offered graduate programs that focused on education and administration,
to prepare graduates as expert educators and administrators. Although the focus of that vision-
ary program was not on nursing science or nursing theory, participants in this program must
have felt that they were in an environment that promoted dialogue and debate of philosophical and
theoretical questions. Of note, in 1999, the nursing education program celebrated 100 years of
influence, a well-placed celebration given that most theorists who offered a conception of nursing
during that decade were educated at Teachers College; these included Peplau, Henderson, Hall,
Abdellah, King, Wiedenbach, and Rogers (Table 5-3).
Being prepared for functional roles and experiencing a sense of competency in preparing syl-
labi, setting staffing patterns, and so on may have freed the creative abilities of these scholars for
other aspects of the scholarly process, such as theory or conceptual model development. And,
TABLE 5-3 NURSING THEORISTS: 1950–1980
1952 Hildegarde Peplau. Interpersonal relations in nursing. Also published 1962, 1963, 1969.
1955 Virginia Henderson. Textbook of the principles and practice of nursing (with B. Harmer). Also 1966,
1972, 1978.
1959 Dorothy Johnson. “A philosophy of nursing.” Also 1961, 1966, 1974.
1959 Lydia Hall. A philosophy of nursing. Also 1963 (and by others, 1975).
1960 Faye Abdellah. “Patient-centered approaches to nursing.” Also 1965, 1973.
1961 Ida Jean Orlando. The dynamic nurse-patient relationship.
1963 D. Howland and E. McDowell. “A hospital system model.”
1964 D. Howland and E. McDowell. “The measurement of patient care: A conceptual framework.”
1964 Joyce Travelbee. Interpersonal aspects of nursing. Also 1969, 1971, 1979.
1964 E. Wiedenbach. Clinical nursing: A helping art. Also 1967, 1969, 1970, 1977.
1966 Myra Levine. “Adaptation and assessment.”
1966 M. Harms and F. McDonald. “A new curriculum design.”
1967 Myra Levine. Introduction to clinical nursing. Also 1969, 1971, 1973.
1968 Imogene King. “A conceptual framework of reference for nursing.” Also 1971, 1975.
1969 Joyce Travelbee. Interventions in psychiatric nursing. Also 1971 (1979).
1970 Martha Rogers. An introduction to the theoretical basis of nursing. Also 1980.
1970 Sister Callista Roy. “Adaptation: A conceptual framework for nursing.” Also 1974, 1976, 1980, 1984.
1971 Imogene King. Toward a theory for nursing: General concepts of human behavior.
1971 Dorothea Orem. Nursing: Concepts of practice. Also 1981, 1982, 1985, 1991.
1972 Betty Neuman. “The Betty Neuman health-care systems model.” Also 1989.
1976 Josephine Patterson and L. Zderad. “Humanistic nursing.” Also 1988.
For complete citations, see Chapter 20 under appropriate authors.
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70 PART TWO Our Theoretical Heritage
although other experiences and programs may have directly influenced these scholars in their the-
oretical pursuits (e.g., Rogers’ doctoral preparation at Johns Hopkins), it appears that the philoso-
phy of Teachers College indirectly left an impact, not only on psychiatric theory and research, but
also on theoretical thinking in all of nursing (Sills, 1977). Asking and answering questions about
the influence of scholarly environments on preparing productive scholars may have stimulated the
search for the nature of scholarship, which may have led to questions related to the nature of the
nursing identity.
Peplau (1952), using Harry Stack Sullivan’s theory title and concepts to develop her own,
produced the first articulated concept of nursing as an interpersonal relationship, with components
of interpersonal processes central to nursing needing to be elucidated and analyzed. The field of
psychiatric nursing subsequently was substantially developed using Peplau’s ideas. Other theories
that evolved in the 1960s were based on those early conceptions of nursing. For example, Virginia
Henderson, with Bershan Harmer, developed the early seeds of a nursing theory that was pub-
lished in the mid-1950s in a textbook on the principles and practice of nursing.
The request from the International Council of Nursing (ICN) to define nursing and its mis-
sion led to the subsequent ICN statement in 1958 that appeared in a publication with wide distri-
bution and that was adapted internationally (Henderson, 1966, p. 15). The message given by both
Peplau and Henderson was that nursing has a specific and unique mission and that this mission
has some order and organization that can be communicated. These articulated wholes represented
the beginnings of theories in nursing.
Abdellah’s nursing theory, evolving from her work at Columbia University, is another exam-
ple of the influence of that school on theoretical nursing (Abdellah, Beland, Martin, and Matheney,
1961). Abdellah’s doctoral dissertation in 1953 at Teachers College, under the leadership of Hilde-
gard Peplau, focused on determining covert aspects of nursing problems. The results of her
research were subsequently published in Nursing Research, marking the beginning of her attempts
at theorizing the nursing care process. Her conceptualization of nursing care evolved from her dis-
sertation research and from another study completed in 1955, on the needs of patients for nursing
care. The latter was based on data collected from patients, nurses, and doctors. Abdellah developed
her conception of what nursing is by focusing attention on patients rather than on techniques.
Ideas of other theorists were formulated around the need for a binding framework to guide
curricula, but their writing and publications did not have the instant impact as that of Peplau, Hen-
derson, and Abdellah on theoretical nursing. Their conceptions were slow to have an impact on
nursing. Orem’s ideas were first published in a guide for developing a curriculum for practical
nursing in 1959. Patient needs were also the focus. Hall developed, in 1959, and implemented, in
1963, a concept of nursing based on needs and interpersonal relations at the Loeb Center for Nurs-
ing and Rehabilitation. One can see the influence of both Peplau and Henderson in her writing
(Hall, 1963).
Independent of the Teachers College group of theorists, Johnson was beginning to play a cen-
tral role in conceptualizing nursing. Johnson’s (1959) analysis of the nature of science in nursing
was undoubtedly a milestone in drawing attention to the potential of nursing as a scientific disci-
pline and in advocating the development of its unique knowledge base. At that time, Johnson ten-
tatively suggested that nursing knowledge is based on a theory of nursing diagnosis that is distinct
and different from medical diagnosis. The substantive matter for such diagnosis, the beginning of
Johnson’s theory, was starting to be formulated at this time. (See Chapter 20 for appropriate cita-
tions for each theorist.)
Another milestone in nursing progress was the establishment of the special nursing research
fellowship program to facilitate, support, and encourage nurses’ education for research careers.
This program provided financial incentive and support for nurses to pursue their doctoral educa-
tion in related fields such as biology, physiology, sociology, and anthropology, among others.
1961–1965—Theory: A National Goal for Nursing
From a reduced conception of a human being as “an illness” or “a surgery,” with signs and
symptoms, nursing theory in the late 1950s refocused nursing attention on the individual as a set
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CHAPTER 5 On the Way to Theoretical Nursing: Stages and Milestones 71
of needs and nursing as a set of unique functions. Still, a reductionist approach to nursing existed.
The 1960s, with its turbulent society, the Camelot goals of harmony and coexistence, and the
influence of Peplau may have prompted the refocusing of nursing from its stated mission of meet-
ing patients’ needs to the goal of establishing a relationship between the nurse and client. If rela-
tionships are effectively established through interpersonal interactions (as previously articulated
by Peplau, 1952, and as advocated by a new group of theorists), then nursing care can meet the
needs of the patient—not as defined by nurses, but as perceived by the patient.
During this period, the Yale School of Nursing’s position, influenced by the Columbia Teachers
College graduates who became faculty members at Yale, was beginning to be formulated. To these
scholars, nursing was considered a process rather than an end, an interaction rather than content, and
a relationship between two human beings rather than an interaction between unrelated nurse and
patient. Multiple social forces helped the Yale group to develop its ideas into concepts of nursing.
Federal grant money was available for preparation ranging from psychiatric nursing to teaching
positions, for identifying psychiatric concepts in nursing, and for developing an integrated curricu-
lum. The availability of time and resources, therefore, was significant in providing the necessary
push, as well as the appropriate environment in which to reflect on nursing’s mission and goals.
Although the work of the faculty of the Yale School of Nursing may have profoundly influ-
enced nursing research in the United States in the 1960s, its influence on theory was not as
marked at the time. A revival of that impact came in the 1980s, as nurses acknowledged Yale’s
strategies for theory development; this is evidenced by the reconsideration of Orlando’s work
(Schmieding, 1983, 1987, 1988) and by the paradigmatic shift in nursing research to phenomenol-
ogy (Oiler, 1982; Omery, 1983; Silva and Rothbart, 1984). These writers’ conceptualization of
nursing, therefore, was not the milestone that prompted the evolution of the next stage of theory.
Rather, it was the position paper of the American Nurses Association (ANA)—in which nursing
was defined as care, cure, and coordination, and in which theory development was identified as a
most significant goal for the profession of nursing—that may have been influential in the further
development of theoretical nursing (ANA, 1965).
Two other significant developments occurred during this period. First, federal support was
provided to nurses wishing to pursue doctoral education in one of the basic sciences. The gradu-
ates of these programs are those who, in the mid-1970s, further developed metatheoretical ideas.
The second development was the inauguration of the journal, Nursing Science. Although short-
lived, it was a medium for the exchange of ideas on theory and science in nursing and a confirma-
tion that nursing is an evolving science with theoretical principles and underpinnings.
1966–1970—Theory Development: A Tangible Goal for Academics
With the ANA’s recommendation that theory development was of highest priority in the pro-
fession, and with the availability of federal support, a symposium sponsored by Case Western
Reserve University was held as part of the nursing science program. This symposium was divided
into three parts. The part focusing on theory was held on October 7, 1967, and was considered a
milestone during this period (Table 5-4). The papers were published in Nursing Research a year
later. These publications supported what were previously considered simply perceptions and con-
ceptions of theoretical nursing from an isolated number of theorists. Not only did a group of sig-
nificant people in nursing get together to discuss theory in nursing, but the official scientific
journal of the field recognized the significance of these proceedings by publishing them.
Nurses also received confirmation from two philosophers and a nurse theorist (who had been
involved in teaching nurses at Yale for 5 years) that theories are significant for the practice of nurs-
ing, that the practice of nursing is amenable to theoretical development, and that nurses are capa-
ble of developing theories (Dickoff, James, and Wiedenbach, 1968). The presentations and the
subsequent series of publications by Dickoff and James (1968) and Dickoff, et al. (1968a, 1968b)
influenced the discipline of nursing profoundly, as evidenced by the classic nature of those publi-
cations and by the subsequent acceleration in publications related to theory. Nursing theory was
defined, goals for theory development were set, and the confirmation of outsiders (people outside
the field of nursing, nonnursing philosophers) was productive.
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72 PART TWO Our Theoretical Heritage
TABLE 5-4 THEORY DEVELOPMENT IN NURSING:
A HISTORICAL PERSPECTIVE
1860 Florence Nightingale addresses the need for research and the educational preparation of nurses.
1900–1950 Diploma schools served as major source of nurses—the Flexner Report for Medicine.
1952 Nursing Research first published.
1955 Establishment of the Special Nurse Research Fellowship Program in the National Institutes of
Health, Division of Nursing.
1959 D.E. Johnson. The nature of a science of nursing. Nursing Outlook, 7, 292–294.
1960 R.N. Schlotfeldt. Reflections on nursing research. American Journal of Nursing. 60(4), 492–494.
(The primary task of nursing research is to develop theories that serve as a guide to practice.)
1961 Surgeon General’s Consultant Group on Nursing appointed to advise the Surgeon General on nursing
needs and to identify the appropriate role of the federal government in assuring adequate nursing
services in the nation. This group strongly supported nursing research and recommended a sub-
stantial increase in funds.
1961 D.E. Johnson. Patterns in professional nursing education. Nursing Outlook, 9, 608. (Nursing science
may evolve more easily through the identification of common but major problems of patients that
are of direct concern to nursing.)
1962 Nurse Scientist Graduate Training Grants Program
1963 Nursing Science first published
1963 M.E. Rogers. Some comments on the theoretical basis of nursing practice. Nursing Science, 1,
11–13. (The theoretical base of nursing practice is nursing science . . . a body of scientific knowl-
edge characterized by descriptive, explanatory, and predictive principles . . . developed through syn-
thesis and resynthesis of selected knowledges from the humanities and the biological, physical,
and social sciences. . . . It assumes its own “unique scientific” mix through selection and pattern-
ing of these knowledges.)
1963 M.E. Rogers. Building a strong educational foundation. American Journal of Nursing, 63(6), 941.
(The explanatory and predictive principles of nursing make possible nursing diagnosis and knowl-
edgeable intervention toward predictable goals . . . nursing science is not additive, but creative.)
1964 D.E. Johnson. Nursing and health education. International Journal of Nursing Studies, 1, 219.
(Nurses must be socialized as scholars and must develop commitment to inquiry and skill in the use
of scientific knowledge.)
J.S. Berthold. Theoretical and empirical clarification of concepts. Nursing Science, 406–422.
M.I. Brown. (Spring). Research in the development of nursing theory. Nursing Research, 13,
109–112. (Assess progress of theory development in nursing and emphasize need for explicit
relationship of research to theory.)
F.S. Wald and R. C. Leonard. (1964). Toward development of nursing practice theory. Nursing
Research, 13(4), 309–313.
1965 American Nurses’ Association. Educational preparation for nurse practitioners and assistants to
nurses: A position paper.
P. Putnam. A conceptual approach to nursing theory. Nursing Science, 430–442.
1967 V.S. Cleland. The use of existing theories. Nursing Research, 16(2), 118–121.
1967 L.H. Conant. (Spring). A search for resolution of existing problems in nursing. Nursing Research, 16, 115.
Symposium on Theory Development in Nursing. (Reported in Nursing Research, 1968, 17(3).)
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CHAPTER 5 On the Way to Theoretical Nursing: Stages and Milestones 73
TABLE 5-4 THEORY DEVELOPMENT IN NURSING:
A HISTORICAL PERSPECTIVE (Continued )
1967–1970 National Commission for the Study of Nursing and Nursing Education, Jerome F. Lysaught, director.
1968 First Nurse Scientist Conference on The Nature of Science in Nursing. Sponsored by University of
Colorado School of Nursing, Dr. Madeleine Leininger, chair. (Reported in Nursing Research,
1969, 18[5].)
First Annual WCHEN Communicating Research Conference
1968 J. Dickoff and P. James. A theory of theories: A position paper. Nursing Research, 17(3), 197–206.
(Professional disciplines are obligated to go a step further than explanation and prediction in theory
construction, to the development of prescriptive theory.)
J. Dickoff, P. James, and E. Wiedenbach. Theory in a practice discipline: Part I. Practice oriented
theory. Nursing Research, 17(5), 415–435.
Idem. theory in a practice discipline: Part II. Practice oriented theory. Nursing Research, 17(6), 545–554.
R. Ellis. (1968). Characteristics of significant theories. Nursing Research, 17(3), 217–222.
D.E. Johnson. Theory in nursing: Borrowed and unique. Nursing Research, 17(3), 206–209.
M. Moore. Nursing: A scientific discipline. Forum, 7(4), 340–347.
J.L. Sasmor. Toward developing theory in nursing. Nursing Forum, 7(2), 191–200.
1969 G. Mathwig. Nursing science: The theoretical core of nursing knowledge. Image, 3, 9–14, 20–23.
R. McKay. Theories, models, and systems for nursing. Nursing Research, 18(5), 393–399.
C.M. Norris (Ed.). Proceedings: First, second, and third nursing theory conference. University of
Kansas, 1969 and 1970.
1971 F. Cleary. A theoretical model: Its potential for adaptation to nursing. Image, 4(1), 14–20.
I.M. Harris. Theory building in nursing: A review of the literature. Image, 4(1), 6–10.
M. Jacobson. Qualitative data as a potential source of theory in nursing. Image, 4(1), 10–14.
J.F. Murphy (Ed.). Theoretical issues in professional nursing. New York: Appleton-Century-Crofts.
I. Walker. Toward a clearer understanding of the concept of nursing theory. Nursing Research, 20(5),
428–435.
1972 M. Newman. Nursing’s theoretical evolution. Nursing Outlook, 20(7), 449–453.
NLN Council of Baccalaureate and Higher Degree Programs approved its “Criteria for the Appraisal
of Baccalaureate and Higher Degree Programs in Nursing,” including criterion stating that curric-
ula should be based on a conceptual framework.
1973 M.E. Hardy. The nature of theories. In M. Hardy (Ed.), Theoretical foundations for nursing. New York:
MSS Information Corporation.
The Nursing Development Conference Group. (1973). Concept formulation in nursing: Process and
product. Boston: Little, Brown & Co.
1974 M.E. Hardy. Theories: Components, development, evaluation. Nursing Research, 18, 100–107.
A. Jacox. Theory construction in nursing: An overview. Nursing Research, 23, 4–13.
D.E. Johnson. Development of theory: Requisite for nursing as a primary health profession. Nursing
Research, 18, 372–377.
1975 Nursing Theories Conference Group. (Formed out of a concern for the need for materials to help
students of nursing understand and use nursing theories in nursing practice.)
1978 Advances in Nursing Science. S.K. Donaldson and D. Crowley. The Discipline of Nursing. Nursing
Outlook, 26(2), 113–120.
1979 M.A. Newman. Theory development in nursing. Philadelphia: F. A. Davis.
(continued )
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74 PART TWO Our Theoretical Heritage
TABLE 5-4 THEORY DEVELOPMENT IN NURSING:
A HISTORICAL PERSPECTIVE (Continued )
1982 M.J. Kim and D.A. Moritz. Classifications of nursing diagnosis. New York: McGraw-Hill.
1983 L.O. Walker and K.C. Avant. Strategies for theory construction in nursing. New York: Appleton-
Century-Crofts.
J. Fitzpatrick and A. Whall. Conceptual models of nursing: Analysis and application. Bowie, MD: R.J.
Brady Co.
P.L. Chinn and M.K. Jacobs. Theory and nursing: A systematic approach. St. Louis: C.V. Mosby.
H.S. Kim. The nature of theoretical thinking in nursing. New York: Appleton-Century-Crofts.
I.W. Clements and F.B. Roberts. Family health: A theoretical approach to nursing care. New York:
John Wiley & Sons.
P.L. Chinn. Advances in nursing theory development. Rockville, MD: Aspen Systems.
1984 J. Fawcett. Analysis and evaluation of conceptual models. Philadelphia: F.A. Davis.
See Chapters 11–13 and 20 for evidence of increasing publications related to each of the theorists.
Although the insiders (the nurse theorists) may have charted the course of action for theory
development, the doubts and skepticism about theory (from the critics who viewed theory as sci-
entific and as evolving from an empirical, positivistic model) that dominated nursing until then
were somewhat squelched by the presentations and discussions that went on during that signifi-
cant meeting in which Dickoff and James (1968, 1971) and Dickoff, James, and Weidenbach
(1968a, 1968b) presented their metatheory of nursing. The evidence for skepticism is derived
from omission rather than commission. When theories were used during this period, they were
used in conjunction with education and not in practice (except by New York and Yale Universities
faculty and students) or research. (Refer to the theory literature in Chapter 19 for documentation
of the omission.)
The metatheorists in nursing started their questioning during this period. Questions of this era
were related to what types of theories nurses should develop rather than to the nature of the sub-
stantive content of those theories. The first metatheorists were Ellis (1968) and Wiedenbach
(Dickoff et al., 1968a, 1968b). Dickoff and James (1968), philosophers by training, addressed
metatheoretical concerns that focused on types of theories and content of theories. Debates
occurred about whether the theories should be basic or borrowed, pure or applied, descriptive or
prescriptive.
Accomplishments at this stage can be summarized as:
• Nursing is a field amenable to theorizing.
• Nurses can develop theories.
• Practice is a rich area for theory.
• Practice theory should be the goal for theory development in nursing.
• Nurses’ highest theory goal should be prescriptive theory, but it is acceptable to develop
descriptive and explanatory theories.
1971–1975—Theory Syntax
There was a period, just before the research enterprise in nursing focused on answering sig-
nificant questions in the field, when nurse researchers focused on discussing and writing about
research methodology. A parallel exists in the area of theory. The period from 1966 to 1970
resulted in a beginning focus on theory development, which was followed by attempts at identi-
fying the structural components of theory (see Table 5-4). Metatheorists dominated this period.
The emphasis was on articulating, defining, and explicating theory components and on the
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CHAPTER 5 On the Way to Theoretical Nursing: Stages and Milestones 75
processes inherent in theory analysis and critique. Nurse theorists were no longer questioning
whether nursing needed a theory or whether or not theory could be developed in nursing; ques-
tions of this period focused on what is meant by theory (Ellis, 1968, 1971; Walker, 1971), on
what are the major components of theory (Hardy, 1974; Jacox, 1974), and on ways to analyze
and critique theories (Duffey and Muhlenkamp, 1974). Education of nurses in basic, natural, and
social sciences through the federally supported nurse–scientist programs produced a cadre of
nurses who shared a common goal: the establishment of the unique knowledge base of nursing.
Discussions of what constituted theory and the identification of theory syntax seemed to be the
means to achieve that goal.
Just before the close of this period, a milestone was achieved. Just as the ANA acknowledged
the significance of theory development during the previous period, the National League for Nurs-
ing (NLN) not only acknowledged theory but also made theory-based curriculum a requirement
for accreditation. Schools of nursing were expected to select, develop, and implement a concep-
tual framework for their curricula. This requirement for accreditation was both a moving force and
a major barrier to theory development. To use theory for curriculum development further height-
ened awareness of academic nursing to the significance of theory and to the available nursing the-
ories. However, this requirement diverted the goal of developing theories for practice (those
theories that would answer significant questions related to practice) to the goal of using theory for
education. Nevertheless, this milestone increased the use of theory and discussions about theory
and prompted more writing about the syntax of theory to help academicians and students under-
stand and use theories in curriculum and teaching. The limited number of journals that acknowl-
edge and promote theoretical nursing, the focus on promoting the publication of empirical
research findings, and the growing financial difficulties of some journals were barriers to written
exchanges on theory and theorizing.
1976–1980—A Time to Reflect
Nurse theorists were invited to participate in presentations, discussions, and debates in con-
ferences sponsored by nurse educators, marking a significant milestone in the progress of theoret-
ical nursing. A national conference devoted to nursing theory and the formation of the Nursing
Theory Think Tank in 1978 further supported the direction of the profession toward the utilization
of existing theory and the development of further theory to describe and explain nursing phenom-
ena, to predict relationships, and to guide nursing care (Preview, 1978). This was the time for
nurse academicians, who had used nursing theories as guiding frameworks for curricula, to con-
sider putting theory to other uses, particularly in practice.
The inauguration of the journal, Advances in Nursing Science, with its focus on “the full
range of activities involved in the development of science,” including “theory construction, con-
cept, and analysis” and the application of theory, was another significant milestone during this
period (Chinn, 1978) (see Table 5-4). The focus of the journal on theory and theory development
added more support to the significance of theoretical nursing and simultaneously gave nurses who
were interested in theory the necessary medium in which to present and discuss their ideas. It
allowed for the questioning and debate that is necessary for the development of theoretical bases
in any discipline.
This period was characterized by questioning whether nursing’s progress would benefit from
the adoption of a single paradigm and a single theory of truth (Carper, 1978; Silva, 1977). More
sophisticated debates about what types of theory nursing needs (Beckstrand, 1978a, 1978b, 1980)
and about issues in theory (Crawford, Dufault, and Rudy, 1979) appeared in nursing literature. A
more solid commitment to the development of theory emerged, combined with a specific direction
to nurses’ efforts in theory development (Donaldson and Crowley, 1978; Hardy, 1978). The links
between theory and research were considered and discussed (Batey, 1977; Fawcett and Downs,
1986), the path was charted for bridging the theory–research gaps between theory and practice
(Barnum, 1990), theory and philosophy were examined (Silva, 1977), and the role of each in the
development of nursing knowledge was clarified (see Fig. 5-1). Domain concepts were beginning
to be identified, and their acceptance was demonstrated in the next period.
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76 PART TWO Our Theoretical Heritage
1981–1985—Nursing Theories’ Revival: Emergence of the Domain Concepts
In this period, theory began to be questioned less and pluralism debated less. This period was
characterized by an acceptance of the significance of theory for nursing and, furthermore, by the
inevitability of the need for the development of nursing theory. Doctoral programs in nursing
incorporated theory into their curricula and considered it a core content area, ranking it at the top
of all other core content (Beare, Gray, and Ptak, 1981). This period was also characterized by
enlightened international interest in theoretical nursing as manifested in conferences in Sweden
and demand for consultations on theory teaching in Thailand, Korea, and Egypt, among other
countries.
A review of theory literature during this period reveals the lack of debate on whether to use
theory–practice versus basic theory or borrowed versus nursing theory. Instead, there appeared to
be more writing on the examination of nursing theories in relation to different research and prac-
tice problems and on comparisons between the different conceptualizations (Jacobson, 1984;
Spangler and Spangler, 1983). Questions of this period included:
• What have we learned from theory?
• How can we use theory?
The second question was one that clinicians began to ask and for which there have been many
useful dialogues.
The newly emerging syntax was used to analyze existing theories (Fawcett, 1984; Fitzpatrick
and Whall, 1983). In addition, existing theories came to be thought of as the means to develop
unique nursing knowledge. Concepts central to nursing were identified, and existing theory, the
source of the identified concepts, was in turn re-examined in terms of further development and
refinement (Crawford, 1982; Reeder, 1984).
This period was characterized by the nursing theory advocates who pleaded for the use of a
nursing perspective in general or for the specific utilization of nursing theory (Adam, 1983;
Dickson and Lee-Villasenor, 1982). (See Advances in Nursing Science, Journal of Nursing
Administration, and American Journal of Nursing for examples of the American advocates and
Journal of Advanced Nursing for examples of international advocates.) Another group also
emerged during this period: the theory synthesizers. The difference between the advocates and
the synthesizers was in the level of the scope of analysis. The advocates promoted nursing theory
and demonstrated its use in research projects or in a limited practice arena. The synthesizers
went beyond that limited use to describe and analyze how nursing theory had influenced nursing
practice, education, research, and administration. The synthesizers are exemplified by, but not
limited to, Fitzpatrick and Whall (1983, 1996) and Fawcett (1984, 1995). The Rogerian First
National Conference (1983) and subsequent ones, in which theoreticians, practitioners, and
researchers discussed the utility of Rogers’ theory from different perspectives, is a different exam-
ple of an effective synthesis of different uses of a theory. The planners of this conference belong to
the group of theory synthesizers.
A few theory synthesizers graduated from New York University in the mid-1970s. One thing
that cannot be ignored, is the influence of New York University nursing program on advancing
theoretical nursing. This is made evident by a review of the titles of doctoral dissertations in nurs-
ing from New York University from 1941 to 1983, which provide a clear example of how a school
of nursing using a coherent theoretical framework can drive a coherent research agenda. Most of
the titles of the dissertations indicate a nursing perspective, and there appears to have been an
attempt at cumulative knowledge development. How and in what ways such a pattern may have
influenced and may continue to influence theory development is an area worth further investiga-
tion and analysis, however, we do see a Rogerian conference every once in a while that brings
many nurse scholars together to speak the same theory language and to show their research. The
outcome of such gatherings on discovery, integration, and innovation of nursing knowledge is yet
to be documented.
This period was characterized by an acceptance of theory as a tool that emanates from signif-
icant practice problems and that can be used to guide practice and research. This period was also
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CHAPTER 5 On the Way to Theoretical Nursing: Stages and Milestones 77
characterized by a greater clarity in the relationship between theory and research than between
theory and practice.
One remaining confusion during this period was related to semantics. Conceptual models
were referred to as conceptual frameworks, theories, metatheories, paradigms, and metapara-
digms and, when differentiated, boundaries were not totally clear and properties not entirely dis-
tinct. (See discussion about Rogers’ theory in chapter 13.)
1986–1990—From Metatheory to Concept Development
Three characteristics of this milestone were epistemological debates, ontological analyses,
and an increase in concept development and analyses. One other characteristic of this period was
the acknowledgment of the gap between theory and practice. The epistemological debates
included questions related to describing alternative approaches to knowledge development, such
as the use of phenomenology, critical theory, and feminist or empiricist methodologies, and how
to connect the dialectal approach to theory and practice (e.g., Allen, 1985; Allen et al., 1986; Hagell,
1989; Leonard, 1989). Although the debates were focused on knowledge development in general
rather than on theoretical development of the discipline, these debates were related as well to the
development of theoretical nursing. Concept development emerged as a potential link between the
theoretical knowing and the practical doing.
Effective analyses were those that focused on ontological beliefs related to central nursing
concepts, for example, environment (Chopoorian, 1986; Stevens, 1989), and health (Allen, 1985,
1986; Benner, 1984). These analyses added substantially to a more contextual approach to under-
standing each concept. These analyses also raised the awareness and the consciousness of nurses
to the necessity of using frameworks that allow for an integrative, holistic, and contextual
description of nursing phenomena, phenomena that go beyond the individual clients. Such
frameworks, these authors demonstrated, maintained the integrity of the basic ontological beliefs
that have historically guided nursing practice, for example, holism, integrated responses, and
relationship with environment.
The third property of this milestone was an increase in writings related to concept develop-
ment. These developments were different from earlier theory developments that included answers
to such general questions as “What is nursing?” These analyses were more practice oriented, were
integrative, and represented early attempts in the development of single domain theories. This was
also the period in which a plea for substance was made (Chinn, 1987; Downs, 1988; Meleis, 1987;
Woods, 1987). These authors echoed the sentiment of other discipline members by urging dis-
course that was more focused on substantive issues that were confronting health care recipients.
Process debates became more a potential force for theory development when and if they were
grounded in substantive disciplinary content. Therefore, instead of debating whether critical the-
ory or feminist theories were more appropriate as a philosophical base for the discipline, one may
argue whether it was more effective to view environment or comfort from either or both perspec-
tives. Such substantive debates then would add to or revise parameters and dimensions of that area
of knowledge.
1991–1995—Middle-Range and the Beginning of Situation-Specific Theorizing
One significant milestone that marks the considerable progress in knowledge development in
nursing is manifested in the numerous middle-range theories that evolved during this period.
Some of these were labeled as theories (e.g., Younger’s Theory of Mastery [1991] or Mishel’s
Theory of Uncertainty [1990]). Others were considered in the process of becoming theories. (See
Funk, Tornquist, Champage, Copp, and Wiese [1990] for discussions about key aspects of recov-
ery and Hagerty, Lynch-Sauer, Patusky, and Bouwsema [1993] for their emerging theory of
human relatedness.) Middle-range theories focus on specific nursing phenomena that reflect and
emerge from nursing practice and focus on clinical process (Meleis, 1987). They provide a con-
ceptual focus and a mental image that reflect the discipline’s values, but they do not provide pre-
scriptions for practice or specific practice guidelines (Chinn, 1994).
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78 PART TWO Our Theoretical Heritage
Situation-specific theories may be emerging as another milestone, although they were better
defined in later years. They are theories that are more clinically specific, theories that reflect a par-
ticular context, and may include blueprints for action. They are less abstract than middle-range
theories but far more abstract than individual nurses’ frameworks for practice designed for a spe-
cific situation (Meleis, 1997; Im and Meleis, 1999; Im, 2005). These situation-specific theories
may emerge from synthesizing and integrating research findings and clinical exemplars about a
specific situation or population with the intent of giving a framework or blueprint to understand
the particular situation of a group of clients. They are theories that are developed to answer a set of
coherent questions about situations that are limited in scope and limited in focus. For example, a
conceptualization of patterns of responses to health–illness transitions of Middle Eastern immi-
grants could be developed from the results of research studies, the clinical exemplars, and the
experience of nurses in their care of this population (Meleis, Isenberg, Koerner, Lacey, and Stern,
1995). An example is work that has focused on Middle Eastern immigrants (Afghans, Iranians,
Egyptians, and Arabs), supported by similar work on these populations in their native countries,
which helps illuminate patterns of behavior and responses before immigration and helps in pro-
viding a historical and sociocultural context for the responses of immigrants in their new country.
1996–2000—Evidence Means Research, Not Theory
Evidence-based practice evolved after much discourse in the literature from evidence-based
practice to evidence-based nursing. During this milestone, the focus of the literature written about
the discipline was on identifying the similarities and differences between utilizing models of care
with best evidence, translating research into practice, and using applied research (French, 1999).
To determine evidence, methodologies were discussed for defining the quality of individual stud-
ies, the methods for integrating study findings, and criteria for judging integrative findings and
what constitutes evidence that could be used in the literature (Goode, 2000; McKee, Britton,
Black, McPherson, Sanderson, Bain, 1999). Several properties distinguish this milestone. First,
most of the dialogues were initially based on arguments from the medical field, which reduced
“the evidence” to biomedical, empirical, and positivist variables and criteria (Lohr and Carey,
1999). A second property is a critical dialogue about eclectic views of evidence that may incorpo-
rate components that are more congruent with nursing science and emanate from how nursing
knowledge and knowing have been defined. This critical dialogue includes discussions on widen-
ing the meaning of evidence to make it more pluralistic, to incorporate humanistic experiences as
well as personal experiences as evidence of models of care to be used (Clarke, 1999). However,
the criteria for judging evidence from within this framework have not been explored, and no defin-
itive ideas been reached. A third property of this milestone is a focus on best strategies to imple-
ment the best evidence in health care institutions. Different models and approaches to utilizations
are defined and explored utilizing teaching-learning theories as well as organizational change the-
ories (Grol and Grimshaw, 1999).
The Cochrane Database of Systematic Review plays a major role in providing frameworks
for rigorous reviews of data-based evidence, for integrating reviews for determining best sup-
ported evidence, and for developing and implementing best organizational infrastructures to
implement and promote best practices (Foxcroft, Cole, Fullbrook, Johnston, Stevens, 2001).
The fourth property of this milestone is its global appeal and utilization of evidence-based
concepts in different parts of the world. Nurses, researchers, and clinicians in different regions
engaged in dialogues about integrative reviews and accessibility of research-based knowledge for
clinicians. (See Thompson, McCaughan, Cullum, Shelton, Mullhall, and Thompson 2001.)
The last property of this milestone is the absence of a robust theoretical dialogue about the
place of theory or philosophy in driving the nature of evidence, the premises supporting pluralism
in methods, the framework for interpretation, and the principles behind the selection of outcomes.
Shifting from an evidence–based discourse about practice to an inquiry–based dialogue could
bring back a critical theoretical discourse to nursing practice. (Doane and Varcoe, 2008; Holmes,
Murray, Perron, and Rail, 2006; Holmes, Roy, and Perron, 2008.)
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CHAPTER 5 On the Way to Theoretical Nursing: Stages and Milestones 79
2001–2005—Diversity in Thought: Linking Theory and Practice
A focus on diversity is a hallmark of this milestone in the ongoing journey toward the theo-
retical development of the discipline. As the agents of scholarship become diverse in identity,
ethnicity, and heritage, and as they become more comfortable with their differences, their
varices began to appear in the literature reflecting their different values, beliefs, and goals.
Among the examples of the diversity in thought and in theories are those by nurses from differ-
ent countries. Theories were developed by nurses from Finland and Sweden and dialogues
about more authentic theoretical formulations reflecting the realities of different countries
gained more popularity (Salas, 2005).
Similarly, during this milestone, diversity of views on developing theories from a number of
grounded theory research projects as well as through integrating different theories emerged with
more robust dialogues than ever occurred before. Olshansky (2003), for example, conducted six
grounded theory projects and developed a theory of “identity as infertile” and combined this the-
ory with Miller’s (1991) theory of “relational cultural” theory to explain potential vulnerability to
depression of women whose identity is established as “infertile women.” Both theories were inte-
grated and provide a stronger explanation for identity shifts that occur post pregnancy for these
women. The theory explains that although the women identified as “infertile women” were able to
become pregnant, it is very difficult for them to perceive themselves as pregnant. This difficulty in
identity is an obstacle to forming relationships with other pregnant women.
Diversity as a hallmark of this milestone was manifested in a variety of health–illness situa-
tions requiring a careful analysis of the factors that create diversity. Among these are age, race,
ethnicity, country of heritage, gender, and sexual orientation. This awareness led theorists and
researchers to critique prevailing approaches and assumptions and propose alternative and more
contextually situated theoretical thoughts. Examples are Berman (2003) on the myths surrounding
the power of children, Im and Meleis (2001) in their proposal for developing gender-sensitive the-
ories that focus on health and illness, and Anderson et al. (2003) who rewrote a conceptualization
of cultural safety within postcolonial and postnationalist feminist theories.
Georges (2003) defined the prominent discourses that reflect this milestone. Her thesis is
that there are two discourses in nursing that are shaping epistemic diversity in contemporary
nursing. These are the discourses on science that are more broad and enlightened and a post-
modernism discourse on marginalization. Both of these discourses provide a critique of domi-
nant understanding and agreements on scholarship allowing freedom to represent the different
perspectives on knowledge development. Epistemic diversity in an era that honors diversity in
its broadest sense may free members of the discipline to be inclusive and may transform the dis-
cipline to make it truly reflective of the people nurses need to serve. Such diversity would also
allow critique of power inequity as well as existing networks that support such inequities and
transform social practices that tend to institutionalize dominant approaches to theory
(Gustafson, 2005). Once again Hall (2003) reminds us in a powerful autobiographical note from
her illness experience about how medicalization of illness experiences and about how the
stronghold of the biomedical model are not in the best interest of patients and their families.
Georges (2005) uses a critical feminist perspective to uncover her journey in rewriting her own
identity as a clinician-theorist-academician-researcher. She provides a robust philosophical
argument for the linking of theory and practice within the political and social context of the first
decade of the 21st century. Such linking could occur through teaching theory using strategies
that help students to develop their authentic voices about their practice. Properties of this mile-
stone are critique of status quo, reconceptualization that is situated and contexted, and attention
to analysis that honors diversity in cultures, ethnic backgrounds, heritage, language proficiency,
gender, and sexual orientation.
2006–2010––Nurses Empowered: Evidence and Technology as Resources
The post positivism age, the age of interdisciplinarity, and the age of postcolonial feminism
are marked by a major milestone in nursing, the empowerment of nurses and the nursing profession
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80 PART TWO Our Theoretical Heritage
in affecting nursing care. Call me an optimist but let me give some reasons why I believe that such
a turning point is happening. Many addressed the decolonization of nursing from the biomedical
model, from the patriarchal hierarchy, and from nonnursing institutional regulatory mechanisms
(Holmes and Gastaldo, 2004; Holmes, Roy and Perron, 2008). Separating nursing from these par-
adigms is in itself liberating; however, more compelling indicators of this liberation is the use of
different paradigms to guide theory development and research, as is evident in the nursing litera-
ture produced at the end of the first decade of the 20th century (see examples in Advances in Nurs-
ing Science, Nursing Inquiry, and Nursing Scholarship). The prominence of nurses in prime-time
television and their depiction as forceful independent clinicians are other examples of the chang-
ing image and visibility of nurses. The media finds that nursing stories are worth printing, which
is an indication that reporters are recognizing that the public is interested in these valuable experi-
ences. Improving compensation, the availability of diverse employment options, and the selection
of nurses to staff independent mini-clinics are all indications of the shifting power structures in
health care systems.
The health care reform discourse surrounding the moral obligation of the government to pro-
vide safe, quality, and equitable health care for the U.S. population includes an acknowledgment
that the nurse’s role is central to the health care reform. The inclusion in the discourse of the need
for increasing the number of nurses in the workforce, as well as ensuring the utilization of their
full capacity, is in itself empowering for nurses. Therefore, the increasing dialogue about primary
health care, patient-centered care, and collaborative partnerships between physicians and nurses,
whether in conferences or in Institute of Medicine publications, honors and acknowledges the
value of nursing knowledge and nursing care (Frenk et al., 2010; IOM, 2011). These in my view,
are indicators of a milestone: Nurses are empowered.
There are other indications of nurses’ power to make a difference. Entering hospitals and
observing nurses handling patient tracking systems, health care records, automated medication
carts, and remote monitoring systems raises many questions. In particular, how do nurses inte-
grate theoretical frameworks with technological development and the increasing reliance on
communication through computers? How do nurses maintain their focus on the goals of nurs-
ing—patient-centered goals of health promotion, caring, comforting, decreasing suffering, and
promoting self-care and a sense of well-being—while being attentive to the new demands
imposed by the information and monitoring technology characteristic of hospitals and home care
in the 21st century?
The juxtaposition of caring for the individual and her family within the environment of inno-
vation and complexity of information and technology requires the development of new frame-
works and models of care. This stage of the discipline’s development is enriched by forging
different and new partnerships between such disciplines as engineering, pharmacy, and the infor-
mation sciences.
An aging population, as well as an increase in the numbers of people aging at home and of
families living and caring for chronically ill individuals through the lifespan, requires the develop-
ment and use of theories that are more specific to the particular needs of a more defined popula-
tion. Requirements for compensation and reimbursement by insurance companies and the
consequences of massive health care reform frame patterns in advancing knowledge during this
stage. Research evidence is vital for credibility, safety in providing care, and reimbursement for
services. And nurses are taking full advantage of the evidence and the technology.
CONCLUSION
This chapter presented significant historical themes that are related to an interest in theoretical
nursing. Progress and development in theoretical nursing was defined in terms of stages and mile-
stones. A view of historical development offers a significant perspective on which current and
future theoretical thinking can be built. Analysis of present development is deficient without trac-
ing these historical themes.
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CHAPTER 5 On the Way to Theoretical Nursing: Stages and Milestones 81
REFLECTIVE QUESTIONS
1. In what ways does a review of the his-
tory of theoretical nursing development
prevent or promote progress in develop-
ing the discipline of nursing?
2. Which stages and milestones were vital
for advancing nursing theory? Why?
3. Why do you think the environment and
the culture of the schools of nursing at
Columbia and Yale in the 1950s and
1960s contributed to the development of
theoreticians and theoretical thinking?
4. Would the same properties of theoretical
cultures contribute to creating gaps
between theory research and practice? If
so, how could these gaps be avoided
within the political and social systems of
the 21st century?
5. Can you identify more contemporary
theoretical schools of thought? What
environments may have led to each of
these theoretical discourses?
6. Knowing what you do about previous
stages and milestones in the development
of theoretical nursing, what would you
predict about future stages and mile-
stones? Provide strategies for creating
your vision of the future.
7. What stages and milestones that you
consider instrumental in understanding
the history of theoretical nursing were
not included in this discussion? Identify
critical stages and milestones from your
own perspective.
8. What insights have you gained about
theoretical nursing from reading this
chapter?
9. How would you describe the environ-
ment in your school (department)? In
what ways does the environment in your
school contribute to your scholarly
development?
Acknowledgments
The first part of this chapter is based on A.I. Meleis (1983). The evolving nursing scholarliness. In P.L. Chinn (Ed.),
Advances in nursing theory development, pp. 19–34. Reprinted with permission of Aspen Publishers, 1983.
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Our Discipline and Its Structure
SCHOLARSHIP may be defined as a scholar’s ability to focus and connect her inquiries
to the discipline’s ultimate mission and focus. The question is: How could members
of a discipline engage in cumulative knowledge development without giving atten-
tion to the focus and nature of inquiry in the discipline or to the primary mission of
that discipline? Therefore, Part Three is offered as a pause to reflect critically on our
discipline’s progress, which is significant to its continuous growth. This part of the
journey focuses on an analysis of nursing as a discipline and the components that
make it a coherent body of knowledge.
In this part, a bridge exists between past and present in three distinct areas: the
meaning and structure of the evolved discipline, and the evolving epistemic diversity
in the discipline.
Several components define the discipline of nursing. These are described in
Chapter 6—a perspective, a domain, the existing and accepted definitions of nursing,
and patterns of knowing in the discipline. In Chapter 6, the nursing perspective,
which evolved from the nature of its defining characteristics, is presented. Next, the
domain of nursing knowledge, its definitions, its components, and the unique charac-
teristics of nursing are discussed. Last, several key definitions of nursing are pre-
sented and defined. In Chapter 7, sources, resources, and paradoxes in theory
development are discussed. In addition, a theorist needs to engage in intellectual dia-
logues using strategies and tools for theory development. In Chapter 8, the different
patterns of knowing and the human processes involved are discussed. These human
processes––of the theorist, the nurse, and the client––are an integral part of nursing
and its theory. Aspects of empiricism are still significant and useful for nursing,
when added to other processes and aspects of knowing.
Two themes are apparent: a historical and a more contemporary view through
the history of science, and a historical and a more contemporary view in nursing the-
ory. The tension between the opposite poles of these two themes is healthy and effec-
tive, so long as work is not stunted while the tension is resolved. Perhaps the
tensions––the challenges that members of the discipline are facing––should be con-
sidered as integral to nursing’s theoretical progress, and the discipline of nursing and
its scientific base could be considered as a process rather than as an end result. If this
is true, then we can view the effectiveness of an epistemology in its process and in
the number of problems in nursing that it has been able to solve.
P A R T T H R E E
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86 PART THREE Our Discipline and Its Structure
No attempt is made in this part to discredit one philosophy and promote
another; an attempt is made, however, to display our options in the development and
progress of theoretical nursing. An attempt is also made to highlight the tensions, to
demonstrate those aspects of the different paradoxes that are congruent with nursing
and its mission and, finally, to emphasize human aspects of nursing in general and
theoretical nursing in particular.
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C H A P T E R 6
The Discipline of Nursing:
Perspective and Domain
A discipline is defined by goals, structure, and substance. It also has fundamental logic and
thought processes embedded within, connecting its parts. A discipline becomes embodied in its
members. It is important to define disciplines as well as what is meant by a nursing discipline.
However complicated and variable these definitions are, they facilitate a sense of identity related
to a body of knowledge. Understanding the structure of the discipline and defining its boundaries,
however flexible, open, and permeable those boundaries are, is vital for focusing the scholarly
work and the acquisition of new knowledge in the discipline, as well as in facilitating its growth
and advancement. A question to ponder at the outset is how could members of a discipline engage
in cumulative knowledge development without giving attention to the focus and nature of inquiry
in the discipline or to the primary mission of the discipline? A discussion about this question
could help further an analysis of the meaning, structure, and mission of the discipline and clarify
interdisciplinarity as well (Swoboda, 1979).
So, what is meant when we speak of a discipline, and what does it mean when we speak of a
nursing discipline?
A discipline is defined as “a branch of knowledge or teaching” and as the “training expected
to produce a specific character or pattern of behavior” (American Heritage Dictionary, 1992). In
addition, a discipline has a regulatory “set of rules or methods” that govern practice (American
Heritage Dictionary, 1992). The concept discipline refers to “the tools, methods, procedures,
exemplars, concepts, and theories that account coherently for a set of objects and subjects” (Klein,
1990, p. 104), and to methods of training (Turner, 2006). In a discipline, experiences are organ-
ized into a coherent and well-articulated view of the world. Themes of reality recur to form an
understandable pattern that is attributed to those who are members of the discipline. Disciplines
encompass rhythm and regularity of ideas. Disciplines differ in levels of specificity, codification,
paradigmatic fields, and establishment. Mathematics is considered highly specific and highly cod-
ified, whereas sociology, political science, humanities, and social sciences are considered low-
paradigm, less-codified, and less-specific disciplines (Klein, 1990). Toulmin added a term to
define emerging disciplines, calling them “would-be disciplines,” and he described behavioral sci-
ences as falling into this category (Toulmin, 1972a).
How similar are the individuals pursuing education for scholarly careers in nursing––
whether they are in the Karolinska Institute in Stockholm, Sweden, Mahidol University in
Bangkok, Thailand, or the University of Alexandria in Alexandria, Egypt––is a question of the
definition of structure and goals in a discipline. How different are the research questions, the way
the questions are framed, and the methods by which members of the nursing discipline pursue
scholarship as compared to those who are in other disciplines, such as sociology, psychology,
physiology, among other disciplines? Some may answer that there are vast differences, some may
deny any differences, and yet others may simply shrug their shoulders and say, “What difference
does it make? Why even pursue these questions?” These are important questions, worth a robust
dialogue and a critical discourse in any discipline, but particularly in a discipline such as nursing,
which is attached to professional practice and tends to be eclectic, diffuse, and involving a high
degree of receptivity to other disciplines. These dialogues are particularly cogent in the 21st cen-
tury, where a move toward interdisciplinarity has been reinforced by the establishment of interdis-
ciplinary departments in many halls of academia and in governments across the world (Hayes,
2005). Such receptivity to more permeable boundaries with other disciplines encourages heavy
borrowing of theories, concepts, and methods and may decrease significantly enforcing and
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88 PART THREE Our Discipline and Its Structure
supporting an epistemological identity (Swoboda, 1979). Some consequences may be that the fun-
damental scholarly questions most pertinent to nursing are not asked and answered.
A discipline provides the worldview by which phenomena are uncovered, organized, under-
stood, and interpreted. A discipline is also “a unique perspective, a distinct way of viewing all
phenomena,” providing the boundaries that define the nature of the questions investigated (Don-
aldson and Crowley, 1978, p. 113; Moore, 1990). A discipline embodies a central unifying focus
for knowledge (Willis, Grace, and Roy, 2008). The discipline of nursing includes the content and
processes related to all the roles that nurses play, including administrator, teacher, politician, clini-
cian, and consultant (Banks-Wallace, Despins, Adams-Leander, McBroom, and Tandy, 2008). A
discipline also includes the theories developed to describe, explain, and prescribe, as well as the
research findings related to the discipline’s central phenomena and to other related disciplines that
are essential for the functioning of members of a discipline or for the continuous growth of the
discipline.
Discipline-specific inquiry, explorations, and theory development are vital for the develop-
ment of nursing knowledge and become the foundation that drives nurses’ actions. The discipline
of nursing is an intellectual field, with a growing, distinctive knowledge, but it also incorporates
the experiences of its members and the values that they espouse, as well as their specific goals and
purposes (Northrup, Tschanz, Olynyk, Makaroff, Szabo, and Biasio, 2004).
The discipline of nursing could be understood through ways by which the structure and sub-
stance are viewed, organized, examined, researched, and understood. Three broad categories are
delineated to analyze the discipline and to reflect on its focus and goals. These are a perspective,
a domain, and the goals of the discipline as reflected in how the discipline of nursing in particu-
lar is defined.
NURSING PERSPECTIVE
We see the world through different lenses that shape how we understand and interpret it. These
lenses provide us with a perspective through which we perceive, comprehend, and interpret situa-
tions and events in our lives. Disciplines are characterized by perspectives shared by the disci-
pline’s members, and these perspectives shape the way that members of a discipline tend to view
phenomena within, as well as outside, the discipline. As nurses, we have developed some shared
views that define the ways by which we come to assess our clients and their situations. Our indi-
vidual and shared perspectives reflect our culture, education, work experiences, and values, and
these perspectives, in turn, influence our views of events and situations. A perspective is defined
as the way that members of a group view and characterize a situation. It is the sum total of the atti-
tudes and the outlook that help members of a defined group to develop a position or a viewpoint. A
perspective provides a panoramic view of situations; it provides the signposts that characterize an
outlook on the world. A perspective is based on a set of values that help in characterizing the
nature of the world for members of a group. It contains the preferences for certain views and for
certain ways of observing and reacting to situations. A perspective, according to Rosemary Ellis,
is the prevailing view held by members of a discipline or a profession (Algase and Whall, 1993).
A nursing perspective is defined by its unique aspects, the history of the profession, the sociopo-
litical context in which nursing care is provided, and the nature of the orientation of members of
the nursing profession, as well as the discipline.
Although different nurses may perceive nursing somewhat differently and at different
times, Sarvimaki and Lutzen (2004) found that Swedish nurses over several generations con-
sider the discipline of nursing to have a unique perspective, and they agree on having a similar
set of value systems.
The perspective of clinicians and scholars in nursing reflects their academic and professional
approaches to knowledge development, a history of second-class citizenship, a history of devalua-
tion of nursing’s mission of caring, and a history of oppression of its members that reflects world-
wide oppression of women and subordination of nurses to bureaucratic and professional
structures. Therefore, nurses may be more experientially prepared to examine and analyze similar
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CHAPTER 6 The Discipline of Nursing: Perspective and Domain 89
processes that may be encountered by nursing clients. By necessity, too, these experiences drive
the kinds of analyses and interpretations of progress that are performed, as well as the develop-
ment of the discipline. They shape the perspective that evolves and characterizes a discipline. A
nursing perspective is shaped by many defining characteristics. It is the integration of these char-
acteristics that defines the nursing perspective. Four important defining characteristics that deter-
mine our perspective are the:
• Nature of nursing science as a human science
• Practice aspects of nursing
• Caring relationships that nurses and patients develop
• Health and wellness perspective
Each aspect of the nursing perspective is presented and discussed in the following sections.
Nursing: A Human Science
The science underlying the discipline of nursing has shifted away from an emphasis on natu-
ral sciences, and nursing tends now to be described as a human science. A human science has
many unique properties that define the ontology and epistemology of the nursing discipline and
that shape its perspective. Meleis (1992), McWhinney (1989), Holmes (1990), and Cowling and
Chinn (2001) identified some of these properties of human science.
1. A human science focuses on human beings as wholes and advocates understanding the
particulars in terms of the whole (Mariano, 2001; Owen and Holmes, 1993).
2. A human science has at its core an understanding of experiences as lived by its members.
Kim (2000) proposed that nursing deals with “human living.”
3. A human science does not separate the art and the science of nursing, which are the cor-
nerstones on which nursing knowledge is built (Mitchell and Cody, 2002).
4. A human science deals with meanings as seen and perceived by its members. Meanings
include those attached to responses, symbols, events, and situations, and thus guide its
practice. Meanings are achieved from reflecting and processing experiences (Willis,
Grace, and Roy, 2008).
5. To be able to understand meanings and experiences, a scientist needs to enter into a
meaningful dialogue with participants. Interaction is the prime source of meanings and
perceptions of experiences, and participants in the activities of knowledge development
are those who are developing and structuring knowledge and those about whom knowl-
edge is developed. All participants have to verify the meanings of these experiences.
6. “The scope for generalization for a human science is limited” (McWhinney, 1989, p.
298). A generalization has to be made within a context; therefore, generalization may be
presented in terms of patterns.
7. Responses and experiences form patterns. Patterns provide meaningful information about
participants (Newman, 2002).
8. Some conditions, situations, behaviors, and events are reducible for purposes of
description.
Nursing as a human science is concerned with the life experiences of human beings and their
meanings, with health and illness matters and their significance in their lives, as well as with the
experience of dying. It requires qualitative and quantitative research methodologies (Friedman
and Rhinehart, 2000; Glaser and Strauss, 1964, 1967; Malinski, 2002; Rawnsley, 2003). Because
these experiences are shaped by history, significant others, politics, social structures, gender, and
culture, nurses also are concerned with how these perspectives shape the actions and reactions of
human beings (Willis, Grace, Roy, 2008). It is precisely that concern that makes nursing a practice
discipline, which in turn helps to define its perspective. However, a question that must be
addressed is the extent to which this aspect of the nursing perspective—that is, the human science
discourse—is incorporated in nursing education and practice (Pilkington, 2002). When does it get
introduced, and what strategies are used to facilitate its integration into the student’s identity as a
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90 PART THREE Our Discipline and Its Structure
prospective nurse? These questions beg a robust discussion by the readers of this chapter as well
as within our literature. Do the curricula in nursing and educational programs that prepare future
nurses reflect a distinguishable nursing perspective?
Nursing: A Practice-Oriented Discipline
The practice aspects of nursing are a second defining characteristic that shape its perspective.
Nursing exists to provide nursing care for clients who experience illness, as well as for those who
may experience potential health care problems. The discipline’s perspective is shaped by the prag-
matics of a nurse’s work (Litchfield and Jonsdottir, 2008). Nursing has been described as a clini-
cal discipline, an applied field, or a practice-oriented discipline. What do we mean when we say
that nursing is a practice-oriented discipline? It means that it has a primary mission related to
practice. Therefore, its members seek knowledge of what nurses as professionals do, why they do
it, and when they do it. According to Weinberg (2006), even what nurses may consider the “little
things” they do, are really “big things for their patients” (pg. 42–43). Nurses deal with people’s
human condition and their responses to health and illness. Nurses help in monitoring the living
experience of people as they deal with health and illness while caring for them. Nurses help in
assisting individuals and families to care for themselves, and help to empower them to develop
and use resources (Bottorff, 1991). Nursing may use basic and applied knowledge to achieve its
goals, but it is still a practice-oriented discipline.
Nurses need basic knowledge to understand the basic phenomena related to the goals and
mission of nursing; for example, how certain groups of people tend to seek help, how certain con-
nections tend to maintain their balance and health, and how different patterns of responses to such
events as pain, intrusive interventions, hospitalization, and discharge exert their influence
(Mapanga and Mapanga, 2003). Basic understanding of such phenomena as comfort, touch, con-
fusion, ambiguity, sleeplessness, and restlessness is essential for the subsequent development of
applied knowledge. Applied knowledge is that which provides guidelines to maintain, ameliorate,
develop, inhibit, support, change, advocate, clarify, or suppress some of these basic phenomena.
Both basic and applied knowledge are the cornerstones of nursing as a practice-oriented disci-
pline. Nurses also seek knowledge related to the practical care they provide. Practical aspects of
nursing have been dichotomized with its theoretical aspects rather than integrating, incorporating,
and using them as a springboard for further development of the discipline. The shift by nurse
scholars away from practical aspects, and in particular from clinical skills, has been manifested in
the limited research interest related to clinical concerns, in uncovering the daily work of nurses,
in the conflicts between educators and administrators in defining educational end products, and in
the decreasing emphasis on clinical skills, among others (Bjørk, 1995; Clarke, 1986; Titler, Buck-
walter, and Maas, 1993). Such trends have slowly been replaced with more emphasis on biobe-
havioral and biomedical aspects of nursing, with more nurses prepared as nurse practitioners in
the United States.
The goal of knowledge development, then, is to understand the nursing care needs of people
and to learn how to better care for them; therefore, the caring activities that nurses are involved in
on a daily basis may be the focus for knowledge development and may be congruent with activi-
ties involved in knowledge structuring, particularly because the participants in both activities are
human beings. Two types of knowledge development goals drive the activities and the progress in
knowledge. There is “knowledge for the sake of knowledge” and knowledge to provide better
nursing care to people through solving central problems of concern to the discipline (Laudan,
1977, 1981). Nursing as a discipline, and nurses as clinicians and scientists whose mission it is to
care for people and enhance their well-being, cannot afford to participate only in developing
knowledge for the sake of knowledge development.
Thus, the purposes of knowledge development in nursing are shaped by its practice orientation,
which in turn shapes the nursing perspective. The nursing perspective reflects nurses’ interest in:
• Empowering members of the discipline of nursing with knowledge that makes a difference
in the care of patients
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CHAPTER 6 The Discipline of Nursing: Perspective and Domain 91
• Empowering nurses to influence and enhance the well-being of clients, thereby decreasing
their vulnerability to risks to their health
• Empowering clients with knowledge and experience to care for themselves and to manage
their symptoms and their life transitions by fully utilizing available resources and creating
new resources
• Supporting and facilitating activities of informal structures, such as families and commu-
nities who are engaged in caregiving
If these are the main purposes for developing knowledge in nursing, then we have to consider
those approaches to knowledge development that make these purposes possible. To empower the
discipline and its members, nurses look for and identify the same skills that made them effective
and caring clinicians, and build on these as well as other skills that could enhance knowledge
development. Empowering partnerships reflect the goals of nursing as a practice discipline. Such
a perspective calls for competencies that emanate from nurses’ work and may shape the nature of
the questions that nurses investigate.
A unique aspect of nursing as a practice discipline that further defines its perspective is the
around-the-clock care provided by nurses working in institutions. When nurses see patients
around-the-clock, they tend to know more about their daily life processes and patterns, and there-
fore they are more likely to better understand their lived experiences and their health care needs.
They possess a high level of continuity in their knowledge of their patients, which provides a more
textured context for the clients’ needs and responses. Nurses who care for patients in primary
health care settings, including home care, may have to structure their encounters in more creative
ways to increase their understanding of the daily life processes and the integrated patterns of their
clients’ responses to health and illness within a context of limited time and varying space.
Whether in a hospital, a clinic, or a home, nursing encounters are characterized by continuity,
intensity, and involvement in ways that other health care professionals do not experience. To nurse
is to build relationships. Developing caring relationships has been considered a defining aspect of
the nursing perspective by many theorists over many decades (Newman, Smith, Pharris, and
Jones, 2008). Nurses also monitor and coordinate the care of their patients; this includes their own
caregiving as well as the care offered by others in the health care team.
Nurses spend a great deal of time with clients (Masson, 1985). They conduct comprehensive
assessments, including assessing family and medical histories, to establish a better care context and
gain a better understanding of the client’s responses. They perform daily activities such as bed baths,
providing for daily hygienic needs, administering medication, and carrying out treatments. Therefore,
the experiences and responses of clients to health and illness tend to be viewed within the context of
the client’s life relationships, culture, goals, and daily experiences. The ongoing relationship with
nurses prompts clients to share their experiences in more narrative dialogues, allowing more details,
meanings, and history that make their health and illness experiences more understandable and allow
for more congruent plans of action. If patients are given indications that these experiences are impor-
tant for the caring processes, they tend to share more freely with nurses the effects of their complaint,
medical diagnoses, or intervention on their daily lives and on those of significant others in their lives.
In other words, patients naturally are more interested in ways by which illness, altering conditions, or
treatments affect their daily lives and daily routines. Nurses are optimally placed to get the benefit of
hearing narratively about the experiences of their patients. Nurses tend to get to know their patients
differently and more profoundly than do other health care providers (Jenny and Logan, 1992).
Nursing: A Caring Discipline
The caring aspects of nursing also help define its perspective (Cook and Cullen, 2004). Many
questions have been raised about the concept of caring. Is caring the essence of nursing, is it the
field’s special knowledge area, is it equal to the discipline of nursing, is it a central concept in
nursing, or is it the core of its domain? Is it the goal or the mission of nursing, or is it a goal and a
mission of nursing? Caring has been considered and discussed through each of these prisms, and
there are enough writings in nursing to support each of these positions (Cohen, 1991).
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92 PART THREE Our Discipline and Its Structure
Caring, which has been an integral part of the private domain of women, has been discussed
recently as a component of both the public and private domains. Condon (1992) goes further by
suggesting that caring may be the glue that will connect nurses’ public and private domains and
will decrease “the discrepancies between the demands of the private and public domains” (p. 19).
She also proposes that caring and nursing are compatible, and caring and feminist ideals are com-
patible. Caring, for Condon, is the foundational moral value for nursing. It is detrimental to nurs-
ing if it continues to be viewed as a component of public domains and is relegated only to women
in society. She further proposes that we explore how the philosophy of professionalism may con-
flict with the ethics of caring.
Condon (1992) calls for a new metaphor for nursing caring to substitute for the metaphors of
duty and religious calling. There are numerous such metaphors in nursing. Watson (1988, 1990)
describes caring more from an existential philosophy, and she reviews the spiritual bases of car-
ing. To her, caring is the moral ideal of nursing. Leininger (1981) discusses caring from a cultural
perspective. For Brody (1988), caring is the central virtue of nursing. Gendron (1988, 1994) pro-
vides innovative arguments, likening caring to the creativity that is woven on as a structure for the
substance in nursing. The structure is based on the contextual knowledge of scientific facts as well
as conceptual frameworks. The structure also includes skills, nursing interventions, and policies,
among other aspects of structure. All these are brought to the patient’s bedside or home through
creative patterns used in an artistic way. To match nursing actions to people, a nurse needs to know
how to synchronize with a person, and she must know when she is synchronized. The challenge is
then not only in the development of the knowledge base required to provide these caring actions,
but also in how to prepare clinicians to be able to develop a synchronized self–client relationship.
A synchronized relationship is based on “sensing subjective tacit meaning” of experiences and sit-
uations and on attuning “one’s self and others” to these experiences and their meanings. To
develop and carry out these aspects of the caring processes, Gendron (1994) proposes using
“reflective journals” and an “emphasis on dialogue in the sharing of students’ experiences through
narrative” (p. 29), story telling, and analysis.
The art of nursing has also been used as a synonym for caring. An epistemological analysis
by Johnson (1994) about the meaning of art in nursing identified five separate senses of art in
nursing. Nursing art is exemplified when nurses are able to:
1. Grasp the meaning that is inherent in their encounter with patients
2. Establish connections
3. Skillfully perform nursing activities
4. Choose between alternatives
5. Morally conduct nursing practice
Grasping meaning is attributed to perceptions rather than intellect; it depends on observa-
tions, feelings, imagination, and understanding that go beyond description––it depends on inner
experiences and is holistic in nature. Connecting with patients is more than establishing a rela-
tionship; rather, it consists of the experiences in everything the nurse does with patients, including
nonverbal communication. There is an authenticity to this communication that occurs between
human beings. Skill in nursing activities is a behavioral ability in which there is an understand-
ing about the skills needed for providing care and in which there is embedded understanding of
these skills. The skills in such nursing activities can be learned, and they are expressed through
ease and fluidity of movements, among other characteristics yet to be defined. Determining a
course of action is expressed by the group of authors who contend that the nursing art is practical,
and it is through assumptions derived from a disciplinary structure that nurses are making deci-
sions, based on a thorough understanding of all options. The nursing process proponents build
their case on the artistic aspects of nursing as described in this category of definitions. To practice
morally is a definition of nursing art that includes the view that skills are important, but are not a
substitute for other aspects of practice, nor are they enough for the care that patients need. If a
nurse does not make moral choices or address the moral dilemmas in her practice, then she is not
using the artistic aspects of the discipline.
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CHAPTER 6 The Discipline of Nursing: Perspective and Domain 93
Morse, Bottorff, Neander, and Solberg (1991), and Morse, Solberg, Neander, Bottorff, and
Johnson (1990) describe caring as human trait, moral imperative, affect, interpersonal relationship,
and therapeutic intervention. Caring is further described in nursing literature in the following ways:
1. As a human trait, it should be considered from a personal, psychological, or cultural per-
spective.
2. As a moral imperative, Gadow (1985) and Watson (1988, 1990) view the fundamental
essence of nursing as preserving the dignity of others. This meaning of caring provides
the base for all nursing interventions, assessments, and activities.
3. As an affect, this is manifested through emotional feelings or empathy, feelings of dedi-
cation. Demands on time may change this.
4. The nurse–patient relationship is the essence of caring.
5. Caring is also seen as a therapeutic intervention.
Caring for clients is a component of what defines a nursing perspective (Clifford, 1995;
Sanford, 2000, Newman, Smith, Pharris, and Jones, 2008). It is one of the traditions handed down
over the decades (Olson, 1993). It is another lens by which nurses as clinicians view their clients.
It is the core activity in nursing practice (Benner and Wrubel, 1989, Leininger, 1978, Watson,
1985). It may also be the same lens that nurses as scholars need to see the subject matter for their
research or theory development. If caring is an integral part of a nursing perspective, it could also
be an integral component of the subject matter of the theories developed (Newman, Sime, and
Corcoran-Perry, 1991) or the guiding force for the strategies by which theories are developed and
research is formatted (Feldman, 1993). A caring perspective has shaped the processes used for
knowledge development. It is encouraging to observe that there is increasingly more openness in
Western societies to acknowledge the caring aspects of relationships and to bring caring more into
the public domain, a practice that has always been more prevalent in developing countries. The art
of nursing and its caring aspects require time, energy, and skills that are not well acknowledged or
rewarded through appropriate policies. Therefore, the question is: Are nurses rewarded for their
caring activities? MacPherson (1989) contends that nurses are not rewarded for trying to care and
for the time they spend in caring for their patient communities. Educators, clinicians, and adminis-
trators may have to hold and drive the notion that caring is not a negotiated commodity. Defining
caring as a component of the nursing perspective may provide them with the rationale to support
their quest for supportive and rewarding caring activities.
Nursing: A Health-Oriented Discipline
Nursing has been defined as work that focuses on “the human health experience” (Newman,
Sime, and Corcoran-Perry, 1991). To say that a nursing perspective is shaped by its health orienta-
tion is not to deny the work and the caring that nurses provide for clients who are sick, who are
experiencing traumas, or who are recovering from illness. Nurses’ orientation to the health of
individuals and populations is historical, beginning with Nightingale’s writings (1859), in which
she defined nurses’ work in terms of maintaining health and bringing a state of health back to the
individual. Health has been considered integral to nursing (Allen, 1986), a goal (Rogers, 1970), a
construct (Tripp-Reimer, 1984), an idea in nursing (Smith, 1981), a metaparadigm concept (Faw-
cett, 1995), a theory (Newman, 1986), and a concept (Reynolds, 1988).
Health is also a perspective that defines what we consider in our assessments, in making
plans for interventions, in evaluating our interventions, or in considering changes in our interven-
tions (Meleis, 1990). It is the lens by which we view our clients during the course of their illness,
as well as when we attempt to maintain or promote their health. Divergent views of health have
held it as dichotomous to illness or dynamic life experiences, a way to achieve one’s potential, a
unity of body and mind, a view of wellness, and a rhythmic fluctuation of life process (Newman,
Smith, Pharris, and Jones, 2008). Moch (1989) provided a compelling argument for the develop-
ment of the concept of health within illness and demonstrated how such a perspective is receiving
more support in health-related theory development. Examples are Moss (1985), who described the
transformational aspects of illness. Such a view is supported by many personal accounts of
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94 PART THREE Our Discipline and Its Structure
patients, particularly as discussed in the literature on patients with HIV and AIDS. The notion of
“healthy dying” (Fitzpatrick, 1983) might be another supportive argument for health as an impor-
tant component of the discipline’s perspective.
There is also support for a health perspective in the daily work of nurses. Patients are
assessed in terms of their perception of their well-being throughout their experiences with health
care professionals, and are instructed in how to maintain their health despite a grave diagnosis or
intrusive procedure. Many theorists speak of this perspective; Travelbee (1966, 1971) was a pio-
neer in encouraging nurses to help their clients find meaning in their illness experience. Paterson
and Zderad (1976) described their nursing perspective in terms of health and connected interac-
tions with clients. Although health for Newman (1986) may be the goal for caring, or seen as a
process of expanding consciousness, and for Jones and Meleis (1993) as a process of empower-
ment, these analyses provide greater support for a more prevailing view of nursing as understood
from within a health perspective. Through the process of nursing care, nurses uncover health
strengths, mobilize these strengths, and support the available resources, so that the patient may
take charge and fight their illness or injury.
Community health nurses provide useful examples of a health perspective in their work. They
speak of positive resources, available support, healthful habits, and how to empower clients in
using their healthy resources. Although nurses in the intensive care unit (ICU) may consider their
approach more illness oriented, on careful analysis, we find that ICU nurses are concerned with
patients’ safety, well-being, promoting increasing health, maintaining healthful habits, and sup-
porting as much normality in daily life as possible. These activities and goals reflect a health
perspective.
DOMAIN OF NURSING KNOWLEDGE
A second essential component that defines the discipline of nursing is the domain of nursing
knowledge. All disciplines are formed around a domain of knowledge. The concept domain, as
well as the nursing domain, are extensively described and discussed in the following text. A
domain of knowledge is the crux of a discipline (Fig. 6-1). A domain is a territory that has both
theoretical and practical boundaries. Domains of knowledge have a defined repertoire of princi-
ples, the rules used for applying and using these principles, and the constituencies to which these
rules are applied (Gelman, 2000). The practical boundaries represent the current state of investiga-
tive interests that emerge from questions significant to members of the domain. The theoretical
boundaries are formulated by the visionary questions proposed for exploration, as well as those
that occupy the intellectual energies of members of disciplines. These visionary questions are not
bound by, or limited to, current concerns of the members of the discipline. These are the main phe-
nomenon of interest, and are of central concern to the members of the discipline. Core domains
are those aspects of a discipline that represent universal knowledge structures (Gelman, 2000).
Other aspects of the domain are more dynamic and changeable, such as the way phenomena are
conceptualized; the nature of questions asked about the phenomena, as well as those phenomena
that reflect societal or policy changes; and during periods of transition, those phenomena that
result from these changes. For example, some current questions that determine the territory of
nursing include what is involved in caring for people who are not able to care for themselves
because of illness or anticipated illness; how best to help individuals and populations to maintain
their health and well-being; what is involved in self-care and how to support the promotion of self-
care activities; and what are the best strategies that nurses could use to maintain or promote health,
support recovery, and manage illness. In the future, theoretical boundaries may extend to include
questions about caring for individuals who are in hemispheric transition or who may reside in a
space shuttle for an extended period. Some elements of the domain may be maintained; for exam-
ple, a focus on human beings and their environment. Others may require some modification, for
example, the nature and the content of the surroundings may have to be changed considerably to
reflect changing environments. The environment for clients living on Earth may be similar as well
as different from the environments of individuals living in space stations, or in the future, on other
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CHAPTER 6 The Discipline of Nursing: Perspective and Domain 95
planets. The language used, the concepts defined, and the questions explored and examined are
shaped by the structure of the discipline. The structure, in turn, shapes the nature of questions
asked about the phenomena (Mitchell, 1994). Nurse scientists have made major contributions to
the development of the domain of nursing using a focus on person and environment (Heitkemper
and Bond, 2003), on patterns of behavior, and on health and lifestyles.
Domains: A Definition
Domains are defined differently by different philosophers of science. The following defini-
tions of a domain synthesize some aspects of Kuhn (1970), Merton (1973), Parsons (1968), and
Toulmin (1972b).
• It has some broad basic concepts.
• It contains the major problem areas of the field that make up the canons for significant
statements.
• Some of its units of analysis that are used in research investigations are identified.
• It provides evidence of beginning agreement and a genealogy of ideas.
• Its members allow for the synthesis of a number of paradigms.
• Its members are knowledgeable about the different schools of thought, and they acknowl-
edge and accept the use of different paradigms.
• It defines mechanisms to integrate and present the accumulated experiences of its mem-
bers. These experiences are respected, critically assessed, and accepted. The grounds for
analysis and critique are clear and subject to debate.
• The rules, norms, and tools for knowledge development are defined within the domain.
These rules, norms, and tools emerge from the domain goals and are congruent with its
shared assumptions.
FIGURE 6-1 ◆ The disci-
pline of nursing.
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96 PART THREE Our Discipline and Its Structure
• A domain informs and is informed by all outer circles of the discipline (see Fig. 6-1). That
is, a domain is revised and developed through the wisdom and expertise of members of the
discipline, through accumulated research and theory, and through knowledge developed in
other disciplines. In sum, a domain has certain focal elements of stability, but the nature of
its content is dynamic and responsive to changes occurring in other spheres.
A Nursing Domain
When we consider nursing analytically, we find numerous indications that nursing is indeed a
discipline with a particular perspective and a defined domain (Fig. 6-2). As you reflect on what
constitutes our disciplinary domain, keep in mind that the central problems of the domain of nurs-
ing may be examined by other sciences; however, the centrality of these problems to the domain is
what determines primary domain affiliation. Comforting patients during intrusive procedures may
be of concern to a number of health science disciplines, but comfort of clients during all life
processes related to health and illness situations, as well as the ways by which comfort is enhanced,
are central concerns of nurses and nursing.
The interests of some disciplines overlap others. Engineering is an example of another disci-
pline that may encounter such overlap. Premises on which the discipline of engineering is built
may come from physics, chemistry, economics, and behavioral sciences, but the synthesis is
uniquely engineering for the purpose of describing, explaining, and predicting phenomena cen-
tral to engineering (for example, the shielding of nuclear power plants). The problem of shield-
ing is central to the field of nuclear engineering, but only peripheral to physics, chemistry, and
other sciences.
The nursing domain does not simply encompass the results of research (i.e., nursing science),
nursing theories, or nursing practice; rather it encompasses knowledge of nursing practice (New-
man, 1983), which is based on philosophy, history, former practice, common sense, research find-
ings, theory, and genealogy of ideas (see Fig. 6-2). The nursing domain encompasses units of
analysis, congruent methodology, nursing processes, holistic approaches to assessment, and other
practice and methodological procedures that are essential to knowledge development. Central
components of the nursing domain are:
• Major concepts and problems of the field
• Processes for assessment, diagnosis, and intervention
• Tools to assess, diagnose, and intervene
• Research designs and methodologies that are most congruent with nursing knowledge
Theoretical boundaries of the nursing domain result from an explication of the first three
components listed. Research designs and methodologies evolve from acceptable philosophical
FIGURE 6-2 ◆ The domain of nursing.
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CHAPTER 6 The Discipline of Nursing: Perspective and Domain 97
principles in nursing and complement knowledge development related to the discipline’s central
concepts, problems, and goals. Research designs and methodologies also help identify and develop
components of the domain of nursing. (Note the theory-specific research texts and methodologies
that have evolved in nursing, including research texts by Rosemarie Parse and Patricia Benner,
among others [references in Chapter 20].) Also note the revolutionary methodology of
grounded theory that has been adopted in the discipline of nursing for its congruency with the
domain of nursing (Glaser and Strauss, 1964, 1967). Nursing theories are a component of the
domain of nursing, and they provide nurses with different perspectives on nursing and nursing
phenomenon.
In 1975, Yura and Torres delineated and described the major concepts used in baccalaureate
programs that were central to the different conceptual models and frameworks used for nursing
curricula. Four focal concepts emerged: person, society, health, and nursing (Yura and Torres,
1975). The centrality of these concepts in the discipline of nursing continued to be supported
through the 1980s. For example, Newman (1983) asserted that the “domain of nursing has always
included the nurse, the patient, the situation in which they find themselves, and the purpose of
their being together, or the health of the patient” (p. 388). Therefore, she agreed that the major
components of concern to nursing are “nursing (as an action), client (human being), environment
(of the client and of the nurse-client), and health” (p. 389). Others modified the list to exclude
environment (Barnum, 1994), or they expanded the meaning of “person” to encompass both
human being and patient (Barnum, 1994), or they redefined “client” to mean “pluralities of per-
sons and internal units, such as families, groups, and communities” (Schultz, 1987, p. 71). Nurs-
ing theory, it was argued by some, could include one or more of these concepts (Fawcett, 1989);
for example, client, society, health, or nursing. Or, others argued, nursing theories should include
the concept of nursing as an activity, in addition to any one of the other concepts (Flaskerud and
Halloran, 1980), such as any set of “commonplaces” (nursing act, patient, health, nurse–patient
relationships, nursing acts and health, and patient and health). These “commonplaces” differenti-
ate nursing from other disciplines (Barnum, 1994, pp. 14–15). Still others emphasized that nurs-
ing theories should include health and the direction for nursing actions to facilitate the processes
of health (Newman, 1983, p. 390). Although variations occurred in the recommendations of
metatheorists in what, how many, and which central concepts should be included in nursing theo-
ries, none objected to the inclusion of all domain concepts—if indeed a theory is able to address
them all. The position adopted in this text has its own unique features also, but it falls within gen-
eral patterns of agreement within the discipline (Meleis, 1986). Concepts identified as central to
the domain of nursing are included in Box 6-1.
It is proposed that the nurse interacts (interaction) with a human being in a health/illness sit-
uation (nursing client), who is in an integral part of his sociocultural context (environment), and
who is in some sort of transition or is anticipating a transition (transition); the nurse–patient
interactions are organized around some purpose (nursing process, problem solving, holistic
assessment, or caring actions), and the nurse uses some actions (nursing therapeutics) to enhance,
bring about, or facilitate health (health).
It is argued here that theories developed relative to any of the concepts listed in Box 6-1 are
nursing theories when the ultimate goal is related to the maintenance, promotion, or facilitation of
health and well-being, even though the theory may not specify nursing actions. It is also argued
BOX 6-1 CONCEPTS CENTRAL TO THE DOMAIN OF NURSING
Nursing client Nursing process Nursing therapeutics
Transitions Environment Health
Interaction
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that nursing is an encompassing concept that includes all the concepts listed in Box 6-1 and is
therefore defined by them. It would be an instance of tautological conceptualizing to define nurs-
ing by all its concepts and then include nursing as one of the concepts. Other disciplines may use
nursing theories for different goals; as such, nursing theories lose their original goal, becoming
adapted, “shared” theories (Barnum, 1994).
A conceptual definition is provided for each of the central concepts in nursing. These defini-
tions, evolving from contemporary shared knowledge in nursing and from a current worldview,
are provided as working definitions. The reader should use them as a springboard for further
development and refinement.
The Nursing Client
The most central concept within the domain of nursing is the recipient of care or the potential
recipient of care––the nursing client. Although a client is also central to a number of other disci-
plines, the perspective from which that client is considered is invariably different and evolves
from the domain of the discipline. Please note that the nursing client has been used to define a
patient and a consumer of care. Note also that, in the United States, a definition of professional
nursing has in it a return to the concept of patient rather than client or consumer (ANA, 2003).
Nurses have claimed that individuals are the focus of their actions ever since nurses began caring
for patients and ever since they attempted to describe the care they provide. For example, Nightin-
gale described nursing as having to “put the patient in the best condition for nature to act upon
him” (Nightingale, 1946, p. 74). Others spoke of nursing in terms of helping individuals develop
their self-care activities (Orem, 1988) and doing what needs to be done to help individuals adapt
to their illness or environment (Roy, 1984). Newman and her colleagues defined a client as a per-
son who is primarily identified by a pattern of consciousness that also incorporates a sense of
recognition of how they fit within a larger system (Newman, Smith, Pharris, & Jones, 2008).
To illustrate, when a physician thinks of a person, the image is one of biologic systems with
structure and function. That image may include a person’s occupation, family, socioeconomic
class, or other variable; however, the central image is of a biologic system. When a sociologist
thinks of a person, she thinks of the roles, status, interaction, and significant others of individuals
as part of a society. When a psychologist thinks of a human being, she thinks in terms of intrapsy-
chic processes. A human being to a cell biologist is made up of groups of cells.
Who the clients are and how they tend to define and interpret their patient status will drive
theoretical nursing in the future. Clients have become more informed over the years, and they are
vocal about what they need from their health care providers. Clients are embedded in multidimen-
sional and dynamic contexts that are constantly changing (Reed, 1995). Theories that have
defined clients as passive recipients of care or as human beings who are waiting for information,
and those theorists who assumed that the nurse’s role is to ensure compliance are no longer con-
gruent with how clients define themselves (Allen, 1987). Clients come to the health care system
either with their consciousness raised about their rights for information, care, and participation in
decision making, or if they do not come with such expectations, the caring encounter may then
include opportunities for consciousness-raising. In either case, theories for the future must be
developed to reflect changing assumptions about clients and their levels of awareness and con-
sciousness, and they must also provide some strategies by which consciousness may be raised
within the value and belief systems of these clients.
Nurses deal with much more diversity in clients than has been the case historically. Client
diversity, with regard to gender, race, ethnicity, or religion, has always been, to a certain extent, a
hallmark of health care practice; however, at the turn of the century, diversity has taken on another,
more significant meaning because it comes with attached questions about the melting pot model
of integration. Clients assert their identities, whether that identity is related to ethnic background
or to sexual orientation. Clients are saying, “We like who we are, we do not want to assume or pre-
tend otherwise, and we want to be respected and treated with sensitivity and with competence that
includes our value systems and beliefs.” This assertion requires different assumptions and differ-
ent propositions that must be reflected in future nursing theories.
98 PART THREE Our Discipline and Its Structure
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CHAPTER 6 The Discipline of Nursing: Perspective and Domain 99
In addition, many world events are increasing transitions of people between countries and
within countries through immigration and emigration. These transitions profoundly influence
the health care and health outcomes of populations. The world’s population is increasingly eld-
erly, and this brings with it a corresponding increase in health care needs, since the elderly
require different types of expertise from nurses. Nurses are also needed to help individuals live
and cope with long-term illnesses. Who the clients are, how they respond to their situations,
how society has defined them, and how they define and redefine themselves are questions that
can be answered only within sociocultural, economic, and political contexts. Attention to these
questions and their answers could increase the power of theories to explain responses to health
care.
Nursing theories claim that nursing focuses on the person whose needs are not met because
of illness or the person who needs help in maintaining or enhancing wellness. Nurse theorists pro-
vide us with several views of our clients. A nursing client probably is a composite of all of the con-
ceptions provided by these nurse theorists, and perhaps the context determines which image is
more central at any one time. Some of these conceptions are complementary, whereas others are
based on conflicting value systems. The following are some examples of nurse theorist’s concep-
tions of the nursing client:
• The nursing client has a set of basic human needs (Abdellah [1969]––21 problems; Hen-
derson [1966]––14 daily activities; Orem [1988]––the deficit between self-care capabili-
ties and self-care demands). The focus of nursing is on assisting with activities to fulfill
the client’s needs.
• The nursing client is an open system, an adaptive being who changes to accommodate out-
side changes.
• The nursing client is conceptualized as a person in disequilibrium or at risk of disequilib-
rium due to insufficiency or incompatibility between one or more of his or her subsystems.
• The nursing client is a person who is unable, or is at risk of being unable, to be a self-care
agent.
• The nursing client has a lifestyle that may render the person vulnerable or resistant to
health risks.
These theories provided us with varied conceptions described in the social policy statement
of the American Nurses Association (2003). These conceptions should be used as guidelines for
analyses to determine their congruency with the values and mission of the discipline (Allen,
1987). A nursing client is defined in this book as a human being with needs, who is in constant
interaction with the environment and has an ability to adapt to that environment but, due to illness,
risk, or vulnerability to potential illness, is experiencing disequilibrium or is at risk of experienc-
ing disequilibrium. Disequilibrium is manifested in unmet needs, inability to take care of oneself,
and nonadaptive responses. More contemporary definitions are of “human living” (Willis, Grace,
and Roy, 2008) and “human dignity” (Jacobs, 2001).
Theoretical developments of phenomena related to nursing clients encompass but are not
limited to six areas.
1. Research and theories to describe philosophical principles governing views of human
beings in nursing, including analyses of values and norms related to human beings and
their relationships
2. Research and theories that relate to the fundamental process of responses to human and
environmental conditions that are considered within normal ranges
3. Research and theories to describe, explain, and predict responses of human beings’ health
and illness situations
4. Research and theories to describe human responses to nursing therapeutics
5. Research and theories to describe groups, communities, and organizational responses to
health and illness and nursing therapeutics
6. Theoretical development of person models that are congruent with the disciplinary values
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100 PART THREE Our Discipline and Its Structure
The nursing client is increasingly defined by his or her experiences (McIntyre, 1995). These
experiences are expressed and related to others in continuous and discontinuous ways, in isolation
or within a context, and are expressed through narration and various responses, whether verbal,
written, nonverbal, or through silences. Experiences can be uncovered and understood through
involvement and participation in dialogues and discourses.
One of the discipline’s immediate goals is to discover and develop techniques and method-
ologies to capture the holistic nature of human beings and the nature of integrated responses to the
environment that are considered central to the domain of nursing. It is also to develop ways by
which the nature of the lived experiences of human beings can be accessed, captured, and used as
the basis for caring for people (McIntyre, 1995). Until this goal is realized, nurses may have to
continue to resort to a more reductionist approach to the study of clients. However, a focus on
lived experiences must include the presence of the body in the analyses. Experiences and
responses to pain and illness are the embodied experiences of a person that include their physical
bodies (McDonald and McIntyre, 2001). McDonald and McIntyre (2001) go even further with a
warning that the body of patient and nurse included in the development of knowledge must not be
objective and stripped from the synthesis of emotion and physicality. Another goal is to focus
knowledge development on populations that have been marginalized, in the health care systems in
particular and in society in general.
Examples of the types of theories that need to be developed are:
1. Descriptive theories (e.g., patterns of normal responses)
2. Explanatory theories (e.g., how and why different groups of clients respond in certain
ways to noxious stimuli)
3. Prescriptive theories (e.g., how and in what ways nurses enhance a sense of comfort or
well-being in clients)
Transitions
Nurses deal with people who are experiencing transition, anticipating transition, or completing
the act of transition (Chick and Meleis, 1986; Meleis and Trangenstein, 1994). Transition denotes a
change in health status, or in role relationships, expectations, or abilities. It denotes changes in needs
of all human systems. Transition requires the person to incorporate new knowledge, to alter behavior,
and therefore to change the definition of self in social context. Transitions are developmental, situa-
tional, or health/illness events. Two significant developmental transitions may be associated with
health problems (both psychosocial and biophysiologic): the transition from childhood to adoles-
cence, which has the potential of being associated with ensuing problems such as substance abuse and
teen pregnancies; and the transition from adulthood to mature adulthood, a period accompanied by
gerontologic problems relating to identity, retirement, and chronic illness (Schumacher and Meleis,
1994). (See Chapter 17 for a comprehensive discussion of transition as a middle-range theory.)
Another transition falling within the domain of nursing is the situational transition, which
includes the addition or loss of a member of the family through birth or death. Each situation
requires a definition or redefinition of the roles that the client (a person or a family) is involved in.
The transition from a nonparental role to a parental one, the change from double parenting to sin-
gle parenting, and the attempts of women to move from the battered role to the nonbattered role
are three examples of situational transitions that affect a human being in totality, although we are
concerned with them in terms of health. Nurses are also concerned with the transition from insti-
tutional care to community care.
The last, but not least important, transition category is the health/illness transition. This cate-
gory includes such transitions as sudden role changes that result from moving from a well state to
an acute illness, from wellness to chronic illness, or from chronicity to a new wellness that encom-
passes the chronicity (Tornberg, McGrath, and Benoliel, 1984). Transitions are therefore one
component of the nursing domain. There is evidence that transitional care of patients who are dis-
charged from hospitals and whose care requires advanced nursing practice enhances their healing
and recovery (Naylor, 2002).
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CHAPTER 6 The Discipline of Nursing: Perspective and Domain 101
The sociologist, psychologist, biologist, and physiologist are all interested in transitions at
the micro and macro levels, and the objective of their interest is to know. Because domains are
not only identified by the types of objects with which they deal but also by the questions they
ask, the different domain interests can be differentiated by considering types of questions that
nurses ask. Only the nurse is interested in articulating transitions that are biopsychosociocul-
tural––not only to know, but ultimately to have knowledge of the utility of what we know and, in
particular, to have ways to effectively use that knowledge in enhancing individuals’ healthy tran-
sitions. Unlike other academic disciplines, nursing is accountable to the public; it is expected to
meet the public’s needs.
An example of a multidimensional transitional interest is my own interest in the health care
of immigrants, which arose from the needs of health care systems dealing with this population and
the need for a broader knowledge base to support the provision of culturally competent care. It
concerns immigrants in sociocultural transition, and it considers the effect of transition on clients’
biologic, psychological, sociological, and cultural needs and the effect of transitions on health
behavior, illness behavior, illness episodes, and coping styles of any group of immigrants to the
United States. The interest evolved from a nursing perspective, uses a sociological model, and will
add to the domain of nursing.
Nursing does not deal with the transition of an individual, a family, or a community in isolation
from an environment. How human beings cope with transition and how the environment affects that
coping are fundamental questions for nursing. Nursing seeks to maximize clients’ strengths, assets,
and potentials or to contribute to the restoration of the client to optimal levels of health, function,
comfort, and self-fulfillment. Coping and adapting are multidisciplinary and interdisciplinary con-
cepts. The menopausal experience, for example, is a developmental transition and a multidomain
concept. Although research in nursing considers menopause from a biopsychosociocultural perspec-
tive, the sociologist looks at it in terms of societal expectations, with the roles and status normatively
accorded the menopausal woman. The psychologist views menopause from an intrapsychic perspec-
tive; the physician views it in terms of changes in cells in the endocrine system. The nurse researcher
considers the subjective meaning of the entire experience, what biopsychosociocultural variables
influence that meaning, what the consequences are for the person, as well as for that person’s signif-
icant others, how the person is adapting to changes, and, finally, how the nurse can help the
menopausal woman cope with the experience, if indeed there is a need to do so.
Although each nurse researcher considers the nursing phenomenon according to the basic
premises of the field and according to a total view of the human being, the goals of research will dic-
tate the dominant model. For example, one nurse researcher conceptualizes phenomena predomi-
nantly from a physiologic model, whereas another may use a sociological model. Both explicate
nursing phenomena and work toward the goals of enhancing healthful living, an adaptive stance, and
a higher sense of well-being. Both are adding to the nursing conceptualization of an experience.
Theories are needed to describe the nature of transitions and normal patterns of responses to
transitions, to explain relationships between transitions and health, and to provide guidelines for
enhancing a perception of well-being.
Relationships and Interactions
Relationships are emerging as a defining aspect of the domain of nursing or—as described by
Newman, Smith, Pharris and Jones (2008)—as the central focus of the discipline of nursing, or indi-
rectly as a unifying focus for the discipline (Willis, Grace, and Roy, 2008). Some theorists focused
on the process of building relationships and on the tools of assessment, and, therefore, viewed nurs-
ing as a relationship and an interaction process. Relationships are formed through interactions, and
together they provide us with the genesis of one or more interaction theories. These theorists spoke
of the properties of the nurse–patient dialogue, of therapeutic interaction, and of the components of
interacting as being the sensing, perceiving, and validating of the patient’s need for help and the shar-
ing of information. They explicated properties of perception, thought, and feelings during health and
illness situations. Together they provided us with a framework that contains major concepts central
to nursing. Theories relating these concepts could come from inside or outside nursing. They could
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102 PART THREE Our Discipline and Its Structure
evolve from studying the work of the different theories in conjunction with patient care situations or
in conjunction with other interaction theories, such as those of Sullivan (1953) and Mead (1937).
Interaction is a tool for assessment, diagnosis, or intervention, and for building relationships
(Hawthorne and Yurkovich, 2002). It is one of the central concepts in nursing for the following
reasons:
1. A nursing client is in constant interaction with the environment (King, 1981; Nightingale,
1946; Rogers, 1970). Therefore, nursing focuses not only on individuals but also on mon-
itoring, regulating, maintaining, and changing environments.
2. Interaction is the major tool by which nurses build trusting relationships and assess a
client’s needs and resources, and it is also a central tool in providing nursing therapeutics
(King, 1981; Orlando, 1961; Paterson and Zderad, 1976; Travelbee, 1971; Wiedenbach,
1963).
There is some agreement that interaction is a domain concept and that interactions occur both
as person–environment interactions (Flaskerud and Halloran, 1980; Forchuk, 1995) and nurse–
patient interactions (Barnum, 1994). Interaction is considered here in its broadest sense to incor-
porate both of these situations.
In reviewing published research reports between 1999 and 2008 about nurse practitioners–
patient interaction, Charlton, Dearing, Berry, and Johnson (2008) identified two major communi-
cation styles, a biomedical one and a biopsychosocial one. The biopsychosocial style is a more
patient-centered approach to communication; it was associated with improved patient outcomes
such as patient satisfaction, adherence to treatment plans, and general improvement of health.
These results demonstrate the potential for advancing nursing knowledge when the domain is
more specifically defined (interaction styles) to point out the potential consequences of how a
nursing perspective (biopsychosocial) may influence outcomes that are central to the nursing dis-
cipline (patient satisfaction, adherence, health).
Several kinds of theories related to interactions need to be developed, including the following:
1. Theories that describe normal patterns of the interactions of human beings with signifi-
cant aspects of their environments
2. Theories that describe normal patterns of interactions between clients and their environ-
ments within a context of health and illness, which should account for developmental,
sociocultural, and cognitive variations
3. Theories that describe and explain interactions and the consequences of interactions that
are related to assessment, diagnosis, and interventions
Kim (1987) identified four sets of variables that are related to client–nurse contacts for pro-
viding nursing care: client and nurse, a social context for the contact, a process of interaction, and
outcomes. The conceptual linkages between each of these sets of variables are then amenable to
theory development (Kim, 1987, p. 105).
Nurses have claimed nurse–patient interactions as central to the nursing diagnosis; however,
Kim (1987) reminded us:
While there has been a great deal of theoretical emphasis on the importance of client–nurse
interaction in the delivery of nursing care, very little has been done either in theory develop-
ment or in empirical testing of these theories. More needs to be done on the meaning of thera-
peutic relationships and ways by which such relationships are established, nurtured,
supported, discouraged, or avoided. There is a rich array of theoretical and empirical work
accomplished in sociology and social psychology that is transferable to this nursing domain.
There is a need to have an understanding of how the special nature of client–nurse interactions
modifies sociological, social, psychological, and communication theories. Much work, there-
fore, needs to be done to revise and reformulate existing knowledge to explain and predict
phenomena in the client–nurse domain. (Kim, 1987, p. 107)
Communication, interaction, and being present in relationships and interpersonal relationships
gained a new momentum in popular literature, as well as in clinical and managerial literature, at the
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CHAPTER 6 The Discipline of Nursing: Perspective and Domain 103
turn of the 21st century (Newman, Smith, Pharris, and Jones, 2008). Going back to the basics in
human relationships may have been a reaction to computerization and the increasing use of gadgets
and machines. Reports from the Institute of Medicine in the United States, an independent policy
analysis arm of the U.S. Congress, proposed, with ample documentation, the need for a patient
focus and an interaction focus in the education of health care professionals. The discipline of nurs-
ing was first in claiming interaction and communication as the tools of professional practice. That
momentum in developing the science of nurse–patient and patient–environment communication by
nurse scientists should be continued and advanced (Institute of Medicine [IOM], 2003).
Nursing Process
Another concept central to the discipline of nursing, as demonstrated in the many discourses
in the literature and by many nursing theories, is that of the nursing process. The nursing process
is built on communication and interaction tools and processes for nursing practice. The distinct
properties of the nursing process as they differ from client–nurse or client–environment interac-
tions have not yet been as clearly defined and distinguished. Despite some apparent overlap, it is
proposed here that propositions about the nursing process, about approaches that are more effec-
tive in the process of assessing, diagnosing, or providing nursing therapeutics, and about the goals
of the nursing process can be derived from the work of several theorists: Abdellah, Henderson,
Orem, Orlando, Travelbee, and Wiedenbach. Together, they provided nursing with a perspective
on assessment, diagnosis, plan for intervention, and evaluation (Abdellah, 1969; Henderson,
1966; Orem, 1988), and on the process of defining and attaining goals (King, 1981); and placed
emphasis on the patient’s perception of his own condition (Wiedenbach, 1963).
The nursing process, a tool for nursing practice, was introduced to nursing first by Orlando
(1961) and became central to many nursing publications. It has even been considered a framework
for nursing practice and nursing education (Yura and Walsh, 1978a, 1978b). Most of the theorists
described and discussed the nursing process. Although some components of the process of clinical
judgments are an integral part of all professional–client relationships, the process in nursing dif-
fers, just as the goals of each profession are different. It is proposed here that the nursing process
is a central concept in the domain of nursing.
Many nurse metatheorists agree with this position (e.g., Torres, 1986; Walker and Avant,
1995), as demonstrated by the extensive literature on and use of the nursing process, and by those
who maintain that emerging theories and models in nursing must consider the nursing process
(Thibodeau, 1983). Others question the compatibility of the holistic mission of nursing and the
reductionist approach dictated by the use of the nursing process (Barnum, 1987). Barnum (1987)
pointed out the potential for other processes in decision making to be more compatible with the
holistic principles of nursing, such as the problematic method described by Dewey (1966). These
debates in the nursing literature demonstrate the need for further theoretical development of dif-
ferent processes for assessment and diagnoses and for providing nursing therapeutics.
One significant component of the nursing process that has received the attention of the disci-
pline throughout the 1980s is a taxonomy of nursing diagnoses. The movement toward the devel-
opment of the taxonomy began in the early 1970s, starting with Kristine Gebbie (a graduate of
University of California, Los Angeles, a faculty member at UCLA, and a collaborative author with
Betty Neuman and later a faculty member at Columbia University, New York). The nursing diag-
noses described by participants in annual nursing-diagnoses conferences were without a binding
theoretical framework to guide their development. Although these taxonomies appear to be a
unifying diagnostic language for communication between nurses, they:
cannot contribute to the development of scientific solutions (i.e., nursing therapeutics),
[because] nursing diagnoses that are not developed within an explanatory framework have to
be accepted only as descriptive “averages” to be used for the purpose of communication and
documentation only. (Kim, 1987, p. 102)
Several types of theories related to the nursing process need to be developed (Frisch, 1994).
Examples of these are: theories to describe the actual processes that nurses use in assessing,
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104 PART THREE Our Discipline and Its Structure
diagnosing, and providing nursing therapeutics to different types and categories of clients; theories
to describe nursing diagnoses and those that can “give order to the nomenclature” (Kim, 1987,
p. 103); theories to explain diagnostic categories within the different contexts; and theories that explain
nurse–patient contacts within the contexts of client variables and diagnostic categories. Processes for
assessment, diagnosis, and intervention have emerged as central to nursing and its mission.
Finally, a dialogue about the congruency between a reductionist approach to viewing nursing
phenomena, as assumed through using the nursing process, and the assumptions of holism, must
continue. This dialogue began with effective arguments supporting the incongruity between
assumptions inherent in theories of nursing process and the nature of holism in nursing (Barnum,
1987). Similarly, questions arise about the role of nursing process in curricula and in nursing sci-
ence that evolve from considering it as central to nursing. Duldt (1995) argued for better clarifica-
tion of the properties inherent in the nursing process, as differentiated from the clinical inquiry
process and the research processes, and proposed that such differentiation enhances the potential
of using these differentiated processes to structure advanced nurse practitioner courses. Students
may be better able to move easily between the different processes when they are aware of their
similarities and differences in process and goals.
Environment
Ever since Florence Nightingale (1946) identified nursing in relation to a focus on optimizing
an environment to promote healing and optimal health, environment has been a concept central to
the nursing domain. Nightingale considered both the discomfort and suffering that patients experi-
ence as a result of inadequacies in the environment, as well as the nurses’ actions that focus on that
environment. We lost track of this concept during those years when biologic systems dominated
nursing and when nursing focused on illness, medical treatment, and assistance with a medical reg-
imen. As central as the concept of environment may be, nursing theorists have not addressed it in
the same depth and with the same conviction about its centrality as did Nightingale––nor as they
did when considering the individual. Clinicians appear to pay lip service to the environment.
More contemporary theorists see the environment as central to nursing, particularly as it
relates to human beings and their responses (e.g., Paterson and Zderad, 1976; Rogers, 1970). To
these theorists, environment encompasses energy fields, social systems, family, society, culture,
the patient’s room, the nurse, and all that surrounds the client. Rogers’ theory focuses on a
description of person and environment energy fields as inseparable, and on the dynamics of
human being–“environment” interactions. According to her, the process inherent in such interac-
tions can only be understood through a careful consideration of the environment. This view
assumes the person and the environment to be in constant interaction and recognizes changes in
one as integral and simultaneous to changes in the other. Therefore, the aim of nursing interven-
tion is to promote, maintain, regulate, or change the environment and/or the life processes of peo-
ple to effect changes in either or in both.
Chopoorian (1986) argued for considering the environment as the central focus for nurs-
ing interventions and warned us against continuing to develop knowledge based on the central-
ity of clients. She suggested her thesis by demonstrating the limited roles that nurses play in
instituting policy changes when clients are considered the central focus for nursing. In recon-
ceptualizing environment for the discipline of nursing, she suggested that, “nurses develop a
consciousness of environment as social, economic, and political structures; . . . as human
social relations, . . . as everyday life” (Chopoorian, 1986, p. 47). She further argued that this
approach has the potential to open up new opportunities for nurses to go beyond the accept-
ance of the status quo for patients and make contributions to resolving society’s problems
(p. 53). A focus on environment may prompt nurses to reconsider their goals and the mission
of the discipline.
Environment, as a central domain concept, includes but is not limited to immediate client set-
tings, family, significant others, health care professionals, and the socioeconomic and political
contexts of the client’s families and communities (Hedin, 1986). Stevens (1989) proposes the use
of critical theory to illuminate oppressive environmental factors that influence health, hinder
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CHAPTER 6 The Discipline of Nursing: Perspective and Domain 105
human potential and life possibilities, and “restrict their equal and fully conscious participation in
society” (p. 63).
Both clients’ and nurses’ environments are undergoing tremendous changes that will drive
theory development in different ways. A plausible scenario is the expansion of the environment to
include outer space, with all the changes in the nature of care that will need to become more con-
gruent with this changing environment. Other changes in environment are related to levels of
risks, such as increased pollution, decreased protection offered by the ozone layer, increased
aggression and decreased safety, and increased globalization. Each one of these will influence and
drive the nature of theories in different ways and will require models that address the nature of
healthy environments and strategies by which a healthy environment may be created and sup-
ported. Theories of the future will also have to address global issues, as well as strategies to pro-
vide care that evolve from an international perspective (Kleffel, 1996).
There have been many natural disasters (the tsunami in 2004 and the hurricanes in 2005) and
human-made disasters (wars, nuclear plant explosions like the one in Chernobyl, Ukraine in 1986;
the terrorist attack on the World Trade Center in September 2001) that not only require the imme-
diate involvement of nurses, but require long-term attention while people are coping with the
aftermath of these events. These situations drive the need for even more informed theories about
environments and the different meanings of environments. For example, the earthquake in Kobe,
Japan in 1995, and the Loma Prieta earthquake near San Francisco in 1989, prompted a reflection
on nursing and ways by which nursing could contribute to the health care of people who have
experienced such devastating events. The questions that these events raise for nurses are:
• Who are the target populations?
• Who gets marginalized during the disaster and during the long healing process?
• What processes do people go through as they begin to heal from the effects of the experience?
• What strategies do nurses use to create a healing environment and to enhance people’s
well-being in the process of transition toward healing?
• What milestones and critical periods in the long recovery process do nurses need to be
aware of?
These are some of the questions that will drive new theories that will be developed to inform
nursing practice.
Several types of environment-related theories need to be developed. Theories centering on
environment are expected to describe those properties, components, and dimensions of environ-
ment that are healthy or that help in maintaining or in changing health care outcomes. These
theories are also expected to describe the environment that promotes a client’s abilities for self-
care and adaptation. In addition, they are expected to guide the development of effective inter-
ventions that may change systems that constrain access and equality in giving and receiving
health care. Examples of environmental nursing theories are descriptive theories of healthy
environments; theories that describe societal mechanisms that constrain the development, pro-
vision, and maintenance of healthy environments; theories that describe and explain policies for
health care; and theories that guide actions for environmental changes (Salazar and Primomo,
1994).
Nursing Therapeutics
Nursing therapeutics is defined as all nursing activities and actions deliberately designed to
care for nursing clients (Barnard, 1980; 1983). Although the nursing process addresses patterns in
assessing, diagnosing, and intervening, nursing therapeutics considers the content of nursing
interventions and the goals of intervention. The ultimate goal of theory development in nursing is
to develop theories that guide the care nurses give to patients. The existing nursing theories, as
categories, provide nursing with the beginnings of nursing therapeutics. For example, interaction
theorists suggest that, because we define nursing as a process and as an interaction, nursing prob-
lems reflect process and interactional problems; therefore, to these theorists, nursing therapeutics
are related to making the interaction process more effective. These theorists recommend the
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106 PART THREE Our Discipline and Its Structure
development of empathy, the use of validation, and the use of deliberative nursing process as
strategies to deal with communication and interaction problems.
Examples of nursing therapeutics that are being used in the nursing literature are:
• Touch (stimulation and repatterning of human fields) (Krieger, Johnson, Weiss, Rogers
Neuman)
• Care (Orem, Henderson, Leininger)
• Role supplementation (Meleis, Swendsen, Dracup)
• Protection (Johnson, Norris)
• Manipulation of focal, residual, and contextual stimuli (Roy)
• Comfort (Arruda, Larson, and Meleis; Morse)
• Use of self as a nursing therapeutic (Hall and Allan, 1994)
• Symptom management (Lenz, Pugh, Milligan, Gift, and Suppe, 1997)
• Transitional care (Naylor, Brooten, Campbell, Maislin, McCauley, and Schwartz, 2004)
See Chapter 20 for examples of appropriate references. Each of these concepts related to
nursing therapeutics could become the nucleus of a middle-range or situation-specific theory in
therapeutics (see Chapters 15, 16, and 17) for the different strategies to use in developing concepts
and theories.
Health
Health, a goal shared by a number of health professions, emerged as a central goal in nursing
in the writings of Florence Nightingale in the mid-1800s. Since then, theorists have considered
health with different degrees of specificity, reductionism, and centrality. Health has been accepted
as more than the absence of disease, and that concept is becoming more emphasized in nursing
(Neuman, 1989; Newman, 1983, 1986; Smith, 1983).
Several different models of health were identified from the nursing literature (Meleis, 1990):
health as an absence of disease (Smith, 1983), health as an internal homeostasis (Johnson, 1980),
health as adaptation (Roy, 1984; Smith, 1982), health as performing roles and functions (Orem, 1988;
Smith, 1982), and an existential view of health that focuses on symbolism and the place of the self in
an intricate web of relations among objects and subjects (Paterson and Zderad, 1976; Travelbee,
1971). A sixth model relies on space/time/energy and consciousness expansion; health in this model is
viewed in terms of awareness, personal control, personal empowerment, and mastery over body
(Newman, 1986; Rogers, 1970). The last model considers the cultural/social/political aspects of
health (Allen, 1986; Jones and Meleis, 1993; Meleis, 1990; Tripp-Reimer, 1984). For further theoreti-
cal development of health as a central concept, the unity and diversity among these models need to be
addressed, compared, and contrasted. Several conditions were identified as needing to be included in
further theoretical development of health. These are the need to focus on an understanding of the
health care needs of underserved populations, the potential advantage in using a feminist framework,
the integration between a static conception of being healthy, and a process/dynamic/becoming con-
ception of health (Meleis, 1990). A strong argument could also be made about the unique contribution
the discipline of nursing is making in building the science of health promotion (Northrup and Purkis,
2001), as well as healthy work environments (Caruana, 2008).
DEFINITION OF NURSING
A discipline is also shaped, and it reflects the definition attached to it by its members and by the soci-
ety at large. Several definitions of nursing could drive the process and the goals of knowledge devel-
opment in the discipline and, in turn, help to further define the structure of the discipline. These
definitions, in turn, were shaped by the progress made in theoretical nursing. One of the most influ-
ential definitions of nursing has been the one offered by Nightingale (1859, 1946), in which nursing
was defined as “taking charge of the personal health” of individuals and to “put” the individual in the
best possible state and “allow nature to act upon him.” This definition although old, continues to
hold true, and it set the stage for nursing to claim “personal health” as part of its domain.
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CHAPTER 6 The Discipline of Nursing: Perspective and Domain 107
A second influential definition is one that was commissioned by the International Council of
Nurses (ICN) for international use. Henderson offered a definition that emphasized a unique role
for nursing and brought in the notion that patients have a role in caring for themselves; when
patients are not able to care for themselves due to health problems, nurses provide the care they
need. Once the patient is again capable, self-care can resume, and nurses are not then expected to
do for patients what they are capable of doing for themselves (Henderson, 1966).
A third significant definition was offered by the ANA (1980). Nursing was defined as “the
diagnosis and treatment of human responses to actual or potential health problems” (p. 9). This
earlier version of the definition has been discussed and critiqued for ignoring the environment,
for its inconsistency with nursing values, for its limitation to individual care instead of commu-
nity care, and for its problem orientation and lack of health orientation (Allen, 1987; Field,
Kritek, Christman et al., 1983; Silva, 1983; White, 1984). However, the definition did help in fur-
ther identifying the domain of the discipline and in providing boundaries that have been reflected
in theory development and in research priorities. In 1995, an updated version of the definition
included affirmation that nursing is committed to caring for ill and well people as individuals,
groups, or communities (ANA, 1995). That definition of professional nursing was further modi-
fied and updated in 2003. At the time of this writing, professional nursing is defined in the
United States as:
The practical, promotion and optimization of health and abilities, prevention of illness and
injury, alleviation of suffering through the diagnosis and treatment of human response, and
advocacy in the care of individuals, families, communities, and populations. (ANA, 2003, p. 6)
Nursing is also defined by the ICN in Geneva as:
The use of clinical judgment in the provision of care to enable people to improve, maintain, or
recover health, to cope with health problems, and to achieve the best possible quality of life,
whatever their disease or disability until death. (Royal College of Nursing, 2003)
The concept, “response,” that appears in the ANA’s definition is yet to be fully defined; nev-
ertheless, it reflects a more integrated approach to viewing clients’ behaviors and actions. It legit-
imizes nurses’ abilities to diagnose and treat or deal with these responses and acknowledges the
significance of giving attention to the daily lived human experiences. The taxonomy of responses
provided as examples reflects the influence of theoretical nursing. Future definitions will need to
reflect progress in other components of the domain, such as the emphasis on environment and its
relationship to nursing care. The addition of such concepts as prevention, protection, promotion,
optimization of abilities for individuals, families, and communities better reflects nurses’ con-
cerns. Each of these concepts requires further analysis and development.
I have selected three other definitions to illustrate the dialectic relationship between domain
definitions and progress and development in disciplines, as well as to demonstrate the systematic
conversion of leading thoughts in the discipline. Based on earlier definitions of nursing, on the
identification of central concepts, and on the authors’ theoretical research and curricular explo-
rations, Newman, Sime, and Corcoran-Perry (1991) defined the focus of the discipline of nursing
as the “study of caring in the human health experience” (p. 3). Similarly, Meleis and Trangenstein
(1994), although their definition is more specific, defined nursing as being concerned with the
process and the experiences of human beings undergoing transitions; therefore, nursing is defined
as “facilitating transitions to enhance a sense of well-being” (p. 257). A third definition reflects an
evolving, coherent approach to defining the discipline of nursing. In searching for a unified focus
of the discipline, Roy and her colleagues engaged in a lengthy dialogue about their work for
2 years. The result is a definition of nursing as:
a health care discipline and healing profession, both an art and science,
which facilitates and empowers human beings in envisioning and fulfilling
health and healing in living and dying through the development,
refinement and application of nursing knowledge for practice. (p. E33)
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108 PART THREE Our Discipline and Its Structure
They further defined the central unifying focus for the discipline as:
facilitating humanization, meaning, choice, quality of life and healing
in living and dying. (p. E33)
All these definitions evolved from previous definitions of nursing, from identification of cen-
tral concepts, from established research traditions, and from previous theoretical work by nurse
scholars. Each of these definitions drives the development of different levels of investigation, one
relating to caring acts and lived experiences in health and illness, and the other focusing on the
nature of transitions, responses, and consequences of transitions, and the different strategies by
which nurses can enhance healthy transitions.
CONCLUSION
Disciplines are defined by the structure and substance that define their missions and goals. In this
chapter, the nursing perspective, the domain of nursing knowledge, and the definition of nursing
are provided. By identifying, acknowledging, and affirming the discipline’s perspective, we could
focus our knowledge development efforts on the phenomena that nurses deal with, using a per-
spective that best reflects nursing views and values. A nursing perspective is known by exploring
nursing as a human science, with a practice orientation, caring tradition, and a health orientation.
The domain of nursing deals with clients who are assumed to be in constant interaction with their
environments, human beings who have unmet needs related to their health or illness status, who
are not able to care for themselves or are not adapting to their environments due to interruptions or
potential interruptions in health. The domain of nursing incorporates a central focus on environ-
ments that includes sociopolitical and economic contexts for nursing clients and their significant
others. The domain of nursing includes a focus on nursing therapeutics to help in meeting the
cussed in this chapter? Why do you think
these components are essential or core?
In what ways would each of these core
components transform the discipline’s
quest for knowledge development?
5. Identify the implicit and explicit assump-
tions that the author had in formulating
the ideas in this chapter. Why do you
agree or disagree with them?
6. In what ways is the discussion in this
chapter about the core domain of nursing
and the nursing perspective reflected in
current dialogues about disciplines in
general and about the discipline of nurs-
ing in particular?
7. Define and analyze the core and second-
ary components of the nursing domain
within your field of nursing. Compare
and contrast them with those presented
in this chapter.
REFLECTIVE QUESTIONS
1. What are the key questions addressed in
this chapter? What are the main points of
view? What could be gained or lost by
critical discourses on disciplines, per-
spectives, domains, and definitions?
2. Discuss your views on the relationships
between domain, perspective, science,
and theory? Present your view of these
relationships schematically. Now, try to
identify questions that incorporate differ-
ent combinations of these relationships.
Discuss ways by which different combi-
nations may or may not advance the
knowledge base of nursing.
3. What inferences might you make about
the discipline of nursing after reviewing
this chapter? What would change these
inferences?
4. What are other essential components
(core) of a discipline that were not dis-
(Continued on page 109)
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CHAPTER 6 The Discipline of Nursing: Perspective and Domain 109
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C H A P T E R 7
Sources, Resources, and
Paradoxes for Theory
Where do the ideas for theories come from? What does it mean to advance knowledge, and what
are the reasons for developing theories? Are there particular conditions that support the develop-
ment of theories?
In this chapter, the sources and resources of theory essential to theory development are dis-
cussed and analyzed. It is assumed that to engage, in some form or another, in the theoretical
development of the discipline, members of the discipline should be aware of the sources and
resources for theory, and use and promote them. The conditions that are proposed to facilitate the
sources and the resources for theory development are necessary but not sufficient for theory devel-
opment. Other conditions include the identification and resolution of paradoxes that may influ-
ence the processes of developing theories. Two paradoxes are identified and discussed herein.
Additional conditions, such as knowledge of strategies for the development and evaluation of con-
cepts and theories are discussed in Chapters 15, 16, and 17. These conditions provide the contexts
that enhance the processes needed for knowledge development and support the development of
abilities and expertise in developing theories.
SPINOZA ON KNOWLEDGE DEVELOPMENT
To Spinoza, a 17th-century Dutch philosopher, one of the most significant goals a human being
can pursue is knowledge development because knowledge represents power and freedom for
humanity. Spinoza considered the pursuit of knowledge and the pleasures of understanding to be
precursors to permanent happiness, which in turn leads to healthful living. His philosophy inte-
grates mind, body, and nature in articulating the sources and resources of knowledge. He consid-
ered some conditions essential for knowledge development, two of which are of concern to us
here. He proposed that a high level of understanding of the sources of knowledge and the avail-
ability of human beings who are interested and committed to activities related to the processes of
development are two essential criteria for knowledge development.
On the sources of knowledge, Spinoza distinguished among four forms of knowledge. The
first is “hearsay knowledge,” knowing one’s birthday because we were told of the day, the time,
the circumstances, and who one’s parents are; the source of that knowledge is not personal experi-
ence. The second type of knowledge is perceived through the source of “vague or confused expe-
rience.” Here, “general impressions” that something has “usually worked” is the source of a great
deal of our knowledge, such as knowing that dogs bark, that we will die, and that water extin-
guishes flame. The third type of knowledge is achieved through “immediate deduction, or by rea-
soning, one thing is inferred from the essence of another.” Specific relationships are absent;
therefore, part of the reality is out there to be observed, and the other part is logically deduced.
Experience may refute this type of knowledge. Hence, the fourth form (which is the highest, and
which incorporates deduction and perception, and combines reality, perception, intuition, and feel-
ings) Spinoza called intuitive knowledge (scientia intuitiva). It is not totally unlike the third form of
knowledge. It is the kind of knowing that proceeds from “an adequate idea” to the “adequate
knowledge of the essence of things” (Copleston, 1963; Durant, 1953).
Of human beings in pursuit of knowledge development, Spinoza said a person who is:
in pursuit of knowledge should be able 1. To speak in a manner comprehensible to the people
and to do for them all things that do not prevent us from attaining our ends. . . . 2. To enjoy
only such pleasures as are necessary for the preservation of health. 3. Finally, to seek only
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114 PART THREE Our Discipline and Its Structure
enough money . . . to comply with such customs as are not opposed to what we seek. (Spinoza,
cited in Durant, 1953, p. 128)
SOURCES FOR THEORY DEVELOPMENT
Ideas, questions, and phenomena are sources for theory development. Ideas originate in the mind,
and it is through the power of the mind that they are analyzed, separated, and sorted into mere
passing thoughts or intellectual ideas worth pausing to examine and further pursue. Early philoso-
phers differed in their discussions of where ideas come from. John Locke (cited in Nidditch, 1975)
used the image of the tabula rasa, the “blank slate,” to describe the meaning of ideas. To Locke,
experience is the source of all ideas, reason, and knowledge. Knowledge is founded in experience
and is derived from experience. Locke spoke of observations and reflections as mechanisms for
experiences to be translated into ideas. Experience is not limited to the external senses, although
these sensations are extremely important for knowledge development, but also include internal
senses, reflections of the mind. It is the combination of the discourse between external and inter-
nal senses, between observations and reflections, and between the internal and external dialogue
that creates ideas. The conscious experience, according to Locke, is significant but inseparable
from the internal experience.
Although the tabula rasa idea has long since died, the inseparability of internal and external
sensations is the essence of theory development in nursing. It is through the connection between
experience and thinking that ideas may be formed. The mind is ultimately the vehicle through
which ideas evolve, yet one question may be: What mechanisms could be used that may promote
noticing and observing? Nurses have many rich sources for ideas. These sources have gone
through four different eras:
1. During the first era nurses were almost totally dependent on other disciplines and para-
digms for ideas that advanced nursing knowledge. When it continues to be dependent on
other disciplines and paradigms for its sources of ideas, a scholarly discipline cannot
have its needed autonomy to pursue ideas that are fundamental to the discipline or a
sense of accountability. Such dependence dictates the significant phenomena or prob-
lems, instead of allowing the discipline itself to drive the generation of its areas of phe-
nomena and problems. A focus emanating from educational paradigms promoted the
development of theories that explained and predicted phenomena that better answered
questions in the educational field, such as theories regarding modularized instruction or
teaching and learning strategies. A medical model allowed for observations related to
signs, symptoms, illness, and observations. A sociological framework focuses on behav-
iors of collectivities and patterns of social order. These other disciplines do not ade-
quately address the development of knowledge about responses to health and illness, and
they do not help to elucidate patterns of behavior in daily lives as individuals attempt to
respond to and live with health and illness episodes.
2. During the second era, methodology and functions dominated the idea reservoirs of the
discipline of nursing. Ideas related to what nurses do and how nurses conduct research
led to conceptualizations of nurses’ roles and of methods of research (Gortner and
Nahm, 1977). The few dissatisfied scholars who continued to consider sources of ideas
such as patients and patient care were rejected. They were thought to advocate a single
paradigm in nursing—one single explanation of the world, one system of thought and
action that would cover everything. That was perceived to be the route to discipline
development. The ideas of these scholars were rejected by the majority, and decades
went by in which ideas were methodological and functional—research and theory
methodologies—rather than substantive. Some perceived the approach of one paradigm
for the entire field to be a method of mind control, a stifling approach conducive to
insignificant work.
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CHAPTER 7 Sources, Resources, and Paradoxes for Theory 115
3. During the third era the acknowledgment of multiple sources of ideas predominated.
This era allowed different schools of philosophical thought to exist side by side. This is
the era of retrospectively considering all sources of ideas, philosophy, experience, theo-
ries, concepts, and interventions, among others, and using any and all that help to address
problem areas of nursing for the purpose of developing theories.
4. A fourth era that reflected the first decade in the 21st century is the era for evidence and
outcomes. Quality of life, cost of care, failure to rescue, medical errors, morbidity, and
mortality were some of the outcomes that provided the impetus for concept development
and for advancing knowledge through empirical investigations. Preoccupation with evi-
dence that is supported by competitively peer-reviewed research dominated this era
(Fawcett, Watson, Neuman, Walker, and Fitzpatrick, 2001). However, there was also
support for theory-based evidence.
Each one of these eras drove different discourses in the nursing literature. Some of these dis-
courses connected practice to theory and/or research more than others. Each was important in
advancing the discipline of nursing by elucidating a different component in the discipline. For
example, the discourse during the methodology era resulted in more acceptance and better con-
sensus about the significance of the different designs in developing theories in a human science.
Similarly, the rich discourse during that era about combined methods and integrative meta-analysis
were significant in launching the next era of multiple sources of theory and knowledge develop-
ment. In many ways, each of these eras also prompted the exploration and development of differ-
ent theoretical dialogues that have informed the development of theory. Examples of theoretical
developments are system management, feminist theories, grounded theory, and quality of life.
Several sources have been significant in theory development. Each source provides a medium
for articulating significant theoretical questions, and each lends itself to further theoretical analy-
sis and development. Because the context and the source influence the type and the nature of the
phenomena to be considered, it is important for nurses to understand the different sources and to
make deliberate choices based on the discipline’s mission and priorities. Each source should con-
tinue to be deliberately sought in the future for advancing nursing theory. The sources discussed in
this chapter are extant nursing practice; biomedical model; nurses’ experiences, roles that nurses
play, basic science, ideal nursing practice, nursing process (including nursing diagnosis, nursing
interventions, concepts, nursing research, and nursing theory), and combined sources of ideas.
Each is briefly discussed in the following sections.
Extant Nursing Practice
One of the earliest sources of theoretical nursing was the practice of nursing care and the
actual nursing care offered and received. The writings of Florence Nightingale attest to the signif-
icance of nurses’ experience in caring for patients suffering from disease and injury during the
Crimean War, in developing a conceptualization that defined nursing and its mission. Nightin-
gale’s conceptualization of environment as the focus of nursing care, and her admonition to nurses
that it is not enough to know only about diseases to help patients recover, are the earliest attempts
at differentiation between the focuses of nursing and medicine. Her concept of nursing, which
reemerged with more strength after it was reconsidered more carefully in the 1980s, includes the
proper use of fresh air, light, warmth, cleanliness, and quiet; the proper selection and administra-
tion of diet; and the preservation of vital energy and power to the patient. For example, the state-
ment, “Nursing should be to assist the reparative process, and decrease suffering” (Nightingale,
1859) includes concepts that have withstood the test of time but that have only been fully discussed
and analyzed through other theorists beginning with Travelbee in the early 1960s (Travelbee,
1966). Subsequently, we note that suffering and reparative processes continue to be part of more
contemporary thinking in nursing.
Nightingale’s Notes on Nursing, in which she articulated phenomena central to the domain of
nursing, evolved from extant nursing practice and from experiencing the wholeness of the
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116 PART THREE Our Discipline and Its Structure
processes of caring (Nightingale, 1859). The notes were based on her observations and her experi-
ence in nursing. They are a living indication of the potential for extant nursing practice to be a
source of ideas for theories to describe, predict, and prescribe nursing care. One cannot help but
wonder whether, if nurses had continued to consider extant nursing practice as the major source of
ideas, the theoretical development of the discipline would have taken a different path. Extant nurs-
ing practice as a source of theoretical development was revisited in the late 1980s, with these
advocating for storytelling from the practice arena. The development and analysis of concepts that
are related to clinical phenomena are indicators of the acknowledgment of the centrality of nurs-
ing practice as a source of theoretical nursing.
The phenomena of the discipline are the core source for needed theoretical development. The
phenomena stimulate ideas, questions, and explorations. The phenomena related to understand-
ing, explaining, predicting, and prescribing the caring process that happens between clients and
nurses are, and should be, the focus of theoretical work in the discipline of nursing. Extant nursing
practice continues to be a vital source for shaping nursing theory. Estabrooks and her colleagues
(2005) described taxonomy of knowledge sources used by nurses who worked in pediatric and
adult surgical units in Canada. Nurses in the study categorized the sources of practice knowledge
into four broad categories: social interactions, experiential knowledge, documentary sources, and
a priori knowledge. Nurses obtained knowledge through social interactions with peers, other pro-
fessionals, patients, and discipline-based, institution-based, and hospital units. They also used
their previous experiences, including what had or had not worked in the past, as well as intuitions.
Other sources included procedural knowledge, as well as education, common sense, and beliefs.
The authors conclude that these sources of knowledge should be given more attention as legiti-
mate sources. This review and the authors’ conclusions provide support for other views in the dis-
cipline about the complexity of nursing knowledge and for practice as a source for theory
development.
Biomedical Model
Those who followed Florence Nightingale in the development of schools of nursing to edu-
cate novices in the art and practice of nursing utilized her advice regarding the necessity of pro-
viding education and apprenticeship to young women who wished to become nurses; however,
these followers fell short of continuing to differentiate the focus and goals of nursing and medi-
cine, and did not further Nightingale’s theorization of nursing. The medical domain of practice,
better developed and more powerful, replaced what was starting to become a nursing domain of
practice (health, hygiene, environment, and care).
Ideas evolving from the medical domain of practice addressed medical phenomena, signs,
symptoms, surgery, medication, illness, and diseases. Early textbooks provide documentation of
the context provided to students, which was medicine and surgery. The medical domain, with its
biomedical theories, dictated the questions that may have been more appropriately asked by
nurses from a nursing care perspective. The richness of nursing practice did not provide the impe-
tus for a focus on generalizing, describing, and predicting nursing phenomena, or for prescribing
nursing care interventions.
The era of total dependence of nurses’ education and practice on the medical model neg-
lected the focus on the patient as a human being and on the environment as vital in the care of ill
people and the reparative process. This is well described by Norris (1982):
Nursing knowledge, because of nurses’ close alliance with medicine, has been traditionally
oriented to symptoms. Symptoms represent processes whose end products are failure of bod-
ily systems unless there is medical intervention. It follows that much of the nursing assess-
ment has arisen out of a process of identifying a problem and tracing it back into the medical
model where it is considered from the point of view of failure of the human organism. Much
of nursing intervention has emerged from attempts to assist in or complement medical inter-
vention and to provide measures that reduce the discomfort caused by the pathology or med-
ical treatment of it. (Norris, 1982, p. 405)
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CHAPTER 7 Sources, Resources, and Paradoxes for Theory 117
The dependence on the biomedical model has resulted in conceptualizing and developing ideas
emanating from and influencing medical care rather than nursing care (Allen and Hall, 1988). The
biomedical model (or paradigm) as a source for knowledge development in nursing has regained
prominence with the increasing number of nurse practitioners who use it extensively in their prac-
tice. In addition, questions driven by the advanced practice roles of nurses that combine the nurse
practitioner and the clinical specialist roles require integration of different paradigms to answer them
fully. The challenge that will continue to face nursing in the future is to develop theories that reflect
the integration among focus on the patient, environment, and the biomedical models of care.
Nurses’ Experiences
Some of nursing care knowledge has been based on personal and group experiences, and has
been transmitted from generation to generation through apprenticeship, teaching, or textbooks.
Ideas generated from experiences of comforting, caring, changing the environment, preparing for
hospitalization, preparing for surgery, or preparing for discharge; ideas related to a sense of timing
of when to help patients and when not to help patients; and properties and types of interactions are
the kinds of ideas that could be developed further into theories. Experiences of patients with cer-
tain diseases and surgeries were exchanged between the seasoned and the novice, the educator and
the student, and the nurse and a colleague. These rich experiences were not articulated into con-
ceptual entities that would have made them more amenable to wider communication, generaliza-
tion, refinement, or testing. To “know” from individual experience permits knowledge that is
influenced by personal beliefs, personal convictions, and personal experiences to be shared.
It is possible that knowing becomes knowing through a method of “tenacity,” in which people
hold firmly to their beliefs because of psychological attachment to the thing they presume to know.
In the case of nurses, knowing may be repeated experiences, and nurses therefore may refuse to
modify their beliefs in the face of new evidence. Fixed beliefs emanating from experiences are then
communicated as knowledge through the method of “authority” (Pierce, cited in Kerlinger, 1964,
pp. 6–8). To frame ideas and relationships as “authoritative” dictates a decrease in the potential of
progress by development or refinement. To develop ideas and relationships as theories allows for
further exploration. To speak only from personal experience in patient care is not a scientific sin;
but to generalize, to transmit from generation to generation these limited ideas based on personal
idiosyncrasies and individual differences, stifles progress in the discipline, limits options for patient
care to individuals, and limits experience.
To use experience, however, as a source of ideas to develop concepts and consider relation-
ships prepares those ideas for further exploration, testing, generalization, and for being challenged
and modified. Experiences, when communicated as personal experiences and on an individual
basis, do not have the same power of explanation, description, or prediction as experiences that
have been raised to a higher level of abstraction and then commitment. Caring for wounds in a cer-
tain way, based on one’s personal experience, can be an impetus for developing wound-care the-
ory that would describe the wounds, the different modes of caring for them, variables to consider,
the proper environment to help the healing process, the materials to use, the outcomes expected,
and the relationship among all these.
Experiential accounts of caring have been published over the years in clinical journals (Agan,
1987; Moch, 1990; Rew, 1988). These accounts have been useful for clinicians but ignored by sci-
entists, who have claimed a scientific discipline has no place for experiential knowledge. Writings
by nurse scholars in the late 1970s and in the 1980s have supported the significance of clinicians’
experiences as sources of knowledge. Carper (1978) demonstrated that the nursing literature
contains four modes of knowledge, only one of which is empirical; others are aesthetic, personal,
and ethical. Benner (1983) acknowledged the clinical know-how of expert nurses. Nurses’ expe-
riences and nursing practice were identified as sources for the discipline’s theories and its knowl-
edge (Meleis, 1985). Lindsay and Smith (2003) proposed that an approach to create
research-based nursing education is to have faculty and students think and write narratively about
their educational experiences. Nurses’ experiences emerged as a source of practice knowledge in
two large studies that queried staff nurses in Canadian Hospitals (Estabrooks, Rutakumwa, O’Leary,
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118 PART THREE Our Discipline and Its Structure
Profetto–McGrath, et al., 2005). Similar findings about the importance of personal practice
knowledge in nursing practice are reported in other studies (an example is Mantzoukas and Jasper,
[2008]). Even when nurses are functioning from a context of a medical model, how that model is
modified to become congruent with nursing’s mission and goals is a significant question that con-
tinues to merit description and investigation.
Extant nursing practice and nursing experience as sources of phenomena for theoretical nurs-
ing are different but related. For example, comfort may be described and explained as perceived
and experienced by different client populations under different sets of circumstances, resulting in
a theory of comfort that addresses the dimensions of comfort, the conditions under which comfort
is needed and experienced. The source of this theory is extant nursing practice, through nurses
promoting comfort to the different populations, and nursing experience, through nurses observing
the different populations’ comfort responses to the care delivered. Both sources may increase the
scope and significance of the theory.
Roles
All the sources of ideas mentioned previously evolved from practice and pertained to prac-
tice. Later in the history of nursing, interest shifted to role preparation, which coincided with the
1950s’ conceptualization of nursing as a set of functions. The pursuit of ideas for the preparation
of nurses for such functional roles as teachers, administrators, consultants, and clinical specialists
prompted a shift to disciplines such as education and business administration. Functions within
the context of nursing, but derived from theories of other disciplines, became the impetus for
investigations and explorations.
Ideas evolving into theoretical propositions were those related to how to prepare for different
roles, the effects of different types of institutional organizations, and the different types and levels
of nursing care delivered on nursing personnel outcomes. Occasionally, patient outcomes were
considered, but even then, patient outcomes that were more congruent with other paradigms (e.g.,
conceptualization of team nursing, nurse satisfaction, and patient satisfaction) were ideas taken
from the time from which nurses conceptualized nursing. Concepts that emanated from the role
preparation paradigm described and predicted effective and efficient functioning as a teacher,
administrator, or consultant. Role preparation was not conducive to theoretical development of the
discipline; it provided, however, a functional framework for graduate education. Nevertheless, as
role preparation in nursing continues to occupy the scholars in nursing, processes and content of
caring by nurse practitioners and nurse anesthetists are a rich source for theory development.
Basic Science
Nurses have relied heavily on paradigms from other fields and disciplines, in addition to the
medical and role-preparation paradigms. The education of nurses at the doctoral level in the fields
of sociology, psychology, anthropology, and physiology has prompted a healthy proliferation of
ideas. A kind of cross-pollination occurred when systems, adaptation, and stress paradigms, among
others, were modified to define and explain nursing phenomena. For example, Peplau (1952) devel-
oped an interpersonal theory of nursing using ideas from a psychoanalytical paradigm. Another
example is the use of Piaget’s theory as a source for developing theories in nursing (Maier, 1969).
Because much of nursing care is predicated on establishing a relationship with patients and
on interaction, it becomes important to assess the cognitive abilities of patients so that appropriate
and congruent messages (e.g., patient education) can be delivered. Whereas Piaget’s work pro-
vided the assumptions and major concepts, propositions specific to nursing care will necessitate
concept refinement and derivation. They will also necessitate consideration of variables that may
influence cognitive abilities in health care situations. Examples within an area that may be the
impetus for theory development based on Piaget (1971) are:
• Changes in cognition, before, during, and after nursing or medical interventions, or as a
result of aging
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CHAPTER 7 Sources, Resources, and Paradoxes for Theory 119
• Effect of intrusiveness of procedures on altered cognition and on patient responses
• Clinical therapeutics to deal with the responses in relation to the cognitive level
• Clinical therapeutics to change the responses in relation to the cognitive level
• Confusion and sundowning post-surgery or for patients with dementia
Therefore, a theory of the cognitive functioning of adults in acute situations may result from a
developmental paradigm (Maier, 1969), but it addresses nursing by explaining, describing, and
predicting nursing phenomena or prescribing interventions for clinical responses related to these
phenomena, such as responses to health/illness situations.
Examples of theories deductively evolving from other paradigms but attempting to address
nursing phenomena and nursing problems are Johnson’s theory (based on a systems paradigm),
Roy’s theory (based on adaptation, systems, and interaction theory), and Rogers’ theory (using
systems and developmental paradigms) (see Chapters 11 through 13).
Ideal Nursing Practice
One other source of ideas for nursing theories has been what Barnum (1998) called the
“ought-to-be” nursing practice, as opposed to the as-is or extant nursing practice. Some theorists
who have developed theories based on ideal or ought-to-be nursing practice did not use a discov-
ery method—that is, by observing, experiencing, categorizing, and analyzing reality. Instead, they
reconstructed reality; they invented what reality should be and how nurses ought to deal with it.
When Johnson (1968a) conceptualized a person as a system of behavior and conceptualized
assessment as a process for identifying behaviors, sets, and goals of subsystems, no nurses were
assessing reality as such. It was her mental image of what nursing could and should be. A person
as an energy field was not a focus of nursing action, and a nurse was not a temporary self-care
agent. However, the conceptual images of nursing dealing with a person as an energy field and a
nurse as a temporary self-care agent were created by Rogers and Orem, respectively. These nurses
combined nonnursing theories, not with actual nursing but with imaginary nursing, or perhaps
with nursing as practiced by the few.
Although they were visionaries in conceptualization, this kind of invention has been prob-
lematical for practicing nurses for two decades and may have slowed down the further develop-
ment and refinement of existing theories and the development of other significant ideas into
theories. (Theories developed in the late 1950s and early 1960s were fully acknowledged for dis-
cussion and refinement in the 1980s.) Nurses in practice could not reconcile the images of the few
with the practice of the many. Theorizing was linked with ideal (albeit nonexisting) practice, and
the usefulness of a theory for practice was severely questioned. Both areas, practice and theory,
were pushed further and further apart.
The Nursing Process
The process of assessment, diagnosis, intervention, and evaluation is another source of ideas
for nursing theory. Interest in the nursing process has resulted in numerous conceptualizations of
process in nurse–patient relationships and of process in decision-making in patient care. Exam-
ples are Peplau’s, Orlando’s, Wiedenbach’s, and Travelbee’s conceptualizations of components of
the nurse–patient interaction process. Other early examples are the Harms and McDonald (1966)
and Abdellah, Beland, Martin, and Matheney (1961) conceptualizations of the decision-making
process. Ideas related to problem solving, priority setting, and decision making evolved from a
focus on the nursing process and from questions such as: What are the best approaches to identify
needs of patients and to deliver nursing therapeutics? What are the similarities and differences
between nursing process, clinical judgment process, and other decision-making processes?
(Duldt, 1995; Gordon, Murphy, Candee, and Hiltunen, 1994). Frisch (1994) asked the question of
whether we need the nursing process, and answered by proposing it as the foundation for practice
and teaching to explain and document care.
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120 PART THREE Our Discipline and Its Structure
CLASSIFICATIONS OF NURSING DIAGNOSIS, NURSING INTERVENTIONS,
AND DECISION MAKING
Ideas for theory may emanate from classification systems such as those developed for nursing diag-
nosis and nursing interventions. Nursing diagnoses are defined as labels given to problems that fall
within the domain of nursing. “It is a concise summary, a conceptual statement of the client’s health
status” (Kim and Moritz, 1982, p. 84). A diagnosis states a conclusion that is based on some order
and pattern that the diagnostician arrived at through nursing investigation (Durand and Prince,
1966). It incorporates a nurse’s judgment. The process of developing theories through the use of
nursing diagnosis is in agreement with stages in theory development, beginning from concepts.
Jacox identified the first step in theory development as a period of specifying, defining, and
classifying concepts used in describing the phenomena of the field (Jacox, 1974, p. 5). Therefore,
if there is agreement that a first step in theory development is a period of specifying and classify-
ing, and if practice is the arena for theory development, then indeed nursing diagnosis provides a
springboard for theory development. Dickoff, James, and Wiedenbach (1968) would classify the
result of the process of classifying diagnosis as a step toward a first-level theory. However, label-
ing without description of what is labeled and without propositions for testing is in itself not a the-
ory; it is only a step toward building theories.
A classification system for nursing diagnosis began with the efforts of the St. Louis University
School of Nursing, which sponsored the first conference on diagnosis in 1976 (Gebbie, 1976). The
nurses who participated made a decision that theory development in nursing could not begin without
the development of and agreement on its terminology. The work of nurses who participated in sev-
eral of these nursing diagnosis conferences is inspiring and should continue to be the impetus for
ideas that could be developed further into theories (Moorhead, Head, Johnson, and Maas, 1998).
A warning, however, is in order. The taxonomy that evolved out of these three decades of
work resulted in a list of diagnoses that some may consider esoteric in language and nonrepresen-
tative of the complexity of human beings. They are nontheoretical or do not emanate from a coher-
ent theoretical perspective, and there is no evidence that they have contributed to clarifying the
nursing mission or to improving communication among nurses and with the rest of the health care
team (Gordon, Sweeny, and McKeehan, 1980; Shamansky and Yanni, 1983). Nursing diagnoses
are only meaningful if we look at diagnosis as a concept denoting a phenomenon (Kritek, 1978).
Then, questions arise such as:
• When does the phenomenon occur?
• Why does it occur?
• How do we deal with it?
• How do we prevent it?
• What other conditions occur at the same time?
These questions help in developing theories based on nursing diagnoses. In addition, the
extensive reviews of research related to nursing diagnosis (e.g., Gordon, 1985; Kim, 1989) can be
the impetus for the development and validation of concepts, as well as for furthering theoretical
synthesis (e.g., Burns, Archbold, Stewart, and Shelton, 1993; Dougherty, Jankin, Lunney, and
Whitley, 1993; Grant, Kinney, and Guzzetta, 1990). How nursing diagnosis and nursing theory are
related should continue to be the subject of exploration (Frisch and Kelley, 2002).
Another taxonomy was developed during the early 1990s, which could also be used as a
source for theory development, and this is the one related to nursing therapeutics or nursing inter-
ventions. Efforts to identify, label, describe, and categorize the interventions and therapeutics that
nurses use in their practice resulted in a three-level taxonomy of nursing interventions or thera-
peutics (Iowa Intervention Project, 1993). Nursing therapeutics are defined as:
singular or multiple interventions (actions) by the nurse to alter life processes, life patterns,
functional health patterns, and responses in order to alter the health–illness trajectory of a per-
son. (Eisenhauer, 1994)
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CHAPTER 7 Sources, Resources, and Paradoxes for Theory 121
The typology was created to reflect the level of alteration related to patient responses, pat-
terns, or life processes. The Iowa Intervention Project (1993, 1995) resulted in a three-level taxon-
omy of nursing interventions, with the top level containing six domains, the second level
containing 26 classes, and the third level consisting of 357 interventions. There is a pattern of
increasing numbers of interventions in each subsequent publication, based on ongoing validation
and coding studies.
Another classification system that is also an important source for theory development is that
of clinical decision making (Thompson, 1999). To be able to compare and contrast outcomes of
patient care, it is important to assess and evaluate processes of clinical judgment. Theories of deci-
sion processes that are more congruent with the nursing perspective could be developed either
through observing extant practice of nursing or from decision-making theories in other disci-
plines. Buckingham and Adams (2000) investigated issues in applying a range of theories and pro-
posed a more unifying framework that incorporates intuitive and scientific principles.
All these classification systems were driven by nursing practice, and if considered as tenta-
tive, dynamic, and evolving, could stimulate growth in the knowledge base for the discipline of
nursing and inspire continuous validation (Grobe, 1990; Fagerstrom, Rainio, Rauhala, and
Nojonen, 2000). However, if they are perceived and used in practice as static, procedural, and ter-
minal, they may become a constraint to the development of the theoretical aspects of the discipline
of nursing.
Concepts Clarified and Classified
Delineated and described concepts central to the field of nursing, other than those dealing
with diagnosis and intervention, constitute another source of ideas for theory development. The
sources of knowledge discussed here are already-clarified concepts. As early as the 1980s, Norris
(1982) and others delineated and described 15 concepts that are significant in acute-care nursing.
Norris (1982) reviewed and considered common elements in the concepts and looked for an
umbrella concept under which she synthesized all classified concepts. Therefore, the concepts
comprised the source for the development of a construct, “basic physiological protection mecha-
nisms.” The new synthesis, with relationships among all delineated concepts and with a binding
label, underscores a new entity, a nursing perspective. This new synthesis allows for viewing each
of the clarified concepts (nausea, vomiting, morning sickness nausea without vomiting, thirst,
hunger, insomnia, fatigue, immobility, chilling, itching, disorientation, bed sores, diarrhea, consti-
pation, flatulence, urinary frequency, and perspiration) as a “functional behavioral response that
attempts to remove threat” by sounding an alarm or an all-out bulletin announcing some aspect of
the law of dynamic homeostasis. Each of the concepts has a protective function. Emotions after
responding to protective warnings can be observed and delineated. For example, after vomiting
there is a great sense of relief. Some common attributes can bind groups of these responses (e.g.,
restlessness and insomnia have the common attribute of increased vigilance). With identification
of assumptions, linkages, nursing population, types of nursing therapeutics, and nurses’ actions, a
theory of protection evolved.
Hunt (2002) used existing multiconcepts to describe the effects of caregiving to propose a
synthesis of negative and positive outcomes that could promote a nurse’s abilities to better meet
the needs of caregivers and the goals of caring for them. The plethora of concepts that are devel-
oped and communicated in the literature makes them more acceptable and feasible to others to
further refine and develop them.
These clarified concepts are considered sources of ideas for synthesis and further development
of theory; this process of delineating and describing concepts began in the 1960s and 1970s (Byrne
and Thompson, 1978; Carlson and Blackwell, 1978; Kintzel, 1971; Zderad and Belcher, 1968).
However, from the 1980s through the turn of the 21st century, major contributions were made to the
development of the discipline through concept development. In addition to the continuing clarifica-
tion and development of concepts, a second generation of concept reclarification occurred through
integrative analyses of literature. An example is Canales’ (2010) 10-year analysis and synthesis of
the concept of “othering.” Reviewing literature, synthesizing findings, and developing integrative
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122 PART THREE Our Discipline and Its Structure
conclusions allows the development of more coherent programs of research (an example is the con-
cept of quality of life [Register and Herman, 2010]). See Chapter 15 for an extensive discussion of
concept development.
Nursing Research and Nursing Theory
A new source of ideas for further development has been available to nurses since the early
1950s. Research already completed and theory already developed are two sources of ideas for refine-
ment and further development (Evers, 2003). Some examples are Barnard’s (1980) research on stim-
ulation and development of infants, potentially leading to a set of systematic and coherent
propositions, and Lindeman’s (1980) work on preoperative teaching, which, together with Johnson’s
(1972) work, has the potential for becoming a coherent set of propositions about anticipatory
guidance. Reviews of research findings related to central nursing concepts or phenomena are sig-
nificant sources for the development of nursing theory (e.g., those published in Annual Review of
Nursing Research).
Each of the existing nursing theories is a potential source of ideas for further theorizing. For
example, Levine stated that she will develop two theories that she calls “therapeutic intention and
redundancy.” These theories emanate from her existing nursing theory (Fawcett, 1989, p. 156). A
review of doctoral dissertations from 2000–2004 shows that about 27% of the research used nurs-
ing theories as a source for the studies, and another 27% of the studies were a source for theory
generation (Spear, 2007).
Combined Sources of Ideas
The complexity and contextuality of nursing practice requires a multiplicity of sources for its
theories. These sources include clinicians who encounter phenomena that have not been expli-
cated before, researchers who encounter relationships that have not been accounted for in previ-
ously developed theories, historians who get a new insight into the development of nursing
knowledge, and philosophers who question some of the agreed-on assumptions or who uncover an
implicit assumption; all give significant impetus to conceptualization and theorizing. Theory
development can proceed from any of those vantage points.
RESOURCES FOR THEORY DEVELOPMENT
The sources for theory development are only one essential component in the development of the-
ory. Resources are the second major component. Resources for the theoretical development of the
discipline are the nurses themselves and the environment that nurtures and supports such develop-
ment. Each resource is discussed here.
Being Theoretical
Theoretical thinking, theoretical approaches to viewing situations, and the development of a
theoretical identity are essential in engaging in the theoretical development of the discipline. Cer-
tain myths surround theory development. Some of these are related to who could and should
develop theories. One of these myths is that “idea people” are “ivory-tower types of individuals,”
that only extremely intelligent people can develop theories. Another myth delineates the differ-
ences and the contrast between theoreticians and practitioners; the former cannot practice and the
latter cannot theorize.
These myths have greatly influenced the process of conceptualizing in nursing. The intent
of this chapter is to demonstrate that, even if the myths were true at one time, perpetuating them
now does not promote the discipline of nursing’s ability to influence health care policies or,
more importantly, the quality of patient care outcomes. There are no theories without ideas, but
there are ideas without theories. Theories evolve from ideas, and ideas evolve from hunches,
personal experiences, insights, inspirations, intuition, and others’ work and experiences. New
ideas could be based on the discovery of a new phenomenon, the invention of a new theoretical
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CHAPTER 7 Sources, Resources, and Paradoxes for Theory 123
concept, reintegration of old concepts with new realities, a reformulation of an existing idea, or a
new way of organizing old concepts. New ideas also may evolve from asking new questions or
even from asking old questions but finding that the old answers no longer provide the solutions.
Theorizing is a process of deconstructing and constructing undertaken by critical thinkers through
critical scholarship (Holmes, 2002).
Although ideas abound, some of which drive theory development, ten conditions may assist
in the development of theories, and each of these conditions may be subjected to further study to
support or refute their importance in generating theory.
1. An idea is usually generated by one person, although others may help to nourish it, oth-
ers may be triggered to follow through, or even two people on opposite sides of the
globe may get the same idea simultaneously; however, for each one, the “aha” is a per-
sonal matter (Reynolds, 1971). Therefore, a creative person should have the capacity to
be alone to develop inner resources (Arietti, 1976).
2. Intelligence and intellectual abilities are necessary but not sufficient conditions for
developing theoretical thinking (Reynolds, 1971; Roe, 1951, 1963). Theoretical thinkers
also need creativity and persistence.
3. Theoretical thinkers have an extra sense by which they can differentiate between a good
and a bad idea; therefore, they do not spin their wheels on something that will not mate-
rialize or on an idea that has no potential for development (Reynolds, 1971).
4. They have thorough knowledge of the field in which their idea may fit (Meleis and May,
1981). They know the accepted notions surrounding their ideas, and they have a sense of
history and context; otherwise, they would not be able to tell whether their discovery, inven-
tion, or conceptualization is new or whether they have the context within which to place their
ideas. “In short, they know when a good idea is a new idea” (Reynolds, 1971, p. 152).
5. These individuals are not particularly committed to all the ideas of the field or to the
ideas held by the scholarly community. They are open to new ideas and are able to stand
independently and apart from others (Roe, 1951, 1963). They stand alone to support
their own convictions (Armiger, 1974).
6. They are in touch with the phenomenon in some way. They are either deeply engrossed
in a clinical area, are committed to researching a particular phenomenon, are trying to
synthesize some of the concepts in the field, or are involved in an in-depth study of a
particular theory. “No matter what the endeavor, the individuals are deeply engrossed in
the subject matter, so deeply that an intuitive or incommunicable organization of new
concepts and their relationships may develop a feeling that later takes form as a theory”
(Reynolds, 1971, p. 153).
7. Developers of ideas are willing to take risks.
8. A person whose ideas go beyond the initial idea stage possesses a sense of persistence
to work, self-discipline, and an ability for developing a sense of satisfaction that goes
with the hard work (Arietti, 1976; Roe, 1951, 1963).
9. Ideas flourish and develop when a person is able to articulate and communicate them to
others. Communication of ideas allows for a healthy debate and a healthy critique, both
of which are essential for the continuous clarification and refinement of ideas. Fear of
“idea snatching” may have prevented some good ideas from being communicated and
therefore may have kept them from the potential of further development.
10. Whether aware of it or not, a person with an idea that is potentially productive may have
an intuitive capability, and, furthermore, accepts intuition as a significant asset in the
development of ideas. To develop that sense, a person needs periods of inactivity to day-
dream, to think freely with no specific structure, and also to be able to suspend judg-
ment until ideas develop (Arietti, 1976). Finally, a person whose ideas go far is usually a
person with a good sense of timing.
Nurses, wherever they are and in whichever settings, are observing new phenomena, are
articulating significant questions and, moreover, may have developed their own personal theories
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124 PART THREE Our Discipline and Its Structure
about patient care. Some may not have been aware of the significance or the timeliness of the phe-
nomena they observed or the relationships or hunches they developed; or, they may have not dis-
cussed or communicated these hunches to others. Awareness, reflection, and/or discussion of
these initial hunches allows them to grow, flourish, and attain more potential for a systematic the-
oretical development. For example, the observations (or intuition, or both) of a nurse in a kidney
dialysis unit who is consistently able to decide, within a few minutes of interaction with patients
who come in weekly for dialysis, whether that patient’s dialysis will be completed efficiently and
effectively, without complication, could evolve into the articulation of antecedent variables and
outcome criteria that are more predictive. This nurse, then, is able to formulate questions about an
important phenomenon and may be able to offer a conceptualization of an important aspect of
patient care. Other conditions for theory development, such as communication of this clinical
knowledge, form the next step to further development of these conceptual ideas. Clinicians with
such embodied clinical knowledge need to be provided with opportunities to further develop these
ideas through collaboration with others who are experienced in the development of theories per-
taining to practice.
Conditions for theory development, therefore, are: the presence of a cadre of individuals who
are firm believers in the significance of theoretical thinking for nursing practice and who have and
are provided with the conditions outlined in the preceding text. In addition, they need the avail-
ability of a theoretically supportive environment.
Theoretically Supportive Environment
Even if a person has the characteristics listed previously, she may not be able to engage in the
activities and processes inherent in theoretical reflection and development without an intellectually
nurturing environment that acknowledges the strength and weakness of the practice environment
(Nelson, Gordon, and McGillian, 2002). An intellectually nurturing environment is one that values
theoretical nursing, allows time to clarify values, time to articulate and relate ideas, and time to
question. It is an environment that permits ambiguity, that does not press for immediate solutions,
that allows dissension and does not press for consensus, and that permits philosophical discourse
(Jennings and Meleis, 1988; Meleis and Jennings, 1989; Meleis and Price, 1988). What is needed is
an environment that acknowledges theoretical abilities and rewards theoretical thinking.
Strategies to develop such environments could evolve from the nature of nursing to comple-
ment its natural activities. A team report, for example, could be the medium for questioning and
reflecting on clinical phenomena. Members of an administrative team may devote some time to
discussing a pressing problem theoretically and from different perspectives. Goals related to theo-
retical nursing are somewhat different from those related to immediate problem solving. Goals
related to theoretical nursing are the development of a concept or the analysis of a theoretical per-
spective. Problem solving, however, focuses on resolving a problem. Creating a supportive envi-
ronment should not be analogous to creating an environment that is artificial or foreign to an
institution; it should fit within an institution’s mission and goals and within its daily experiences
and functions.
IDENTIFYING DOMAIN PARADOXES
Another condition for theoretical development in a discipline is to identify, acknowledge, and
accept or transcend the paradoxes that may be related to theory development. Living with para-
doxes in a discipline is as effective in the development of its theories as confronting the paradoxes,
making a choice, and then moving on with the business of developing the discipline. What is not
effective is to pretend there is only one view or to be immobilized by the paradox, and to make
resolving it the focus rather than the means.
A commitment to theory development was made in nursing by the American Nursing Associ-
ation in the mid-1960s. However, the debates related to nursing theory may have delayed the
process. Much has been written and debated about nursing theory and about the differences for
practice between nursing theories and nonnursing theories. Other debates centered around
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CHAPTER 7 Sources, Resources, and Paradoxes for Theory 125
whether nursing needs theory in nursing, of nursing, or for nursing. Others developed a rather
strong case for the lack of need of practice theory. Still others showed that nurses borrow all the-
ory. Another group of debaters demonstrated that other practice fields have no theory of their own,
and therefore nursing’s quest for theories is an unwarranted one.
Theory is not a status symbol or a special honorary card that nursing needs to remain in the
halls of academia or to achieve professional status. Theory provides the mechanism from which
we can organize our observations, focus our inquiry, and communicate our findings. Theory helps
to explain, describe, and predict the range of phenomena of interest to nurses that are central in
meeting the identified goals and in highlighting gaps in our knowledge. Instead of getting on with
the business of developing theories related to our substantive area of practice and advancing nurs-
ing knowledge, a good part of two decades (1960–1980) has been spent debating whether nurses
are capable of developing theories, whether they should develop theories, and whether theories
are even necessary to nursing. On the whole, the theories that were developed in nursing have not
been developed further or refined. (There are some exceptions; for example, Roy has been sys-
tematic in developing her theory and in proposing refinements and theoretical propositions. See
Chapter 13 for an analysis of Roy’s ideas and for citations.)
In general, theories have become subjects of debate about whether they are philosophies, the-
ories, concepts, metaparadigms, paradigms, grand theories, or, even worse, not theories at all.
From all these debates, more concepts have evolved to describe theoretical thinking in nursing,
such as conceptual frameworks, theoretical models, and conceptual models. This evolution only
managed to add considerably to the confusion of nurses. The muddle may have delayed the sea-
soned theoreticians and researchers in their attempts at knowledge development; it has kept the
novice from getting involved in the process of theory building; it has confused those outside the
discipline, who have not understood what nurses are quibbling about; and it has stood in the way
of nurses understanding, contributing to, and improving patient care.
In this section, historical examples of the confusion in the discipline, as related to its theoret-
ical development, are identified and discussed. Only two of the paradoxes that have been the sub-
ject of debates in the past are analyzed. These paradoxes were selected for three reasons: they
transcend time; their influence on the level of development of theoretical nursing during the 1970s
to 1990s is hypothesized to be profound; and understanding these two paradoxes through careful
analyses can be useful for analyzing and understanding other contemporary and future paradoxes.
These paradoxes symbolize a significant period in the development of the theoretical aspects of
the nursing discipline. The full meanings of these debates and their roles in enhancing or con-
straining the intellectual environment in the discipline have not yet been fully extracted. By
reflecting on the meanings of each side of the debates, students of theory and theory development
may be able to develop some insights and some visions about forces and constraints in theory
development.
Conceptual Models Versus Theory
In one of the first theory classes in the United States, taught at the University of California,
Los Angeles in the late 1960s, Dorothy Johnson classified the conceptualizations of nursing that
existed at that time as nursing models. It appears that, since then, terms such as models, frame-
works, or theories have been used freely and interchangeably to refer to any conceptualization of
nursing reality. An example of a common usage of models is when one is used to denote that the
study of a system B is based on the study of a system A, and that all parts of system B correspond
to all parts of system A. Then, it is said that B is modeled after A, but it does not say that any
causal relationship exists between A and B. It only means that some of system A’s properties are
in system B. It also means that the properties of system B that are different from system A’s prop-
erties need to be identified. Therefore, modeling denotes similarities in most of the pattern and
order and in some of the properties. In other words, “when one system is a model of another, they
resemble one another in form and not in content” (Kaplan, 1964, p. 263).
Although this is the common use, there are different types of models. The physical model
duplicates the form and structure but differs in scale; the miniature train and the baby doll who
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126 PART THREE Our Discipline and Its Structure
cries, laughs, and sucks are examples of physical models. They are replicas; in other words, laws
that govern the original are obeyed by the model. The semantic model is built by using similar sym-
bols and could be called a conceptual analogue. We use semantic models when we reduce our
hypothesis to statistical symbols for the purpose of analysis. A widely used model in nursing is the
formal model. To develop formal models, we resort to deductive logic, deducing from the original
theory by using the central components and crucial relationships as a model for data gathering. For-
mal models exhibit the same properties in components and the same structure, but the context may
be different. For example, we may use an epidemiologic theory of disease transmission with its com-
ponents of incubation, contagiousness, and quarantine to describe how nursing theories are transmit-
ted. Whereas correspondence in the formal model is theoretical, abstract correspondence exists
between theoretical ideas and empirical observations in the interpretive model. Data may be inter-
preted using an old theory. The model for interpretation combines both data and the old theory.
The notion that nursing conceptualizations are conceptual models evolved out of ideas repre-
senting two different assumptions. In the nursing theory course developed by Johnson in the
1960s, the idea that nursing conceptualizations were modeled after guiding paradigms (systems,
adaptation, developmental, and symbolic interaction) was introduced. Other writings and analyses
were based on the same premise of guiding paradigms. The second idea, that of models, was
based on interpretive models and assumed that nursing is the reality, and that each of the existing
conceptualizations model that reality at different levels of isomorphism. Early designations of
nursing thought correspond to the first idea, that conceptualizations are formally modeled after
other conceptual schemata (Riehl and Roy, 1974), and later designations correspond to the second
idea, that conceptualizations are based on interpretive models (Fawcett, 1995; Fitzpatrick and
Whall, 1989).
Use of models also differs in another respect. In some usage, models correspond more to
reality: they are less abstract than theories; they contain all variables of the subject matter; and
they describe reality more fully. Theories describe fewer variables and are more abstract, but they
also correspond more or less to reality (Kaplan, 1964). Others considered models as simplified
forms of reality. Chin (1961) defined model as “a constructed simplification of some part of real-
ity that retains only those features regarded as essential for relating similar processes whenever
and wherever they occur” (p. 201).
Conceptual models and theories have been used synonymously (Dickoff and James, 1968), or
definitions for one were used for the other: a set of concepts that are interrelated into a coherent
whole and a set of propositions. Johnson (1968a) viewed a model as an “invention of the mind for a
purpose” that “is drawn from reality and pertains to reality, but it does not constitute reality” (p. 2).
Both sets of definitions could be used to define one or the other; that is, conceptual framework or
theory.
Further confusion has arisen because of other interchangeable terms. Conceptual frameworks
have been used by some interchangeably with conceptual models and by others interchangeably
with theory. Fawcett (1989), among others, dismissed the matter by equating conceptual frame-
work with conceptual model and blamed the difference on semantics. Dickoff and James (1968)
defined theory as a mental image being invented for the purpose of describing, relating, and pre-
dicting a desired situation. To them, theories are conceptual frameworks; they do not differentiate
between the two.
Some attempts have been made to differentiate between theory and conceptual models on
such criteria as level of abstraction, degree of explication, level of specificity, types of linkage, and
degree to which concepts and assumptions are interdefined (Fawcett, 1989; Fitzpatrick and Whall,
1989; Klein and Hill, 1972, cited in Rodman, 1980). They argued that conceptual frameworks (or
models, as they are used interchangeably) are more abstract than theories. They represent a global
view of a field—its main concepts and propositions—and therefore provide the blueprint for prac-
tice, education, and research (Johnson, 1968a).
Whether conceptual frameworks are necessary steps in the process of developing theories has
also been debated. Some contend that the conceptual framework is a stepping stone toward theory
development (Hill and Hansen, 1960; Nye and Berardo, 1966), a view that has been adopted by
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CHAPTER 7 Sources, Resources, and Paradoxes for Theory 127
some in nursing (Fawcett, 2005). Others question the necessity of conceptual frameworks for
development of theory and argue that conceptual frameworks are neither necessary steps nor
likely to promote or hinder theory development (Rodman, 1980).
The interchangeable use of the different concepts such as conceptual frameworks, models,
and theories to describe the same thing has been a problem to the pure semanticists in the field.
The attempt to differentiate between them has frequently taken on the dimension of splitting hairs
and has only added to the confusion. It is just such confusion that may have contributed to the
slow progress and, at times, stilted theory development in nursing and has led to an almost exclu-
sive preoccupation with method and process rather than content and consequences. Instead of
addressing the central issues in providing quality care to clients, we have had to debate and defend
the methodology for theory development. Theorizing is a painstakingly long process, the results
of which may be minimized by relegating them to the level of “it is only a conceptual framework.”
This, in itself, may decrease the impact of the conceptualizations and may make the framework
(or the theoretical model) less significant. The discipline using only conceptual frameworks tends
to be regarded as pretheoretical and, as a result, nursing’s contribution to knowledge about patient
care processes and outcomes are minimized.
There are other disadvantages to the preference of using conceptual frameworks and models
when the use of theory would have been much clearer. One such disadvantage could be under-
stood by examining analogous situations—one in which conceptual frameworks and models were
used before the use of theory, and one in which theories were used from the outset.
Sociology, particularly family sociology, has been unique in believing that conceptual mod-
els are distinct from theories. Sociologists have maintained, and nursing scholars have begun to
agree, that conceptual models provide a step in the development of theory. However, modern soci-
ologists have since questioned the wisdom of using a conceptual framework to denote the results
of theorizing. The skeptics in sociology have pointed out numerous examples in which conceptual
frameworks have resulted in theorizing that lacked specification and definition and the slow
process of developing propositions for testing (Rodman, 1980).
Conversely, physical and natural sciences do not use conceptual frameworks and models as
steps toward development of theory. Instead, they may use the term developing theory versus
tested theory. Notice that many theories (genetic fat theory of obesity, cholesterol theory of car-
diovascular diseases, psychoanalytical theory of neurosis) are at different levels of abstraction and
different levels of sophistication and have different scopes, different levels of clarity, and varying
degrees of understandable definitions; however, they are all called theories.
To be sure, some differences exist between models, conceptual frameworks, and theory. A
model has to model another entity, whereas a theory may or may not model other properties, struc-
tures, or functions. Conceptual frameworks may present a set of discrete concepts that are not as
interrelated and linked in sets of propositions as we expect from theory. However, this varies,
based on the level of development of the theory. Models tend to evoke the idea of empirical posi-
tivism mixed with rationalism as a guiding philosophy or a goal, rather than the tool it ought to be.
Functions attributed to models as frameworks or directives for the development of research,
frameworks for the generation of a hypothesis, guides for data collection, or depositories for
research findings or the further development of theory are the same functions attributed to theory.
It is not entirely clear that nursing theorists, in using different labels for their conceptualiza-
tions, have done so in any systematic way. For example, in a 1983 text, eight theorists used four
different labels when referring to their conceptualizations: theory, model, science, and paradigm
(Clements and Roberts, 1983). Others used theory to describe their conceptualizations, and then
developed and/or isolated one part of these conceptualizations and defined it as conceptual
frameworks and another part that was labeled a theory (King, 1995a, 1995b). The similarities
and the differences in degree of specificity, level of abstraction, and number of concepts and
propositions are not always consistent with the labels. One option for using these conceptualiza-
tions is to attach the label preferred by the theorist; another option is to use whatever label the
user prefers, as long as a definition and rationale are given. Some literature could always be
found to document any of the uses.
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128 PART THREE Our Discipline and Its Structure
The perspective of this text is to minimize the differences between conceptual models, frame-
works, and theories, and to relegate most of these differences to semantics and the confusion cre-
ated by the many nursing scientists and theoreticians who have been educated in a multitude of
fields. The rationale for taking this perspective is not to argue for a new position or to initiate a
debate, but rather to cast some doubt on the significance of the differences between theories and
conceptual models.
“Theory” is sufficient to describe the conceptualizations that have been proposed by our the-
orists. The three related aspects claimed to differentiate between theory and conceptual model are
definitions, interrelationships, and level of abstraction. The first two, which state that concepts
should be defined and interrelated, are considered in the present perspective as a necessity for both
theory and conceptual models. The third aspect, level of abstraction, remains an important consid-
eration. Because theories could be classified as grand, middle-range, or single domain, based on
the number of phenomena that the theory addresses, the number of propositions, and the opera-
tional level of the definitions, the present perspective proposes this schema to classify nursing the-
ory, rather than to relegate the classification system to such different labels as conceptual model,
framework, metaparadigm, paradigm, and theory.
Although this perspective is proposed to enhance a common language across disciplines and
to divert energy into development and progress in theoretical nursing rather than into circular
debates, the final choice of a label is a personal matter and depends on the purpose for which the
label is applied. Just as role theory has been proposed and used as a concept, a framework, a
model, or a theory in research, practice, and administration in a number of disciplines, and just as
the user may consider role theory from a cultural, structural, or intra-actionist perspective, nursing
theories could also be used in the same way. The manner and the goal of the utilization may help
determine the appropriate label.
Based on the perspective proposed here, nursing theory is defined as an articulated and com-
municated conceptualization of invented or discovered reality pertaining to nursing for the pur-
pose of describing, explaining, predicting, or prescribing nursing care. Nursing theory is
developed to answer central domain questions.
Nursing Theory Versus Borrowed Theory
Some old debates endure. Among them are the concerns and meaning of borrowed theories
(Fawcett, 2000). For some time now, nurses have been involved in a debate over the types of the-
ory that ought to be developed. They have taken either practice or basic theory positions. Each
side has developed a good case as to why one or the other type is possible. The significance of tak-
ing one or the other position lies in the idea that the practice theory position encourages forging
ahead with theory development, and the borrowed theory position discourages nurses from partic-
ipating in the seemingly futile attempt to develop theories, when theories that exist in other disci-
plines could easily be borrowed and used to explicate nursing phenomena.
The proponents and supporters of the development of practice theory in nursing (Dickoff et al.,
1968; Jacox, 1974; Johnson, 1968a; Wald and Leonard, 1964) view nursing theory as a conceptual
framework invented by the theorist for the ultimate purpose of creating situations to meet desired,
preferred end results. Therefore, the ultimate goal for theory development in nursing is to produce
a change in a nursing client or a nursing situation that is desired by the nurse or the client. Dickoff
and James (1968, p. 200) called this a situation-producing theory.
This is a fourth-level theory; theories at other levels are invented and articulated with the pur-
pose of ultimately leading to this level. The first level is factor isolating, a level where theories
help delineate and describe a phenomenon. The second level is a correlating theory, where factors
or concepts are related to depict theories, and the third level is a situation in which theories permit
prediction and allow the promotion or inhibition of nursing care. Each of these levels brings the
theorist closer to the goals of nursing that are demonstrated in prescriptive theories, or by the
situation-producing level of theory, the fourth level. The development of fourth-level theory is
congruent with the purpose of the profession, which ought to be action-oriented, as opposed to
only academically oriented. Nurses are shapers, not just observers, of reality.
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CHAPTER 7 Sources, Resources, and Paradoxes for Theory 129
The first-level theory, the factor-isolating theory, helps to articulate and label concepts. The
significance of this kind of theory is to enable one to refer back to those concepts that are
invented. Without a label, we have no concepts; without concepts, we have no relationships.
Labeling allows for the creation of conceptual entities that become the cornerstones for each
subsequent theory level. What Dickoff and James helped nurses to see was the significance of
this level of theory, in which they had been engaged long before they began to speak of theory
development.
Norris (1975), a “curious nurse clinician,” observed numerous incidents of restlessness and
noted that, although the term was frequently used in charting, it was not clear how restlessness
was identified, when it was identified, why it occurred, and what its consequences were. More
importantly, it was not clear what the nursing intervention should be. Norris’ conceptual work to
describe the phenomena and to label it as “Restlessness” is an excellent example of first-level the-
ory, according to Dickoff and James (1968). Other examples are Norbeck’s (1981) social support
concept, Norris’ (1982) classification of 15 concepts related to basic physiologic protection mech-
anisms, and my own (Meleis, 1975) work on role supplementation and role insufficiency.
Other nurses have proposed that nursing be organizing around concepts and, in so doing,
have provided nursing with numerous identified and labeled concepts (Carlson, 1970; Meltzer,
Abdellah, and Kitchell, 1969; Mitchell, 1973). Still others researched labeled concepts in search
of validity and reliability (Kim, 1980; Norbeck, 1981; Weiss, 1979). All these are considered first-
level theories, an end in their own right, and a beginning of other theory levels when considering
the definitions of Dickoff et al. (1968). (For a review of concept and theory development, see
Chapters 15 and 16.)
Once concepts are delineated and labeled, a theorist is ready to develop relationships. Corre-
lating theories result when theorists invent relationships between labeled concepts. These theories
are second-level, factor-relating theories. Relating preoperative teaching to postoperative behav-
ior, restless and muscular tension under different conditions, social support and health, or role
insufficiency and role supplementation could result in a factor-relating theory.
To predict postoperative behavior by varying preoperative teaching is an instance of third-
level, predictive theory. Third-level theory depicts and predicts, using a time reference. It is not
only relational—as is second-level theory—it is causal, as the theorist discovers that certain con-
ditions lead to others. In fact, all three levels incorporate a discovery of reality but not an invention
of reality. None of these three levels purports to change or influence reality. Rather, all lead to the
development of the most powerful of theories for a professional practice discipline, the situation-
producing theory, which is a fourth-level theory.
One of the significant differences between third- and fourth-level theories is in commitment
to a goal. A predictive theory describes what happens, such as postoperative behavior with differ-
ent strategies of preoperative teaching. In a fourth-level theory, there is a commitment to finding
out how it happened. An example could be that certain postoperative behavior is conceived as
appropriate behavior to bring about. The theory then proceeds to describe what to do preopera-
tively to bring about that desired behavior. This level of theory, therefore, has several essential
components: (1) an aim or goal specified by the theorist as desirable; (2) a prescription to bring
about the desired aim; and (3) a “survey list” to use in future prescriptions.
The survey list is designed to respond to six crucial questions for prescriptive theory:
1. Who or what performs the activity? (Agency)
2. Who or what is the recipient of the activity? (Patiency)
3. In what context is the activity performed? (Framework)
4. What is the end point of the activity? (Terminus)
5. What is the guiding procedure, technique, or protocol of the activity? (Procedure)
6. What is the energy source for the activity? (Dynamics) (Dickoff et al., 1968, p. 422)
The activities in a prescriptive theory expected to correspond to these questions are agency,
patiency, framework, terminus, procedure, and dynamics. Each incorporates internal and external
resources, as well as the potential for using theories from other disciplines if deemed useful.
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130 PART THREE Our Discipline and Its Structure
All survey questions are asked from the viewpoint of the goal of the activity and take the pre-
scription into consideration. It is assumed, and practice supports such assumption, that the agent
who is expected to perform the prescription does not always hold full jurisdiction over the pre-
scription. A combination of internal resources, such as certain skills, experiences, and techniques,
and external resources, such as policies and environment, specifies the agent. In some instances,
prescription may be delegated; in others, it may be relegated. A fourth-level theory should include
the kinds of agents who are expected to perform the prescription to bring about the desired end
result. The authors (Dickoff et al., 1968) proposed a broad concept of agency to include all those
who have the internal and external resources; they proposed a similar one about patiency. Nurses,
physicians, family members, visitors, and so on may be agents performing nursing activities
toward nursing goals. Therefore, a theory should specify all possible agents.
Patiency specifies the recipients of the prescriptions with whom agency interfaces for the
purpose of bringing about the desired goal. Patiency may designate sick or well people, interact-
ing or noninteracting things or people, animate or inanimate objects, recipients of activities done
by registered nurses, and activities done by people other than nurses, but all are bound together
by the goal of the activity. Patients are “interactors” with agency and others geared toward the
“activity of a desired kind and as possessed of a repertoire of capacities and limitations (much as
is the agent) to see a great range of latitude as to ways of producing desired outcomes” (Dickoff
et al., 1968).
The agent and the patient in a theory have to be specific in terms of the context within
which both occur. The context, called the framework by Dickoff and colleagues, requires that
the situation-producing theory specify all variables that should be considered to bring about the
desired goals through an activity produced by an agent and received by a patient. The end product
of the activity is the terminus, the situation to be produced.
A situation-producing theory also includes the pattern by which the activity is performed.
Procedure includes the steps to be taken to bring about the desired goal. Procedure, then, includes
the arena, the equipment, the type of charting, the type of follow-up, policies to govern it, timing,
and the rules-of-thumb governing activity. Although procedures could be detailed, most often they
are guidelines and safeguards.
Finally, a nursing theory of the situation-producing type should consider the aesthetic satis-
faction of performing the activity and the desire for self-esteem. These are motivating factors in
performing and sustaining activities to realize a nursing goal. The more developed the theory, the
more likely these two factors are considered. These factors are grouped under what Dickoff and
colleagues called the dynamics of the theory. When the dynamics are conceptualized adequately,
all factors that relate to the agent, such as education, reputation of institution, and rewards, or to
patients, such as insurance, will have to be considered in a situation-producing theory.
To understand, explain, predict, and prescribe nursing phenomena and nursing care, nurses
should develop practice theories that emanate from the discipline and guide the discipline’s
actions. There is one significant feature of theory in a practice discipline. Although descriptive,
relating, and predictive theories are equally important, nursing practice theory needs to strive for
prescriptive theory. Nurses may develop basic theories that describe discovered concepts, relation-
ships related to human beings, nursing situations, nurse–patient interactions, environments, or
health, but the ultimate goal is to develop theories to change situations. Therefore, theories that
stress change as their goal are practice theories.
Discovery charts a more probable process for the development of basic theories; conversely,
invention is a more probable goal of practice theory. Properties or dimensions of transitions, for
example, lend themselves to basic theory that describes and explains when transitions are healthy,
under what circumstances transitions in health and illness occur, what the consequences of vari-
ous types and levels of transitions are, and why the variability of consequences exists. What to do
to enhance smooth transitions for nursing clients, how to maintain the person–environment har-
mony in transition, and how to maintain homeostasis and enhance adjustment are questions that
lend themselves to practice theories.
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CHAPTER 7 Sources, Resources, and Paradoxes for Theory 131
Even when theories developed in other disciplines are used to explain nursing phenomena
and nursing problems, the new derivations and new syntheses make them nursing theories. The
concept “nursing” does not denote who developed it or where it is used; rather, it reflects the phe-
nomenon that the theory addresses. Nursing theories evolve out of the practice arena or anything
that pertains to the practice arena. They are then tested in research. Until the time-consuming job
of research is accomplished, the face validity of a theory, as it pertains to practice, should be
enough to allow the theory to be a blueprint for action.
Some challenge the notion that nursing should develop its theoretical base. Their arguments
are based on the premise that nursing is a practice discipline and that practice disciplines depend
on other disciplines for their theoretical underpinnings. Beckstrand (1978a, 1978b, 1980), for
example, contends that nursing is concerned with practice theory. For practice theory to be mean-
ingful, practice knowledge should be different from scientific and ethical knowledge. Beckstrand
then examined two aspects of practice knowledge, the knowledge of how to control and how to
make changes and the knowledge of what is morally good. She examined these aspects with the
question in mind of whether it is possible for practice theory to exist as distinct from science and
ethics. The first part of the question needs knowledge of science and the second needs knowledge
of what is morally good.
Science, to Beckstrand, seeks to develop the knowledge necessary to change and control.
This knowledge, containing lawlike relationships, is synonymous with scientific knowledge. Con-
trols are possible in practice situations; however, practice methodology proceeds by valid deduc-
tions from scientific laws. Beckstrand then showed that the field of philosophy known as ethics
provides the other body of knowledge that is necessary for practice but substitutes for practice the-
ory. Both normative ethics and metaethics have relevance to practice, and we can easily borrow
and co-opt theories to explain moral obligations and moral values in the discipline. The method of
obtaining such knowledge and using it is that of logical reasoning, also a borrowed concept. Nurs-
ing uses scientific knowledge and logic to meet its ethical goals—all that constitutes the knowl-
edge base of nursing. So, in essence, there is no need for practice theory (Beckstrand, 1978a,
1978b).
Others who agreed that nursing does not need its own theory made a case for borrowed theo-
ries to describe, explain, and predict phenomena significant to nursing. Family theory, systems
theory, and psychological theory are examples of theories that could be borrowed. Johnson, who
was the first to use the concept of borrowing (1968a, 1974), defined borrowed theory as “that
knowledge which is developed in the main by other disciplines and is drawn upon by nursing” and
defined unique theory as “that knowledge derived from the observation of phenomena and the
asking of questions unlike those which characterize other disciplines” (Johnson, 1968b, p. 3).
However, she warned that any attempts at differentiation are hazardous, first of all because the
man-made, more or less arbitrary, divisions between the sciences are neither firm nor constant. It
appears a special unity exists in knowledge, corresponding to a unity in nature, which defies
established boundaries and continuously presses for the larger, more cohesive view. Moreover,
knowledge does not innately “belong” to any field of science. It is not exactly happenstance that a
given bit of knowledge is discovered by one discipline rather than another, but the fact of discov-
ery does not confer the right of ownership. Viewed in this light, borrowed and unique have no real
permanence, or any meaning (Johnson, 1968b, p. 206).
Johnson, however, differentiated between them to make a case for the development of a
unique theory of nursing that addresses knowledge of order, disorder, and control and that focuses
on phenomena and research questions in a way that is not characteristic of any other discipline
(1968a).
Some may agree that applied theory could evolve out of these borrowed theories to describe
and explain prediction and prescribe nursing action. These critics make a distinction between
basic theory, emanating from other disciplines, and applied theory, based on basic theory, with the
exclusive purpose of defining nursing care and patterning interventions with predictable
responses. The latter continues to be called borrowed theory by some, which could be considered
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132 PART THREE Our Discipline and Its Structure
a fallacy because if we begin with the premise that knowledge is not the exclusive property of any
one field and that, eventually, knowledge is for all, “knowledge which we share in common”
(Johnson, 1959, p. 199), then knowledge organized into theories in one discipline could freely be
used by members of other disciplines. Therefore “borrowing” is really “adapting” or “deriving.”
Even if we agree that there is such a thing as the borrowing of theories to help in describing,
explaining, and predicting phenomena that are significant to nursing, the mere fact that the ques-
tions and problems under consideration are nursing questions and problems changes the nature of
the so-called borrowed theories. Johnson (1968b) made the point in this way:
If we continue to observe behavior from the perspective of sociology, anthropology, or psy-
chology; or if we continue to study disease with the aim of elucidating etiologies, properties,
or life cycle; or if we continue to inquire into biological functioning or malfunctioning, we
will be serving the cause of science but not necessarily the cause of nursing (p. 209).
Therefore, the nursing perspective guides the reconceptualization of existing theories
(Donaldson and Crowley, 1978). Synthesis of so-called borrowed theory with a nursing perspec-
tive is essential; otherwise, the focus of nursing will continue to remain within other disciplines,
and, therefore, nursing problems will not be addressed (Phillips, 1977). Barnum (1994) supported
this position. She stated that theories from other disciplines must be adapted to the nursing milieu
and to the nursing image of a human being to be meaningful for nursing.
The so-called borrowed theories, then, are given new meaning within a perspective appropri-
ate for nursing. Barnum supported Johnson’s stand and called knowledge used in different disci-
plines “shared”; perhaps we should also have shared theories. To say that nursing theories are
applied theories based on basic theories borrowed from other disciplines is therefore a myth that
only serves to further obfuscate nursing theory. Nursing uses “borrowed theories” originating in
other disciplines to describe phenomena belonging to those disciplines, when propositions remain
in the context of the borrowed theory. Borrowed theories become “shared theories” when used
within a nursing context. Nursing theories describe, explain, and predict domain phenomena.
Nursing needs theories to describe and explain phenomena that are significant in the act and
process of nursing, to prescribe effective strategies of care, and to predict outcomes. Continuing to
use borrowed theories may delay the ongoing activities in developing nursing knowledge (Walker
and Alligood, 2001). Theories that were developed in other disciplines are also useful for deriva-
tion, integration, and synthesis with the nursing perspective. This process yields nursing theories
or theories for nursing practice.
CONCLUSION
The sources of ideas for theory development are numerous and varied, with each inspiring differ-
ent questions and providing different components to theoretical nursing. Some sources (such as
biomedical models) have received more attention from nurses than others (such as nurses’ daily
experiences). Awareness and knowledge of the various sources may drive the development of the-
ories that address the multidimensional and dynamic nature of nursing care.
In this chapter, I have suggested some ways by which an environment could be developed to
nurture critical thinking in nurses. Such a dialogical and affirming environment could nurture and
support nurses’ abilities to capture their experiences and to reflect their clinical wisdom in theo-
retical nursing. Once again in this chapter, support is provided for the extent to which clinical
nurses are a most significant resource for theory development.
Finally, two major historical debates are discussed and a proposal for their resolution is pre-
sented. The two discourses are whether nursing conceptualizations are theories or conceptual
frameworks and whether nurse scholars should be engaged in developing theories or adapting bor-
rowed theories from other disciplines. Although students of theory should be aware of the nature
of these debates, I do not believe that resolving either of them is a crucial step toward knowledge
development. Progress in knowledge and in developing theoretical nursing can and must proceed
despite historical or future paradoxes.
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CHAPTER 7 Sources, Resources, and Paradoxes for Theory 133
4. In this chapter, two historical paradoxes
were discussed that have shaped our
more contemporary thinking on theory.
Identify and critically analyze other
paradoxes that will shape the future of
theory development.
5. In what ways will the move toward out-
comes-based nursing or evidence-based
nursing advance or constrain nursing
theory development? Give examples to
support your arguments to defend them.
6. Allocate time and find colleagues who
think differently about the answers to
previous questions and debate your
positions.
REFLECTIVE QUESTIONS
1. A number of sources were proposed to
drive theory development. Critically con-
sider which of these sources could pro-
mote or constrain the generation of ideas
that could be evolved into theories.
2. What aspects of your own education
prepared you for theoretical thinking?
Why? Similarly, as you think back on
your experiences, which experiences,
educational or clinical, helped or hin-
dered in forming your identity as a the-
oretician?
3. Discuss the dialectic relationship
between sources of theory and the agents
in theory development.
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C H A P T E R 8
Our Syntax: An Epistemological Analysis
Disciplines are characterized by a perspective, a domain, sources for the development of knowl-
edge, and ways by which knowledge is characterized and developed. In this chapter, I discuss the
different patterns of knowing and the prevailing perspectives on theory development. I argue for
epistemic diversity, for inclusive epistemology, and for a serious consideration to using a critical
approach to ways of knowing and to truth.
Epistemology is the branch of philosophy that considers the history of knowledge. It raises
and answers questions related to the kinds, origin, nature, structure, scope, trustworthiness, meth-
ods, and limitations of knowledge development. It outlines the various criteria by which knowl-
edge is accepted. Understanding how knowledge evolves, how it is accumulated, and how
knowledge is accepted is essential for development and progress in any field. Such understanding
helps to further define goals to be pursued, either by the individual scientist or the discipline as a
whole (Andreoli and Thompson, 1997; Baer, 1979; Carper, 1978; Silva, 1977). For nurses, a study
of epistemological issues helps us to accomplish the following:
• Increase our awareness of the complexity and diversity of the perspectives, views, and the-
ories (sometimes conflicting) of scientific progress, truth, and the methodology of truth
• Distinguish between different kinds of problems in knowledge and development and
therefore deliberately pursue those that seem most germane to the theoretical progress of
the nursing discipline
• Deal with potential epistemological constraints, however inappropriate, that evolve from
de facto acceptance of one view, one theory, or one perspective without careful study of
alternatives
• Develop and use methodologies that are innovative and more congruent with the nature of
nursing science
• Utilize, acknowledge, and evaluate different forms of evidence, such as practice-evidence,
research-evidence, and theoretical-evidence
Although this book is concerned primarily with the role of theory in the development of nurs-
ing knowledge, knowledge encompasses far more than theory––it includes research, common
sense, and philosophy, as well as extant and ought-to-be nursing practice. During the last few
decades, we have accumulated much nursing knowledge about caring, interacting, promoting
healthy environments, supplementing roles, enhancing recovery, and supporting healing. If we
allow our knowledge to develop haphazardly, disconnectedly, or aimlessly, it may not progress as
expediently as we wish or in the direction we choose. By reflecting on the course of the develop-
ment of nursing’s knowledge base and where it is located at the turn of the 21st century, particu-
larly its theoretical progress, we can deliberately chart our future progress. More importantly, we
can also better organize our approach to the future acquisition, development, and advancement of
nursing knowledge.
In this chapter, I discuss two central components in our epistemology of the discipline:
• Knowing from the received view to postmodernism view
• Truth from correspondence to integrative view of truth
KNOWING FROM THE RECEIVED VIEW TO POSTMODERNISM VIEW
Knowing is not static, but dynamic and changeable, and patterns of knowing in a discipline are not
discrete; they reflect the progress and maturity of the discipline as well as the agents of knowing
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CHAPTER 8 Our Syntax: An Epistemological Analysis 137
in a discipline. Patterns of knowing in a discipline are constantly evolving, multidimensional, and
may be transformed and transforming. They reflect societal trends in defining acceptable patterns,
and these definitions may change over time. We still remember when knowing in nursing
emanated only from traditions, history, and experiences, when all alternative complementary the-
ories were completely ignored and rejected, and when only scientific methods were the methods
of choice. We also saw new concepts such as practice theories, personal knowing, expert knowing,
and interpretive knowing become mainstream in the knowledge development arenas. To under-
stand and appreciate the framework for our most contemporary syntax in nursing, one that is
likely to endure long into the future, I will present it within the context of our history. In many
ways, that history has shaped our current level of tolerance of the epistemic diversity we are expe-
riencing and in the different ways by which we claim “to know” in our discipline.
Knowing includes knowledge based on observations, research findings, clinical manifesta-
tions, and scientific approaches. Although knowing has been viewed to be more dependent on
sense data, it also includes other types of data. To understand is to connect bits of knowledge in a
relational form to other broader statements. For example, we know that women who work outside
the household tend to work a double shift: one shift outside their home, and the other taking care
of their home. We also know that women who work outside the home tend to have better mental
health than do women who work only inside the home. On the basis of this knowledge, inferences
could be made about the types of support and health care resources that women who work inside
the home may need. Housework is an activity that was not acknowledged as work or leisure, an
activity with no set hours, wages, rewards, or retirement benefits (Harding, 1988, p. 87). Consid-
ering the findings within this context of meanings may prompt a consideration of the forces and
constraints in using resources that are developed especially for the promotion of health in women
who are engaged primarily in housework. Similarly, we have always known that menopause was a
“deficiency disease” from a biomedical perspective until feminist scholars enhanced our knowl-
edge by demonstrating its transformation from a disease to a normal process that is experienced
differently in different cultures (Andrist and McPherson, 2001). These examples illustrate the
need for developing understanding beyond sense data. Understanding, therefore, includes putting
the experiences and situations of women within historical, gender, and social contexts. It includes
a consideration of the norms, values, and the meanings of housework and the barriers that soci-
eties impose on women and their work. That, then, requires epistemological diversity.
Knowing results from careful systematic research or from repeated experiences in clinical
practice. Reflecting on that knowledge and interpreting the meanings of relationships, as seen and
experienced by all parties concerned, and putting that which is known within a context of feelings,
values, and different perspectives, is what brings us closer to an understanding of that which is
known. One pattern of knowing by itself will not uncover all the knowledge needed for a human
and practice-oriented science.
In a classical analysis that represented a turning point in our epistemological past, Carper
(1978) identified four patterns of knowing in nursing:
1. Empirical (the science of nursing)
2. Personal knowledge (concerned with the quality of interpersonal contacts, promoting
therapeutic relationships, and individualized care)
3. Aesthetic (the art of nursing)
4. Ethics (moral component of nursing)
These patterns, which transcend time, but are neither complete nor static (Fry, 1988),
received a great deal of attention and were instrumental in alerting nurses that science alone will
not answer the significant questions in our discipline (Johnson, 1994). Jacobs-Kramer and Chinn
(1988) extended knowledge about the four patterns by developing a model that includes five
dimensions: creative, expressive, assessment questions, process-context, and credibility index to
describe and explain the four patterns developed by Carper. They further extended this model and
refined it, illustrating how each pattern contributed to a more complete knowing (Chinn and
Kramer, 2003).
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138 PART THREE Our Discipline and Its Structure
The first pattern developed by Carper (1978) and used to guide the development of nursing
knowledge is the empirics, requiring scientific competence leading to explanations and structure,
requiring replication and validation, and resulting in theories and models. The second pattern is
personal knowing, requiring therapeutic use of self, which requires openness and centering and
can be achieved through the use of stories and genuine use of the self. These are organized as
responses and reflections. The third pattern of knowing is the aesthetic, manifested in critical
analysis of works of art that result in transformative expressions of art or acts. The fourth pattern
is ethics, knowing manifested in principles and codes that could evolve through processes of dia-
logues and justification. These could be developed by valuing and clarifying discourses and acts
of caring (Chinn and Kramer, 2003). White (1995) supported the four patterns but added a fifth
one, sociopolitical knowing, which is considered an essential pattern for the understanding that
may evolve from all other patterns of knowing. This pattern focuses on the broader context for the
caring process; it allows and drives inquiry to critically question the status quo of the participants
in the caring process. It includes organizational, cultural, and political processes that influence the
person, the nurse, and other health care providers; the profession; and other structures involved in
the caring process. This pattern of knowing allows for the construction of alternative structures of
reality and is expressed through critiques and transformations. It is a pattern predicated on collab-
oration and on a movement toward more equity in knowledge development.
There are many ways to organize epistemic diversity, which is shaping the next phase of
knowledge development in nursing. I chose to build on previous classifications (Carper, 1978;
Chinn and Kramer, 2003; Allen, Benner, and Dickelman, 1986; Stevenson and Woods, 1986;
Mantzoukas and Jasper, 2008) by presenting here four views of knowing:
• The received view
• The perceived view
• The interpretive view
• The postmodernism, poststructuralism, and postcolonialism views
The Received View
Several philosophers in nursing have been concerned that nurses may have adopted a limited
view of science that directly contradicts nursing’s philosophy, heritage, and goals. Their view
could be summarized under the rubric of “the received view,” which others may call the scientific
method (Suppe, 1977). The received view is philosophically old and outdated, but its effects lin-
gered longer in nursing than in the field of philosophy of science (Suppe and Jacox, 1985).
The received view in any discipline usually denotes a set of ideas that are not to be chal-
lenged––the philosophical equivalent of being engraved in stone. It is the same premise that
declares that holy books were received and therefore should not be challenged. The received view
is also a label given to “empirical positivism” or “logical positivism,” a 19th-century philosophi-
cal movement closely aligned with Rudolph Carnap and rooted in the celebrated Vienna circle of
philosophers. This circle advocated an amalgamation of logic, with the goals of empiricism in the
development of scientific theories (Runggaldier, 1984). Eventually, the concept of “positivism”
was dropped from “logical positivism” and replaced with “empiricism” to avoid the connection
with Auguste Comte, whose ideas were coming into disfavor at that time. When Carnap joined
The University of Chicago in 1936, he introduced logical empiricism to the United States (White,
1955, pp. 203–225).
The following are the tenets of logical empiricism:
1. Theoretical statements that cannot be confirmed by sensory data, and sensory experiences
are not considered worthy of pursuit. As a result, they are disqualified as common sense
statements. Predictive statements that have no corroboration from sensory data are not sci-
entific. A direct relationship has to exist between experience and a meaningful theory.
2. True statements are only those that are a posteriori. That is, they are based on experience
and known from experience.
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CHAPTER 8 Our Syntax: An Epistemological Analysis 139
3. Positivists regard most traditional metaphysics and ethical considerations as meaningless.
They regard such questions as possessing “emotive” meaning and as being “cognitively
meaningless” (White, 1955).
4. Analyses of theories are based on analyses of completed theories, and completed theories
are based on empirical data (Suppe, 1977, p. 125). The context of justification––that is,
the verification and falsification of complete theory propositions––is the only significant
context for consideration by scientists and philosophers alike. Conversely, the contexts of
discovery, such as conceptual ideas, contexts within which theories are developed, logic
in theory development, and usefulness, should be within the province of the sociologists
of knowledge: the psychologist and historian (Reichenback, 1968).
5. Because the received view considers theories to reflect the a posteriori depiction of real-
ity, documented by sensory experiences, it therefore follows that propositions of theories
are presented symbolically, formally, and axiomatically. There is room for a priori analy-
sis, although it is only mathematical in nature.
6. Science is value-free, and there is only one method for science, which is the scientific
method.
The “ghost of the received view” loomed over nursing in its quest for a scientific base,
according to Webster, Jacox, and Baldwin (1981). Others, such as Watson (1981) and Winstead-
Fry (1980), also blamed nursing’s slow scientific progress on the insistence of its leaders to using
the outdated scientific method as its model and to strive for one scientific method.
The scientific method that they were speaking of is one based on the received view, one that
espouses “reductionism, quantifiability, objectivity, and operationalization” (Watson, 1981,
p. 414). As a result, the critics maintained that significant holistic problems in nursing have been
ignored because they are not reducible, quantifiable, or objective. The scientific method adopted
by nursing reduced a problem to its smallest unit or its most significant form and stripped it of the
rich context from which it emanated (Newman, 1981). The scientific method, oriented toward
quantitative methods, and highly accepted and respected, could not address theory and developing
theory; therefore, it has not helped nursing to develop meaningful theories, nor has it advanced
nursing to its projected goal of a scientific discipline.
Historically, some justification existed in blaming the received view for nursing’s slow
progress and development. Many examples support the view that an outmoded and ineffective
philosophical view of science has somewhat disillusioned nurses (Newman, 1994). One example
is the many theoretically disconnected but methodologically immaculate research projects that
nurses have produced, a view that is shared by Batey (1977). Nevertheless, more evidence than we
have been led to believe supports the view that nursing has, in fact, considered and followed a sci-
entific path broader in scope and more integrative in approach than the received view.
Logical empiricism succeeded from logical positivism, and it is how the received view is
expressed. After many transformations, it has come to be accepted as an essential approach to
knowing; it is not, however, the only approach. Although there are variations to how empiricism
may be utilized, it has some common properties.
A theory for empiricists is a product of research findings that is used as a framework for fur-
ther research. The empiricists’ observations are not contextual and usually focus on single behav-
iors, events, or situations. Theorizing for empiricists is based on inductive logic, sense data
supported by a set of value-free assumptions. Empiricists develop theories by providing precise,
well-defined, operationalized concepts––measurable variables. Empiricists are objective, sepa-
rated, and distanced from their theories; they treat theories as objects and are reluctant to share
insights related to findings or evolving ideas with their clients or research subjects. The language
they use is research-specific and their approach is inductive. Statistical model building is a signif-
icant tool for empiricist theory development.
Empirical theories are based on careful and methodologically impeccable research studies
geared to finding relationships between different variables and finding support for a multitude of
statements––all geared to answering a set of well-defined questions, hypotheses, and null
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140 PART THREE Our Discipline and Its Structure
hypotheses that produce prediction and verification (Table 8-1). Empiricists’ theories are well
understood by colleagues from other disciplines, and when theory development is discussed, it is
more likely to be understood in relationship to the development of empirical theories (Dzurec,
2003). The discourse about evidence-based practice emanates and reflects a focus on a limited
view of empiricism (Porter, 2010). Many narrow interpretations of evidence may exist; however,
the prevailing, dominant interpretation is one that is most limited in focus. (Fawcett, Watson,
Neuman, Hinton-Walker, and Fitzpatrick, 2001; Chinn and Kramer, 2003) (Table 8-1).
The Perceived View
Knowing through the more subjective view of those who are experiencing the situation and
those agents who are uncovering the situation reflects another view of knowing. Knowing is not
only based on sense data. Proponents of the perceived view of knowing discuss different patterns
and dimensions.
Nursing theorists who have worked diligently to give us their conception of the discipline
have not followed a received view approach. They have offered several conceptualizations that
encompass the whole of nursing––a perceived view––based on their experiences and theory-
incorporated ideas that are subjective, intuitive, humanistic, integrative, and, in many instances,
not based on sense-oriented data. (See Chapter 20 for citations reflecting this statement.)
TABLE 8-1 COMPARISON OF THE RECEIVED, PERCEIVED, INTERPRETIVE,
AND POSTMODERN VIEWS OF SCIENCE*
Postmodernism,
Poststructuralism, &
Received View Perceived View Interpretive View Postcolonialism
Objectivity Subjectivity Analysis within context Narration
Finding meaning
Deduction Induction Contextual analysis Political and structural analysis
One truth Multiple truths Patterns Different views
Themes
Validation and Trends and Authenticity Uncovering opposing views
replication patterns
Justification Discovery Uncovering meaning Uncovering inequity
Marginalization
Prediction and control Description and Narrative descriptions Metanarrative analysis
understanding
Particulars Patterns Patterns within a structure Stories
and history
Reductionism Holism Uncover weakness Macro-relationship with micro
and flaws structures
Generalization Individuation Knowing about context Knowing about structures
Logical positivism Historicism Historicism Macro-analysis
Logical empiricism Structure
* Based on Meleis, A.I. (1985). Theoretical nursing., Philadelphia: Lippincott; and Stevenson, J.S. and Woods, N.F. (1986). Nursing science and
contemporary science: Emerging paradigms. In G. Sorenson (Ed.), Setting the agenda for the year 2000: Knowledge development in nursing.
Kansas City, MO: American Academy of Nursing.
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CHAPTER 8 Our Syntax: An Epistemological Analysis 141
The discovery of field concepts, theory development, and processes of theorizing in nursing
has not been based on the received view or on a structured and strictly scientific approach. Tradi-
tionally, the context of discovery for these ideas has been case studies, personal anecdotes, and
group insights. The acceptance of those visions then emanating from our nurse theorists has been
slow because some have branded the theories as unscientific. Therein lies the problem.
To generalize, saying that nursing has followed a positivistic path is akin to saying that
physics has followed an intuitive one. The theoreticians in nursing, those who have developed
conceptualizations encompassing the field as a whole, have used the perceived view, which com-
bines the phenomenological and philosophical approaches as alternate methods of theory devel-
opment. The scholars in the field who believe that knowledge emanates from the context of
justification may have helped to orient nursing toward considering concepts such as sensory data,
verification, and falsification as ways to accept or reject nursing conceptualizations. These schol-
ars have therefore precipitated the early mass rejection of nursing theory, as well as the continuous
rejection by many in the field who are skeptical about the use or effectiveness of nursing theories.
In the perceived view, patterns of knowing include both theoretical and practical knowing.
Sarvimaki (1994) makes a distinction between theoretical and practical knowledge, although she
acknowledges their equal significance. Theoretical knowledge includes and reflects the basic val-
ues, guiding principles, elements, and phases of a conception of nursing. Its goals are to drive and
promote thinking and understanding of that which is the nursing discipline. Its base is intellectual,
and it is organized into assumptions, concepts, propositions, and models. Practical knowledge,
however, does not have to be organized in the same way because many parts of this knowledge are
not yet articulated and because the artistic side of practice may not be amenable to total articula-
tion. The channel of communication for theoretical knowledge may be theories and science,
whereas the channel of communication for practical knowledge may be tradition, according to
Sarvimaki (1994). Practical knowledge may be achieved through personal and collective means
and reflections (Winstead-Fry, 1979) and through integrating and blending evidence with clinical
judgment (Paley, 2006). Personal knowing, which may be arrived at through one’s own practice,
reflection, synthesis, and integration of artistic, scientific, and practice components is, according to
Moch (1990), essential to the development of nursing knowledge. She identifies three components
in personal knowing: experiential, interpersonal, and intuitive knowing. Experiential knowing is
achieved through being part of the world of nursing and becoming increasingly aware of the expe-
riences inherent in this participation. (See powerful examples of one aspect of personal knowing
through an illness experience [Hall, 2003].) Interpersonal knowing results from enhanced aware-
ness about situations resulting from extensive, in-depth interactions with others. These interactions
are another source of knowing, and they promote the development of knowledge.
When a person knows without the explicit use of scientifically accepted forms of reasoning,
it is said that the person achieved the knowing through intuition. It is knowing a whole without
resorting to linear reasoning (Polanyi, 1962). It is knowing without knowing how (Benner and
Wrubel, 1982; Rew, 1988; Rew and Barrow, 1987). When nurses use intuition to know, they open
themselves up to allow sensing and understanding of the patient’s responses and situations to
occur, which leads to a better knowledge of the patient’s situation (Agan, 1987; Paul and Heaslip,
1995). Intuitive knowing was a neglected pattern of knowing, but it has been gaining more atten-
tion as a component in “clinical knowing,” as essential in a more holistic understanding of clinical
situations, and as significant in making more effective therapeutic decisions, as evidenced from
the many descriptive studies that affirm its significance (Rew, 1990; Rew and Barrow, 2007).
Intuition by experts is based on rapidly perceiving a whole situation without having to pause
to construct the different processes or steps (Benner, Tanner, and Chesla, 1996). Many discourses
in nursing have established intuition as a source of knowing to be carefully explored, and different
theories about intuitive learning also should be explored (Gobet and Chassy, 2008).
Knowing a patient through perception or intuition, as well as through forms of knowing,
allows for more particular and individualistic approaches that may be based on more general
knowledge related to that patient’s situations. Knowing the patient leads to more appropriately
selecting nursing therapeutics, based on knowing the patient’s resources, readiness, and current
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142 PART THREE Our Discipline and Its Structure
understanding related to his or her responses. Several processes have been identified to elucidate the
meaning of “knowing the patient.” These were defined by Jenny and Logan (1992) as perceiving/
envisioning, communication, self-preservation, and showing concern. Perceiving and envisioning
involve identifying the meaning and significance of the patient’s responses. Knowing the patient
also involves communication and interaction with or about the patient. It includes having the
nurse be present for the patient and being trusted by the patient and family. Knowing the patient is
assumed to be connected to the extent to which a nurse shows and demonstrates concern. To be
able to know a patient or a situation is to be open to know what is unknown about this individual.
Munhall (1993) made a cogent argument for “unknowing” as another pattern of knowing that
requires reflection on oneself––about whom we have a certain degree of knowledge—and the
other (patient) about whom we have a very limited knowledge. Unknowing is another dimension
of knowing; without realizing and understanding the degree, extent, and nature of what one does
not know, knowing is not fully realized (Table 8-2).
Nursing phenomena reflect human conditions and situations, and, therefore, these phenom-
ena could be developed through different patterns of discovery. Uncovering and describing the art
component of nursing is predicated on developing the aesthetic pattern of knowing. Sorrell (1994)
described this pattern as embodying the “unique pattern of knowing that offers enrichment to our
understanding of [the] nursing experience that is not accessible through other ways of knowing”
(p. 61). Aesthetic knowing depends on processes that are imaginative and creative. It allows the
knower to be engaged and interpretive, and it allows for envisioning. It is also expressed through
some creative means such as art, music, and expressive writing. Writing to reflect aesthetic know-
ing is not bound by scientific reporting; it may include poetry, narratives, stories, fiction, letters,
and journals (O’Brien and Pearson, 1993; Sorrell, 1994). The knowing that results from these
modes of expression integrates sensory perceptions with experiences and acts. Aesthetic knowing
requires engagement and distancing from experiences, particularizing and generalizing, abstrac-
tion and concretization, objectivity and subjectivity, and separate and united components and
experiences.
Experiences such as compassion, suffering, and mourning may best be uncovered through
metaphors, and may be understood more fully if scientific methods are used in combination with
aesthetic approaches. Younger (1990) provides an example by using the Book of Job in the Bible,
analyzing it as a “literary work” to uncover knowledge of, and the meaning for, suffering. The art
of nursing is closely tied to the realities of the practice situation (Timpson, 1996). These aspects of
nursing can be somewhat articulated by nurses who value the uniqueness of individual experi-
ences and who can communicate through aesthetic pathways that may fully capture the connec-
tion between the different components (Boykin, Parker, and Schoenhofer, 1994). Clinical
expertise and its dimensions represent one aspect of nursing art (Hampton, 1994).
The art of clinical expertise is always evolving and multidimensional, and may be trans-
formed or transforming. It is not always possible to classify knowledge using only one of these
patterns. Knowing can and does occur through “nonlinear, meditative thinking that moves in all
directions.” Therefore, Silva, Sorrell, and Sorrell (1995) called this type of knowing “the-in-
between” (p. 3). There is also the knowing through “the beyond,” which is knowledge that con-
cerns “those aspects of reality, meaning, and being that persons only come to know with difficulty
or that they cannot articulate or ever know” (p. 3). Accepting the inexplicable and the unknowable
in clients, nurses, relationships, and health and illness may allow an exploration of meanings and
ways by which some lived experiences cannot be felt or explained by those who never had those
experiences. These patterns of knowing bring a nurse closer to a more profound understanding of
the complex multidimensional aspects of reality that characterize human experiences related to
health and illness.
The Interpretive View
Understanding goes beyond knowing and beyond uncovering a perceived view of a situation
and experience. It includes interpretation, a total comprehension of other human beings’
responses based on their “feelings, ideas, choices, and purposes” as they experience the situation,
LWBK821_c08_p136-158 07/01/11 6:09 PM Page 142
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LWBK821_c08_p136-158 07/01/11 6:09 PM Page 143
G
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CHAPTER 8 Our Syntax: An Epistemological Analysis 145
and as they express their own meanings and understanding of the situation through their own words
and through their own responses (Schwartz and Wiggins, 1988, p. 143). The degree to which we
need to develop that understanding depends on the extent to which we want to, and how significant
our attempt to achieve that level of understanding is. It also depends on the degree to which clients
are willing to have their responses and their situations fully uncovered and understood. True under-
standing not only illuminates the situation, it also uncovers weaknesses and flaws, as well as
strengths and abilities. In some ways, true understanding may uncover the individual’s power as
well as areas of vulnerability (Table 8-1 and Table 8-2).
Health and illness situations require a level of understanding that is not required from other
situations in which two strangers might come in contact with each other. However, a true under-
standing of how individuals experience and respond to health and illness mandates an understand-
ing of what a group of people value in life, what priorities they have, how they usually respond to
disruptions in their lives, how they prefer to express their discomfort, and what are the most com-
fortable ways by which they usually prefer to express their feelings.
Knowing about specific groups’ perceptions of health and illness, patterns of help-seeking
behaviors, and patterns of responses to uncomfortable situations is essential for the level of under-
standing required to develop an intervention plan, whether that intervention plan is as specific as
postoperative deep breathing or maintaining prenatal appointments. Knowing about the extent to
which an immigrant is connected to individuals and events in his country of origin may help a
nurse clinician understand the out-of-pattern expressions of pain and discomfort to a seemingly
minimally painful experience. Knowing about normal patterns of touch between members of the
opposite sex in different social classes may help a health care provider understand when (and
when not) to communicate this way.
Understanding includes making connections and achieving syntheses that may go beyond the
perception and knowledge of the client or the provider (Habermas, 1971; Schutz, 1967). Under-
standing has been advocated by interpretive scientists (Allen, 1988, p. 98) as the hallmark for
knowledge development in nursing. This understanding includes specific research findings, the
experience that evolves from the practice arena, and knowledge awareness from primary theoreti-
cal formulations. It includes all these and goes beyond them.
Understanding is predicated on knowing about phenomena, knowing about the contexts in
which certain phenomena occur, and knowing about patterns of presentation of these phenomena.
Knowing about the different roles women enact; knowing about the stresses, strains, and satisfac-
tions in these roles; knowing role theory; and knowing the relationships between levels of role
involvement and number of roles and health status are all important and significant for developing
an understanding of why and when women tend to seek care for themselves or for their children
and how they choose to maintain or enhance their health. That level of understanding is also
achieved through a deliberate effort to reflect theoretically on some of these concepts and put
them together in an organized way to describe and explain some central problems in nursing, such
as maintaining and developing health and patterns of seeking health care.
Jaspers, a physician and a philosopher, addressed the laws of understanding as follows
(Jaspers, 1963; Schwartz and Wiggins, 1988, pp. 153–155):
1. Empirical understanding is an interpretation. The data provide the impetus for interpreta-
tion, and therefore interpretation is not absolute but is subject to other interpretations––
and therefore may be theoretical.
2. Understanding opens up unlimited interpretations. To have understanding as a goal frees
the researcher to consider many different interpretations. These different interpretations
should be subjected to more data to gain support or refutation.
3. Understanding moves in deepening spirals. To understand a certain behavior, one starts at
the part, goes to the whole to put the behavior in context, and then comes back to the part
for better understanding. This process increases understanding.
4. Opposites are equally meaningful. The same evidence can be interpreted in two opposite
ways. In doing that, we attempt to understand the synthesis between the opposites and
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146 PART THREE Our Discipline and Its Structure
not settle for preconceived notions. Schwartz and Wiggins (1988, p. 154) give an example:
“We can understand the stoicism of a patient as stemming from bravery and nobility. But
we can also understand this same stoicism as motivated by profound fears and a complete
inability to face up to a difficult predicament.”
5. Understanding is inconclusive. Not all feelings, meanings, and values can be expressed in
understandable ways, and not all interpretations are willingly shared.
6. To understand is to illustrate and expose. To really comprehend, both the positive and
negative aspects of any group or person have to be exposed. Ethical considerations of the
balance between exposure and illumination need to be considered.
Should nursing knowledge help us to know, to understand, or to care? Does each require dif-
ferent approaches to knowledge development? Can these approaches substitute for each other, or
do they complement each other to enhance knowledge development? I believe that the predomi-
nant goals for research are to know and that the predominant goals for theoretical development of
the discipline are to understand. I am not saying that one leads exclusively to knowing and one
leads exclusively to understanding. I am using the concept “predominant” to differentiate between
goals. Imagine knowing and understanding on two continuums. Imagine each going from none to
high. Research findings and theorizing could be plotted on the two continuums. Research findings
tend to be toward the higher end of the continuum of knowing and may be the middle of the under-
standing pole, whereas theorizing tends to be on the higher pole of understanding and may be the
middle of the knowing pole.
Two frameworks for interpretation inform knowledge development in nursing: a feminist and
a critical interpretation. There are many variations in both, and there are many different ways by
which they intersect.
Feminist Knowing
The history of nursing attests to how the concept of gender permeates and pervades every
aspect of the discipline. Nursing has been predominantly a female profession and continues to be
so in the 1990s, as female nurses continue to claim about 93% membership in the profession
(Ashley, 1980; Doering, 1992; Armour, 2003, para. 10). Despite the many efforts to open the pro-
fession more to men and despite the many contributions men have made to nursing, nursing
remains a woman’s profession and continues to be saddled with all the accompanying issues
related to the value of women’s work, women’s contributions, and the relationship between nurs-
ing and other predominately male professions.
This history could be used to the advantage of the discipline and its clients by utilizing it as a
perspective for the development of gender-sensitive theories. Understanding the constraints inher-
ent in these experiences and the lack of participation in shaping the structure and the goals of
inquiry may sensitize nurses to similar experiences in clients.
Gender-sensitive theories are those based on connections between the theorist and the sub-
ject matter, the involvement of the theorist with the subjects of the theory in the development
and interpretation of the theory (MacPherson, 1983; Sherwin, 1987; Stacy and Thorne, 1985).
These theories are also based on the acknowledgment and affirmation of gender equity, on the
premise that women should be affirmed for their contributions in a patriarchal society, on
the assumption that women should have options and control over their own bodies (Sampselle,
1990), and on the assumption that nursing is also a field of study and a profession for men. The
goal of gender-sensitive theories is understanding rather than just knowing; the goal is based on
uncovering and including personal experiences of the nurse and client, and it evolves from con-
sidering the totality of the experiences, responses, and events described theoretically, as well as
from giving similar consideration to the experience and the context of the theorist (Hagell,
1989) (Table 8-2).
A feminist perspective could be used not only in understanding issues related to women as
clients or women as providers, but as a perspective for developing an understanding of all nursing
clients, regardless of sex, gender, race, or culture. It could be used to understand, to explain, to
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CHAPTER 8 Our Syntax: An Epistemological Analysis 147
raise consciousness, and to develop theories that will bring about needed changes for nursing
clients (Cowling and Chinn, 2001; Cloyes, 2002; Duffy and Hedin, 1988; Jagger, 1988).
Whereas the assumptions of the empiricists may lean toward value-free axioms and facts and
from truths derived from previous research findings, assumptions evolving from feminist perspec-
tives are acknowledged as value-laden and include personal, disciplinary, and societal values
(Harding, 1986, 1987).
Gender-sensitive theories (Table 8-2) could be based on similar principles that have been dis-
cussed in conjunction with gender-sensitive research. Cook and Fonow (1986) and Im and Meleis
(2001) defined some guidelines for conducting gender-sensitive research. These guidelines are
modified and offered for guiding the development of theories related to recipients of care in nurs-
ing. Therefore, gender-sensitive theories are theories that:
• Consider gender as a basic feature and a central agenda in the theory
• Provide guidelines for raising consciousness about the experiences described within the
theory, thus heightening understanding of the role of a social system or organization in
relationship to these experiences
• Challenge any norms or objectivity that create distances between participants or between
theory subject matter and participants in the theory development
• Provide a critique of situations and circumstances that may interfere with healthful living
• Enhance empowerment for options, for understanding, for decision making, or for self-care
• Decrease any potential of exploitation
• Enhance advocacy and provide guidelines for advocacy
• Provide guidelines for changes, including institutional and organizational changes
In caring for patients or clients, nurses knowingly or unknowingly have adhered to some of
these principles. In fact, during the 1960s and 1970s, some nurse theorists described nursing using
the very principles that reflect a gender-sensitive perspective (Paterson and Zderad, 1976; Travelbee,
1963). However, these principles may have been overshadowed by a quest for empiricalization of
theories to render the nursing discipline theoretical and scientific. By considering their caring mis-
sion, nurses––whether theoreticians or researchers––may be able to synthesize their goals for car-
ing and knowing and thus develop theories that enhance understanding of the situation, the daily
experience, and responses of clients.
Gender-sensitive perspective is not to be construed as a substitute for nursing theories. It is a
framework that guides the kind of phenomena that nursing theorists may select for development,
the approach by which such theories are developed, and the interpretation of findings related to
this phenomenon. A gender-sensitive perspective is a framework that guides nurses to study phe-
nomena that represent and emanate from the lives of their clients, phenomena that are important to
these clients, phenomena that reflect and are related to the quality of their lives or their health care
and that may be seen as problematic from their perspective (Harding, 1987; Im and Meleis, 2001).
Several properties characterize gender-sensitive theories. These are acknowledgment and
inclusion of gender equity principles; that participants in practice or research must have options
and control of their own bodies (Sampselle, 1990), and that a connection is made between subject
matter and agent for knowledge development (Im and Meleis, 2001). Gender-sensitive knowledge
includes the voices and experiences of participants, interpreted within a robust analysis of
sociopolitical context, as well as within the historical roots of the experience, the voice, and the
context.
Feminist theorizing “seeks to bring together subjective and objective ways of knowing the
world” (Rose, 1983, p. 87). It challenges attitudes, beliefs, values, and assumptions that discredit
women’s sense of ownership of their own selves, and it also empowers nurses and clients
(Sampselle, 1990; Sohier, 1992). A nursing theory that is developed using a feminist perspective is
one that values the experiences of the developer, values her intuitions and analyses, values the
client’s world, and values the client’s sociocultural and political perceptions. It is one that
includes a sensitive understanding of the conditions that impinge on clients’ responses and one
that is representative of clients from different sociocultural backgrounds. Language is powerful;
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148 PART THREE Our Discipline and Its Structure
therefore, a theory from a feminist perspective is one that uses language that is empowering, that
is gender-sensitive, that values experiences, and that denounces the status quo. For example,
Wuest (1993) critically reviewed research on compliance and demonstrated how it was based on
patriarchal and oppressive assumptions. Feminist principles may be better suited for enhancing
understanding and developing insights about clients’ responses, which might be ultimately more
productive. Nursing theories, whether guided by a feminist perspective or an empirical perspec-
tive, should continue to inform members of the discipline. Therefore, these theories remain
closely connected to the domain of nursing, with its focus on responses of human beings and their
environments to health and illness situations.
Critical Knowing
Critical knowing evolves from critical theory and research. Critical theory is a philosophical
perspective that emanates from the Frankfurt school of thought and was further developed in West
Germany by Habermas (1971) and Gadamer (1979). It includes principles promoted by Paulo
Freire (2000).
To Habermas (1971), who joined the Frankfurt school in 1950, there are three distinct but
connected approaches to scientific inquiry. These approaches are empirical/analytical, historical
hermeneutic, and critical-oriented. The three approaches include the technical, practical, and
emancipatory interests. All three types of knowledge and approaches to knowledge development
are essential for the development of knowledge for human sciences. Habermas (1971) further pro-
posed that technical problems are best understood through an empirical/analytical approach, prac-
tical problems through a historical hermeneutic approach, and problems that include issues
critical to human beings through emancipatory approaches. The latter incorporates both the
empirical/analytical and the historical hermeneutic approaches in a higher-order synthesis.
The goal of the critical-oriented inquiry is an active, reflective stand that includes changes that are
emancipatory (Allen, 1985, 1988; Habermas, 1974; Holter, 1987).
The feminist theorists focus on gender inasmuch as the critical theorists focus on power and
emancipation through reflection and action (Table 8-2). Theories developed through this perspec-
tive provide ways of understanding the sociopolitical structure and patterns of client oppression
within such a structure and also provide guidelines for a reflective approach that is critical of the
situation and ways by which the subjects of theory are transformed and emancipated from unequal
power structures (Bernstein, 1978; Habermas, 1979). The goal of a theorist here is to develop
some means by which the participants can be put on the road toward emancipation from oppres-
sive social structures. The goal is not only to understand, but to change and to do so drastically.
Reflection, understanding, communication, and action are the hallmarks of a nursing theory
developed within this perspective. Critical feminist knowledge includes awareness of gender
inequity as well as other samples of inequity, such as race and cultural inequities (Kusher and
Morrow, 2003). It examines all power relations, with a focus on social control in addition to gen-
der control (George and McGuire, 2004). Emancipation deals with the longstanding history of
social oppression for women and vulnerable populations. Attributes of emancipation are empow-
erment, personal knowledge, awareness of social norms, using reflection in order to articulate the
personal knowledge and social norms, and a flexible environment (Whittman-Price, 2004).
Developing knowledge that is not marginalizing should be an aim of enhancing critical
knowing in nursing (Meleis and Im, 1999). A critical nursing theory should be developed through
the involvement of all constituents and have the aim of informing marginalized and oppressed
populations about ways to enhance their empowerment and emancipation. It is a theory then that
challenges the status quo, actions, power relations, and patterns of thought (Fontana, 2004). To the
critical theorist, reality should be deconstructed to expose true actions, but the theory should also
provide a framework for constructing situations based on principles of emancipation (Habermas,
1971). Critical theory is context-laden; it abhors oppression and promotes empowerment and crit-
ical analysis transformation.
A nursing theory or a research program developed within this perspective offers a focus
on social structure, power, and political structure as units of analyses, a “critique of power and
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CHAPTER 8 Our Syntax: An Epistemological Analysis 149
ideology” in existing societal structures in which the nursing client interacts (Allen, Benner, and
Diekelmann, 1986). The theory or the research findings that emanate from this context incorpo-
rate an understanding of a phenomenon or a situation by all involved parties, and provide insights
about the health/illness situation and a framework of what is to be done about it. Therefore, an
equal partnership between the subject matter of a theory and the developer of the theory must be
maintained.
Critical theory is not a substitute for nursing theory; rather, it is a framework or a perspective
that informs the phenomena to be considered theoretically, guides the approaches for developing
them, provides ways by which the phenomena are to be interpreted, and suggests approaches for
handling these phenomena.
Postmodernism, Poststructuralism, and Postcolonialism Views
A number of other approaches to knowing have been discussed and utilized in the nursing lit-
erature. Among them are postmodernism, poststructuralism and postcolonialism. These reflect
different aspects of critical approaches to knowing and involve the deconstruction of realities
within a framework of oppression and control, and reconstructing the meaning of responses and
experiences within a framework of emancipation and empowerment (Table 8-1).
Postmodernism, which has been the dominant theoretical paradigm in the late 20th century
(Matthewman and Hoey, 2006), goes beyond modernist arguments that separated science from
fiction, myth, religion, and superstitions (Fraser and Nicholson, 1989). Postmodernism is a cri-
tique of modernism. Both are idealistic concepts, and neither may exist in purist form. Postmod-
ernism is based in the Enlightenment era, one that promised science as a path leading to better
understanding of human nature (Table 8-2). It allows the use of multiple methods and lack of sup-
port for developing structured theories, for continuous tentativeness, arbitrariness, and relativism
in theoretical thinking (Closs and Draper, 1998), and it informs the marginalized discourse in our
literature (Georges, 2003; Hall, Stevens, and Meleis, 1994; Hall, 1999). However, there are those
who argue that there was never a coherent view of postmodernism, that it never existed beyond the
20th century (Osborne, 1998; Matthewman and Hoey, 2006), and that it failed to have practical
relevance for health problems within the field of medical sociology (Cockerham, 2007). Similar
assumptions could be made about its utility for nursing science.
Viewing phenomena and situations from the perspectives of poststructuralism raises critical
questions and situations, and provides a framework to transform these situations (Table 8-2). For
example, Drevdahl (1999) raised questions about the taken-for-granted concepts of holism and
uniqueness that are used in nursing to describe both clients and framed interventions. She demon-
strated that the manner in which these are used in nursing leaves out the intricate interactions
between race, class, and gender, and their structural effects on experiences and responses. The use
of these concepts in nursing to describe static variables leaves the structural effects on experiences
and responses unexplained and unchallenged.
Poststructural frameworks offer an approach to viewing hierarchies in nursing practice, as
well as in areas of knowledge, that have been taken for granted as important or unimportant. It
provides the lens by which to examine power influences and how nurses and clients may be posi-
tioned for empowerment (Bradbury-Jones, Sambrook, and Irvine, 2008). Bradbury-Jones and her
colleagues (2008) argue that, to illuminate the dialogue about power oppression and empower-
ment that have been viewed from the perspectives of critical, organizational, and management the-
ories, as well as of social psychological theories, a fourth approach—poststructuralism—is
essential to understanding the dynamic nature of power in nursing. They utilize Foucault’s (1995)
ideas about knowledge and power as a springboard in proposing the primacy of the poststructural
approach as a means to exploring power and empowerment in nursing.
Conversely, some arguments question the use of poststructuralism to inform nursing knowl-
edge. These arguments maintain that although poststructuralism helps in deconstructing struc-
tures, existing discourses, and practices that are detrimental to equity, it does not provide adequate
guidelines for constructing transformative discourses or practices (Francis, 2000). Poststructural-
ism also does not illuminate the essence and properties of the phenomena. Rather, it “historicizes”
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150 PART THREE Our Discipline and Its Structure
a phenomenon and uncovers what it is about this particular phenomenon, situation, or sets of rela-
tionships that may have evolved within the context of sociopolitical, cultural, and scientific con-
text. It forces an analysis of rules that govern behaviors within and outside a discipline (Dzurec,
2003), and an analysis of gender historically (Arslanian-Engoren, 2002).
Postcolonialism is an epistemic system that is critical of colonial relationships and their afteref-
fects (Table 8-2). It links self, responses, and experiences with societal oppressions that result from
the colonial powers of those nations within the “first world,” mainly the West. Said (1999) developed
and promoted the notion of colonialism and orientalism, and thus inaugurated a new era of inquiry.
The dominant voices of the North in shaping what is important, valued, and worth pursuing in
knowledge development is questioned when viewed through a postcolonialism lens (Ali 2007). Post-
colonialism is influenced by critical theory, postmodernism, and poststructuralism. Kirkham and
Anderson (2001) identified several properties of postcolonialism knowing. It is knowing and under-
standing that intersects race, ethnicity, nation, and subjectivity. Each of these is intricately connected
with the other, as well as with power differentials and identity of the person. Postcolonial critique
uncovers resistance to changes and preferences for maintaining the status quo through ideological
processes. It allows for including ways by which people, their responses, and their behaviors are
maintained within boundaries imposed on them either by biology, culture, or gender. It allows a cri-
tique of the legitimacy afforded to those hierarchies created and maintained by sociopolitical forces.
These forces tend to create the notion of “other” or “othering,” in which identity is categorized,
assigned, homogenized, and universalized. The “other” assigned by colonialism denotes inferiority
and abnormality. To colonialism, the dominance of “white,” “Europeanism,” “westernism” pro-
motes images of superiority and normality (Kirkham and Anderson, 2001).
Postcolonialism knowing is a critique of the definitions and allocations of participants—
based on an identity shaped by colonialization, power inequities, and oppression—that interfere in
accessing resources. It provides understanding of human responses within a context of a complex
web of relationships of gender, race, culture, economics, and power. It also provides a framework
that ensures that all people are treated equally (Anderson et al., 2003).
A link exists between feminist and postcolonialist theories, as well as between feminism and
postmodernism. A feminist approach to advancing knowledge utilizes the situation of gender and
power. When combined with postcolonialism, it also engages the politics of positioning in rela-
tionship to ethnicity, race, and nationality. Thus, the emergent integrated feminist postcolonialism
or postcolonial feminism could produce more integrated answers to pressing health and social
questions (Ali, 2007; Anderson, Kirkham, Browne, and Lynam, 2007).
It is often said that all the “post” epistemologies are all for “everything goes” (Chinn and
Kramer, 2003), and that they do not allow for constructing and developing theories. Critics should
continue to inform and challenge epistemic diversity for knowledge development in nursing.
TRUTH: FROM CORRESPONDENCE TO INTEGRATIVE VIEW OF TRUTH
There is another subject of concern to those who are inquisitive about the development of knowl-
edge in nursing. What criteria has nursing used to accept or reject its theoretical notions? What
concepts of truth should it use in the future? When do experiences become knowledge, and when
does knowledge become truth? Does reality exist or appear?
Philosophers since Plato have addressed these epistemological questions. Over the centuries,
three views have emerged: correspondence, coherence, and pragmatism (Armour, 1969; Kaplan,
1964).
Correspondence Theory
Correspondence, with its careful rules, calls for sensory data, very small variables, and opera-
tional definitions. For generations, this view has dominated science, research, and theory construc-
tion in the physical and natural sciences. It is the method of truth on which the received or scientific
view is based. Indeed, many philosophers of science consider truth by correspondence and the
received view one and the same (Table 8-3). Nevertheless, the received view and truth represent
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CHAPTER 8 Our Syntax: An Epistemological Analysis 151
two different processes. The received view addresses the process of research, the methodology by
which data are collected and theories are developed; truth attends to examining realities, the
results of the findings. Whereas the received view asks what to do to know, truth asks how to know
(see Table 8-1, and Table 8-3).
Empiricists, such as Bertrand Russell, and rationalists, such as J.E. McTaggart, preferring to
view truth through correspondence, have designed a set of rules and norms against which they
expect theory development and research to be analyzed. The most significant norm is that of tru-
ism of facts and their correspondence with their encompassing theories. One of the most signifi-
cant correspondence norms is total objectivity; a separation of the observer from the observed
world. Validation is based on congruence between propositions and reality. Reality means one
reality, an existing reality, and not reality as it may appear to different viewers. The theorist’s role
is to match the world with assertions and match the facts with concepts.
The positivists assert that correspondence truth is achieved through corroboration by verifica-
tion. Popper (1959) modified the positivist view and developed the argument for falsification. He
asserted that the central concept in scientific discovery is “marcation.” Demarcation criteria
require that we consider a proposition scientific only if it has the potential to be falsified. Verifica-
tion of the opposite statement occurs with multiple incidents of falsification of the statement
through experience. Once a single falsifying instance counters a proposition, the proposition
should be rejected. On the other hand, a proposition is not scientific if it does not have the poten-
tial for falsification. Continuous attempts to falsify statements make the scientific process rigor-
ous. Truth is achieved when we have exhausted all attempts at falsifying a proposition.
Although Popper warns against the potential for any entirely conclusive statement due to
problems of reliability in testing, we nevertheless come closer to the truth by testing and retesting,
TABLE 8-3 COMPARISON OF DIFFERENT THEORIES OF TRUTH
Analytical Unit Correspondence Coherence Pragmatism Integration
Norms Corroboration Logic Experience Experience and
utility illumination
Contexts Justification Experience Discovery and Justification
justification
Goals Acceptance/rejection Support Understanding Uncovering patterns
Reality One Pattern Multiple Diversity of views
Clicks into a
structure
Role of theorist Match world with Match with Match with users Openness to
assertions assertions Humanness multiplicity
Distance Involvement
Evaluation Verification Simplicity Utility Validation
Falsification Beauty Problem solving Verification
Logic
Utility multiple
Process End Process Process
Validation Congruence between Endurance of Consensus of Use patterns of
propositions and ideas users understanding
reality Restructuring Number of solved
New techniques problems
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152 PART THREE Our Discipline and Its Structure
with the objective of attempting to nullify and falsify the proposition under exploration. To the
correspondence theorists, whether verification or falsification is the focus, truth is achieved
through sensory data and controlled experiments. The correspondence of existing reality, of facts
and propositions, is the goal. No room exists for metaphysics, conceptual truths, multiple realities,
or for perceptions of reality. Other problems arise when viewing truth in mainly correspondence
terms. If facts exist, are not facts already affected by the concepts introduced to explain them?
There are other ways by which we can corroborate theoretical developments that may be
more congruent with epistemic diversity in our discipline. The “warrantable evidence” criteria
proposed by Forbes, King, Kushner, Letourneau, Myrick, and Profetto-McGrath (1999) for
reviews in nursing science could be utilized for the evaluation of theoretical formulations. The
“warrants” common to pluralistic nursing scholarship are:
1. Critical scrutiny of rigor by a community of scientists
2. Use of intersubjectivity
3. Wider scope of the evidence
One approach to establishing corroboration is to use critical reflection among scholars or
among participants (e.g., Gibson, 1999).
Coherence Theory
Truth through coherence differs considerably from truth through correspondence. Truth
through coherence is manifested by the logical way in which relationships and judgments relate.
Whereas the norms for correspondence are verification and falsification using sensory data, the
norms for coherence are an integration of relationships, simplicity of presentation, and a certain
beauty of propositions (Table 8-3). When separate components of a phenomenon “suddenly fall
into a pattern of relatedness, when they click into position,” then truth has been achieved (Kaplan,
1964, p. 314). Truth according to this theory endures, but perhaps in a more transitory fashion or
in ways that may not be reproducible but are no less recognizable. If the proposition is sufficient
for today, there is truth in it.
The coherence norms of logic, simplicity, and aesthetic presentation appear to be norms to be
used in both the context of discovery and the context of justification. They are most suitable, how-
ever, for the discovery of apparent realities. They lend themselves more to the evaluation of con-
cepts that are in the process of development than to those in the process of testing. Although
norms of correspondence and coherence may appear contradictory, it is nonetheless possible to
consider them as complementary. While using the coherence norms to judge and evaluate theo-
ries, we can also use correspondence norms to judge propositions that evolve out of research.
Pragmatism Theory
In the 1930s, a group of American philosophers, called pragmatists, advanced a third type of
theory about truth. In fact, according to Leslie Armour (1969), there are two types of pragmatic
theories of truth. First, an assertion is true if it produces the right type of influence on its follow-
ers. In other words, a proposition is declared to be true when its users determine its usefulness.
Experience and the ability to solve problems are two of the norms considered in this view of truth.
Second, a proposition or any theorized relationship is true if it receives confirmation from a person
or persons who have conducted the right investigations or who are designated as significant by the
community of scholars. Pierce (cited in Kaplan, 1964) suggests that, according to this theory, a
consensus between significant theoreticians or investigators is what constitutes truth.
Pragmatic truth depends less on evidence than on observations––on a declaration of effec-
tiveness by whatever methods the significant members of a community of scholars use. These
measures of effectiveness may be subjective, political, social, or objective. To the proponents of
this view, “a theory is validated, not by showing it to be invulnerable to criticism, but by putting it
to good use, in one’s own problems or in those problems of coworkers” (Kaplan, 1964).
A pragmatic theory of truth allows for the validation of theories through restructuring, use of
new techniques, or even better awareness and realizations of the meanings of old relationships.
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CHAPTER 8 Our Syntax: An Epistemological Analysis 153
The value of these new relationships lies not in the answers they may provide as much as in the
new questions they may ask and the consequences that result from their use (Kaplan, 1964).
Humanity, tentativeness, subjectivity, collectivity, and usefulness are all qualities attached to this
concept of pragmatic truth, which evolved out of the Chicago school of thought (Table 8-3).
Integrative Theory
A tension continues to exist between using a single paradigm, a pluralistic approach to para-
digms, or no paradigm to guide the development of nursing knowledge. Weaver and Olson (2006)
examined a number of paradigms in terms of their philosophical underpinnings and effectiveness
and concluded that no single paradigm emerged as superior for nursing research. The complexity
of human health experience and illness responses may require the use of all of them, or on a more
integrative approach as proposed by others (Aranda 2006, Ali, 2007), and in offering integrative
theory as an approach to discerning “truth” in the knowledge that is developed.
Furthermore, some conceptual problems are not as well addressed by any one of the theories
of truth in isolation. Laudan (1977, p. 54) identified three. The first of these problems is an intra-
scientific problem, which results from two theories representing two inconsistent domains. An
example is Rogers’ (1970) view of a unitary human being as an energy field and of behavior as the
manifestation of the pattern and organization of the energy field. This view presupposes a method-
ological approach to the study of a human being and his or her energy field as a whole. Con-
versely, Johnson (1974) views a social behavioral system, with seven subsystems revolving
around subsystem goals and manifested in observable behavior. Johnson presupposes a study of
humans by reducing humans to their behaviors (Table 8-3).
Because of the theoretical incompatibility between these two fundamental views of the nurs-
ing client, the nursing community may attempt (perhaps prematurely) to accept one in favor of the
other. The theorist’s commitment to adequacy and effectiveness may also prompt one to concede
to the other. Either of these alternatives to resolving the problem may fail because of the level of
conceptual and methodological knowledge. To reject Rogers’ conception of a unitary human
being as an energy field and behavior as a manifestation of pattern and organization of the energy
field will either create a reductionist scientific school of thought in nursing or will prompt Rogers,
a committed theorist, to continue to work on developing a more adequate theory of the unitary
human being. The latter option is acceptable for scientific development, but the former may
impede development because of its prematurity.
It is also possible that the newness of nursing as a discipline makes it easier to reject both
competing views in favor of another, more established view of a human being (such as one that
holds a person to be a biologic system), to the detriment of solving the central problem. Neither
correspondence nor coherence criteria could solve this issue; it is best addressed through a prag-
matic approach to truth.
Nursing, historically, has also been beset by other philosophical inconsistencies (Munhall,
1982). Existential and pragmatic philosophies have dominated clinical nursing, and positivistic,
empirical philosophies have attempted to dominate the academic discipline. This theoretical con-
fusion has managed only to temporarily impede nursing’s theoretical development. Laudan refers
to such conflict between emerging conflicting theoretical and methodological paradigms as nor-
mative difficulties. Those who believe that the correspondence norm has dominated nursing would
attribute the early rejection of nursing theories to this paradox.
It was once believed that the only credible theories in nursing were those inferred from
observable data. Others asserted that a nursing philosophy that espoused holism, integration, and
health was in direct conflict with its methodology of reductionism, objectivity, logic, measure-
ment, verification, and falsification. Where does the truth lie? Which of the two options should
nursing follow––the methodological view or the philosophical premise? Who determines the
truth––the methodologists or the theoreticians? None of the norms in isolation would provide us
with the truth. A combination of all may bring us closer.
A third difficulty that confronts theorists, and one that cannot be resolved by any one of the
theories, Laudan calls “prevalent world view difficulties” (Laudan, 1977, p. 61). This phenomenon
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154 PART THREE Our Discipline and Its Structure
is observed when myths, beliefs, history, and practice are in opposition with developing theories.
The prevalent nursing view ascribed to by clinicians is that nursing is practical and skill-
oriented and that its principles, as well as its skills, are derived from other disciplines. Nursing is
neither theoretical, says this worldview, nor academic.
Tension also exists between the researchers, who hold the belief that theories develop only
from research, and the theoreticians, who believe that theories are culminations of experience, his-
tory, and intuition, as well as research findings. There have been many “world views” in nursing,
with very few ascribing to a theoretical worldview. Weltanschauung attempts to address the many
problems that none of the truth theories can address in isolation.
The scope of meanings of responses, sense data, and findings is wide, and requires hetero-
geneity for different evolving “truths.” Judgment about the “truth” can depend not only on one
source of legitimacy (Clarke, 1999). In the face of relativism, subjectivism, postmodernism, and
deconstructionism and their ideas, truth still matters (Lynch, 2005). However:
People never think there is no truth of the matter; rather they think the other side is wrong.
(Gottlieb, 2005)
Therefore, there are diverse ways to establish truth, and one is by offering alternatives to cor-
respondence norms and to the received view. Suppe (1977) suggested that what is needed is a dif-
ferent way to analyze theories. He called this new way Weltanschauung and defined it as “a
comprehensive world view, especially from a specified standpoint.” According to Suppe, Weltan-
schauung is:
[an] analysis of theories which concerns itself with the epistemic factors governing the discov-
ery, development, and acceptance or rejecting of theories; such an analysis must give serious
attention to the idea that science is done from within a conceptual perspective which deter-
mines in large part which questions are worth investigating and what sorts of answers are
acceptable; the perspective provides a way of thinking about a class of phenomena which
define[s] the class of legitimate problems and delimits the standards for their acceptable solu-
tion. Such a perspective is intimately tied to one’s language which conceptually shapes the
way one experiences the world. (p. 126)
A Weltanschauung, an integrative worldview, of truth in theoretical nursing includes an inte-
gration of norms emanating from different theories of truth. It combines rigor and intuition, sen-
sory data as they exist and as they appear, perceptions of the subject and of the theoretician, and
logic with observable clinical data. What different theorists and researchers have advocated
merely as norms for the acceptance of propositions are not contradictory, because in some situa-
tions, events, and experiences, one set of norms is more appropriate than another. Some research
in nursing has been guided by the positivists’ views and by correspondence. Some theory develop-
ment has been guided by these norms as well. For example, Orlando and Johnson focused on observ-
able, verifiable behavior in developing theories (Johnson, 1974; Orlando, 1961). Rogers spoke of
experiences beyond the five senses (1970).
Nursing theoreticians, however, would not have developed their theories if they adhered to corre-
spondence norms. Numerous examples have shown that nursing has used a pragmatic theory of truth.
Johnson (1974) spoke about criteria for acceptance of knowledge as based on social responsibility and
about how knowledge and nursing action should make a valuable difference in the people’s lives.
Whether the model guiding nursing is right or wrong is a social decision and not exclusively a theo-
rist’s or researcher’s decision. Rogers (1970), in conceptualizing a unitary man as an energy field,
spoke of experiences beyond the five senses and therefore could not use correspondence norms to ver-
ify her conceptualization, but instead used coherence norms. Many others supported the necessity of
considering coherence norms in conceptualizing nursing and suggested that truth emanated from
logic (Batey, 1977; Beckstrand, 1978a, 1978b; Dickoff, James, and Wiedenbach, 1968).
The integrative truth in nursing theory utilizes a diversity of views about truth. It uses validation,
verification, simplicity, logic, consequences, clients, theorists, and actual or potential experiences as
norms against which to compare the truth of the theory. It reflects a broader notion of evidence
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CHAPTER 8 Our Syntax: An Epistemological Analysis 155
that relates to multiple sources of knowledge, particularly knowledge that has been marginalized
due to its softness (Kirkham, Baumbusch, Schultz, and Anderson, 2007). It accepts multiple reali-
ties and “a composite of realities” (Oiler, 1982). It accepts different expressions, different sources,
and criteria such as the number of solved problems within a discipline (Laudan, 1977).
CONCLUSION
Our syntax includes ways of knowing in nursing and approaches by which truth has been
defined. The received, perceived, interpretive, and critical patterns of knowing are more congru-
ent with the nature of nursing as a human science. The received view provided the canons for
acceptance and rejection of the road that nurses have taken in theory development. However, it is
a more acceptable approach to analysis and evolution of knowing within the context of justifica-
tion. The perceived view of knowing that guided nursing practice, nursing theory, and nursing
education historically has been more open, variable, relativistic, and subject to experience and
personal interpretations. It is holistic in approach and based on the perceptions of both the client
and the theoretician. The perceived view is more appropriate to the context of discovery. The
interpretive approach to knowing honors diversity and socioeconomic variations and provides a
view that is critical of gender inequity, as well as of power differentials due to social class, race,
and colonialism.
ing a theoretical framework for a
research question within your field of
practice. What are the most significant
properties that distinguish the process
you have selected?
7. What are the weaknesses and strengths
of each approach to truth discussed in
this chapter?
8. Discuss some of the values nurse scien-
tists hold that may support or negate
each of the ways of knowing and mod-
els of truth discussed in this chapter.
9. In what ways do values about knowing
in the United States, as well as in other
parts of the world, correspond or negate
each way of knowing discussed in this
chapter?
10. In what ways do major funding sources
for nursing research shape patterns of
knowing and models of truths in the
discipline of nursing? Take a pro or con
stand and defend it with evidence.
11. Discuss an Eastern philosophical way of
knowing (e.g., Buddhism) and critically
consider how it could enrich or constrain
knowledge development in nursing.
REFLECTIVE QUESTIONS
1. Discuss epistemic diversity and its
potential outcomes on practice that is
based on evidence (mostly defined from
a received view and correspondence
theory of truth).
2. Critically analyze the progress in the
discipline of nursing within the differ-
ent views of knowing. What criteria are
you using to arrive at your conclusion?
3. Identify ways of knowing within your field
of interest. Compare and contrast ways of
knowing in your field of interest with those
discussed in this chapter. In what ways are
they different or similar, and why?
4. Which one of our discipline’s epistemo-
logical traditions is likely to produce
the evidence needed for quality care
outcomes? Identify and define nursing
discipline-driven quality care outcomes.
5. Compare and contrast the strengths of
the different ways of knowing discussed
in this chapter. What other approaches
to knowing would you add to those dis-
cussed in this chapter?
6. Select one pattern of knowing and dis-
cuss how you would go about develop-
(Continued on page 156)
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156 PART THREE Our Discipline and Its Structure
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Reviewing and Evaluating:
Pioneering Theories
PART Four is devoted to a discussion of nursing theories in relation to current nursing
research, practice, and education. This part emphasizes several themes introduced in
other parts and develops them further by providing interpretive examples. A first
theme is that nursing theories can be reviewed and evaluated through many different
lenses and for different purposes. As you can see, Chapter 9 provides a framework
for a gestalt categorization of theories, which was used as a framework to classify
nursing theories in Chapters 11–13. The second theme is that nursing theories have
evolved from a sociocultural context, were influenced by the educational and experi-
ential background of the theorists, and cannot be understood or adequately analyzed
without considering these influences. The third theme is that existing theories are
not competitive but are complementary and may be used by the same person for dif-
ferent purposes or by different people for different purposes. The fourth theme is
that theories can be viewed, interpreted, and used in many different ways and are not
restricted to the purposes for which they were developed.
Theory users and their interpretations of theories are significant to the progress
of the discipline. A final theme, not directly or explicitly presented in this part, but
one that could be indirectly derived, is that progress in the discipline of nursing is
measured by the development of theories, the conduct of research programs, the
number of theorists and researchers, and the extent to which questions are uncov-
ered, as well as by the breadth and depth in answering central problems.
A model for evaluating theories is presented in Chapter 10. The model is used
in Chapters 11 through 13, which describe, analyze, critique, and provide examples
of tests of nursing theories. Central domain concepts are defined within each theory.
I also encourage you to consider other domain concepts and other nursing theories.
Although the theories are organized to reflect a particular classification system
(Chapter 9), the description is general and encompasses as much of the theorists’
conceptualizations as possible.
P A R T F O U R
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C H A P T E R 9
Nursing Theories Through Mirrors,
Microscopes, or Telescopes
Pioneering nursing theories are reviewed integratively in this chapter. They are exposed to a dif-
ferent lens as a group. This approach allows us to categorize them in terms of their broader epis-
temic origins and in terms of the broad questions the theorists attempted to address. In some ways,
the more contemporary multidimensional analysis (MDS) proposed by Beckstead and Beckstead
(2006) may lead to a more objective categorization of theories that reflects the intellectual her-
itage of theories based on patterns in the citations used. However, even with such objective and
quantifiable analysis, the use of nonmetric and nominal data (theorist cited or not cited) needs to
be complemented by systematic content analysis to determine how the citation of a paradigmatic
origin is utilized, and whether or not the paradigm citation was positively or negatively used. They
contend, and I agree, that multiple methods of analysis help in understanding phenomena.
The phenomena in this chapter are the theories themselves as a whole, responding to such
questions as: What do they reflect? What are their goals? What are the similarities and differences
between them? Can we classify and categorize them to provide some generalization? And, more
importantly, are there some common themes and patterns to describe them?
I have chosen to subject the theories collectively to mirrors, microscopes, and telescopes.
Mirrors reflect all or parts of reality, depending on the type of mirror, and give the parts of reality
different shapes; microscopes zero in on yet another part of reality and magnify it within or with-
out context, and telescopes bring faraway objects and events within reach for observations, careful
study, and better understanding. Nursing theories reflect different realities as seen through mir-
rors, microscopes, or telescopes.
Throughout their development, these theories reflected the interests of nurses of the time, the
sociocultural context, and the theorists’ educational and experiential backgrounds. When we con-
sider all the theories together and hold them up to the realities of nursing practice, a number of
other images are then formulated. The images are not always distinct, well-formulated, or true
mirror images; however, they are not mirages or figments of the theorists’ imaginations either.
They reflect some realities of nursing at the time of development, and they help to shape the reali-
ties of nursing care over time.
This chapter provides several ways in which theories, which are an integral part of our his-
tory, can be viewed. These ways are neither mutually exclusive nor inclusive. They are pre-
sented to stimulate other innovative ways in which to view and classify nursing theories. The
purpose of these different views and classifications is twofold. First, the more ways in which
we can analyze any phenomenon, the more potential we have for seeing different images and
details that are not readily apparent when only viewed from one perspective. The second pur-
pose is related to the first: using theories for different purposes is enhanced by the many differ-
ent perspectives from which we view the theories. It is like seeing the image of a garden in a
mirror, showing many flowers, many colors, and many beds, and then moving the mirror closer
to a bed of California poppies and seeing the rich orange-yellow cups swaying in the fine
breeze, then keeping the mirror in position and stepping back a few feet to get another look, to
discover the different shades of color blending with the green of the stems. Each image depends
on the position of the mirror in relation to the garden and the location of the viewer in relation
to the mirror and the garden. Similarly, using microscopes or telescopes will provide different
highlights and details.
The first section of this chapter provides an analysis of nursing theories that were devel-
oped between 1950 and 1980, according to the images of nursing of that time. In the second
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CHAPTER 9 Nursing Theories Through Mirrors, Microscopes, or Telescopes 161
section, theories are classified according to their primary focus and according to how they will
be evaluated in this book. In the third section, theories are classified according to images of
nurses and the roles that nurses may play. Roles played by nurses are to a large extent deter-
mined by the theoretical perspective guiding their practice. In the fourth section, areas of agree-
ment among and between theories are presented. Whether these are the same images or the
same classifications that the theorists saw when they developed their theories is neither dis-
cussed nor debated here. What becomes apparent is that the theories together offer a number of
images translated into concepts, that both the images and the concepts are reflected in the theo-
ries, and that they reflect nursing practice simultaneously. The classification systems sometimes
reflect the hindsight of critics rather than of the theorists themselves. One of the earliest classi-
fications of theories was done in 1960 by Johnson, which she used in teaching nursing theory
for master students at the University of California, Los Angeles. She classified them by their
paradigmatic origins as:
. . . models based on the developmental theories of Erikson (1963), Freud (1949), Maslow
(1954), Peplau (1952), C. Rogers (1959), and Sullivan (1953), and based on the behaviorist
school (Bijou and Baer, 1961). Among the systems models are found the adaptation system
model of Roy (1970), the triad system of Howland and McDowell (1964), the life process sys-
tem of M. Rogers (1970), and Johnson’s behavioral system model (1968). . . . Then, in addi-
tion, there is another type of model for nursing practice, called an interaction model, since its
conceptual system is dependent on symbolic interaction theory. The most well-known models
in this group are those of Orlando (1961) and Wiedenbach (1964). (Johnson, 1974, p. 376)
See Figure 9-1.
Other ways of classifying theories include the chronological context for the development of
theory, temporal dimensions focusing on different sociocultural contexts, central theory questions,
and central concepts. The purposes of these proposed analyses along the different dimensions are
H. Peplau
J. Paterson & L. Zderad
I. Orlando
J. Travelbee
E. Wiedenbach
I. King
1950
1955
1960
1965
1970
1975
1980
V. Henderson
D. Johnson
D. Orem
F. Abdellah
L. Hall
M. Levine
M. Rogers
C. Roy
B. Neuman
FIGURE 9-1 ◆ Chronology of nursing theories.
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162 PART FOUR Reviewing and Evaluating: Pioneering Theories
twofold: to provide opportunities for critical thinking about theoretical nursing and to stimulate
the development and use of a variety of analytical frameworks. Each analysis uncovers different
aspects and different explanations within and about the theories, and each different analysis and
explanation could drive and further the development of theoretical nursing. The analyses of theo-
ries using these dimensions resulted in three distinct patterns or schools of thought (Table 9-1).
Each school of thought is presented and discussed in this chapter and in the following chapters.
Members of each school of thought are compared in terms of their views of nursing, focus of nurs-
ing, goals of nursing, nursing problems, and nursing therapeutics. The images of nurses and the
central roles that nurses are expected to play when adopting a particular school of thought to prac-
tice are also compared and contrasted in this chapter.
IMAGES OF NURSING, 1950–1970
The First School of Thought: Needs
This school of thought includes theories that reflect an image of nursing as meeting the needs
of clients, and these theories were developed in response to such questions as:
What do nurses do?
What are their functions?
What roles do nurses play?
Answers to these questions focused on a number of theorists describing the functions and
roles of nurses. Conceptualizing functions led theorists to consider a nursing client in terms of a
hierarchy of needs. When any of these needs are unmet, and when a person is unable to fulfill his
own needs, the care provided by nurses is required. Nurses then provide the necessary functions
and play those roles that could help patients meet their needs.
Peplau (1952) preceded Henderson (1964) by providing a theoretical construct of what nurs-
ing is. Hers was a theory designed to give focus to psychiatric nursing. Therefore, although
intrapsychic needs play a major role in her theory, her interest and experience in psychiatric nursing
prompted her introduction of nurse–patient interpersonal relationships as a focus in nursing.
Henderson’s theory, in keeping with the intrapersonal focus of the time and not deviating com-
pletely from medical science, was conceived to describe all nursing care goals in terms of the needs
of patients and in terms of activities that are motivated and driven by patients’ hierarchy of needs.
This school of thought, of need deficits or nurse functions, also included Faye Abdellah (1969)
and Dorothea Orem (1995). One may refer to this group as the need or deficit school of thought,
which is based on Abraham Maslow’s (1954) hierarchy of needs and influenced by Eric Erickson’s
(1978) stages of development (with a neo-Freudian orientation). Although proponents of this
school of thought were the first to promote nursing functions as distinct from medical functions, the
theories developed within this school were still greatly influenced by the biomedical model.
Because most of the theorists who focused on needs and need deficits in patients either graduated
from or worked at Columbia University in New York, this school of thought could also be called the
TABLE 9-1 SCHOOLS OF THOUGHT IN NURSING THEORIES—1950–1970
Needs Theorists Interaction Theorists Outcomes Theorists
Abdellah King Johnson
Henderson Orlando Levine
Orem Paterson and Zderad Rogers
Peplau Roy
Travelbee
Wiedenbach
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CHAPTER 9 Nursing Theories Through Mirrors, Microscopes, or Telescopes 163
TABLE 9-2 NEEDS THEORISTS—A VIEW OF NURSING
Theorists Definition of Nursing
Abdellah Use of problem solving approach to deal with 21 problems related to needs of patients
Henderson Helping with 14 activities contributing to health or recovery, help the individual become
independent of assistance
Orem Self-care agency to meet individual’s need for self-care action in order to sustain life and
health, recover from disease or injury, and cope with the effects
TABLE 9-3 NEEDS THEORISTS—FOCUS OF NURSING
Theorists Focus of Nursing
Abdellah Problem solving approach to 21 nursing activities, sustenal, remedial, restorative, preventive,
self-help, need deficit or excess
Henderson Assistance with 14 daily activities or needs
Orem Deficit between self-care capabilities and self-care demands of patients
Columbia school of thought. Although the theorists may not attribute the development of their theo-
ries to their work or association with Columbia University, by noting that they have a common edu-
cational background, we may be able to consider themes of shared assumptions as well as shared
goals, and therefore explore the influence of Columbia Teachers College on nursing theory develop-
ment and the development of early scholars. Judging from the number and caliber of international
students who graduated from that institution, Columbia Teachers College may have had a significant
influence on the development of theoretical nursing in other countries as well. The extent of the
influence of this university on the development of schools of thought, and on the development of
nursing education and practice nationally and internationally, is yet to be examined.
As Tables 9-2 through 9-6 indicate, “Needs Theorists” provided us with a view of a human being
that was slightly different but close to the view provided by the biomedical model. The hierarchy of
needs begins with physiologic and safety needs and progresses to include other higher-level needs,
such as belonging, love, and esteem. Neither Henderson nor Abdellah considered self-actualization
needs as within the province of the nurse (as manifested in the omission rather than the commis-
sion); Orem added the development of self-care requisites as she continued to develop her theory.
A summary of the needs theorists’ conceptualization of nursing is presented in Table 9-7.
The focus of this school of thought, then, is on problems and needs of patients as seen by health
care providers and on the role of nurses to assess these needs and to fulfill the need requisites.
When lower needs are met, more mature needs may emerge (Peplau, 1952). Perceptions of clients,
a focus on environment, and the role of nurse–patient interactions in dialogues and intervention
are not fully developed.
A Second School of Thought: Interaction
A second set of questions was then beginning to be formulated, based on a view of nursing as
supporting and promoting interactions with patients. The theorists in this group did not totally
ignore the first set of questions; rather, the new sets of questions complemented the first. Whereas
the first questions that guided earlier theorists were related to the central one—“What do nurses
do?”—the second set of questions evolved from the Yale University School of Nursing and was
related to another central question—“How do nurses do whatever it is they do?” Answers to the
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164 PART FOUR Reviewing and Evaluating: Pioneering Theories
TABLE 9-7 NEEDS THEORISTS—A SUMMARY
Concepts Defining Properties
Focus Problems
Nurses’ function
Human being A set of needs or problems
A developmental being
Patient Needs deficit
Orientation Illness, disease
Role of nurse Dependent on medical practice
Beginnings of independent functions
Fulfill needs requisites
Decision making Primarily health care professional
TABLE 9-6 NEEDS THEORISTS—NURSING THERAPEUTICS
Theorists Nursing Therapeutics
Abdellah Preventive care (hygiene, safety, exercise, rest, sleep, body mechanics)
Sustenal care (psychosocial care)
Remedial care (provision of oxygen, fluid, nutrition, elimination)
Restorative care (coping with illness and life adjustment)
Henderson Complementing and supplementing knowledge, will, and strength of patient to perform
14 daily activities and to carry out his medical prescriptions
Orem Wholly compensatory system (nurse performs all self-care for patient)
Partly compensatory system (nurse and patient perform patient self-care)
Supportive-educative system (nurse helps in overcoming any self-care limitations)
TABLE 9-4 NEEDS THEORISTS—GOALS OF NURSING
Theorists Goals of Nursing
Abdellah Help individual meet health needs and adjust to health problems
Henderson Completeness or wholeness and independence of patient to perform daily activities
Orem Eliminate deficit between self-care capabilities and demand
TABLE 9-5 NEEDS THEORISTS—NURSING PROBLEMS
Theorists Nursing Problems
Abdellah Condition faced by patient for which a nurse can assist, overtly and covertly (21 problems)
Henderson Patient’s lack of knowledge, strength, or will to carry out 14 activities
Orem Deficiency in eight universal, two developmental, and six health deviation requisites/needs
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CHAPTER 9 Nursing Theories Through Mirrors, Microscopes, or Telescopes 165
“how” question focused on the interaction process. Peplau was the pioneer in that group (1952);
yet, her answer was more congruent with the prevailing interest at the time in psychoanalytic the-
ory and closer to the biomedical model. It is significant when studying the history of ideas to note
the connection between the first school of thought at Teachers College and the second one at Yale.
The Yale or interactionist school of thought grew out of the needs approach, with some of the con-
cepts still prevailing in both; this will be demonstrated in the following discussion. The conceptu-
alization of Imogene King (1968), also a graduate of Teachers College, evolved out of interest in
the “hows” of making decisions about nursing care.
Interaction theories were conceived in the late 1950s and early 1960s by theorists who viewed
nursing as an interaction process with a focus on the development of a relationship between patients
and nurses. These theories grew out of a social milieu in the United States that included the following:
• This was the post-Sputnik era.
• There was a focus on such values as human integrity, as promoted by President Kennedy.
• The Cuban missile crisis may have promoted a return to focus on humanity and relation-
ships against the fear of outside invasion.
• The beginning formation of hippie groups, communal living, and the flower children
indicated a definite need for intimacy and human relations.
• Technological advances continued, but with a growing distaste for mechanization and
dehumanization.
Interaction theories also reflected several changes that were ongoing within the profession of
nursing. Among them were two that had a direct impact on the development of interactional theories:
• Federal grant support was designated to improve the curricula and education of nurse
researchers.
• A pioneering effort to develop an integrated curricula arose, freeing psychiatric nurses to
identify core concepts and to integrate these concepts throughout nursing curricula, and
allowing them to observe and reflect on the processes of utilizing mental health concepts
in all nursing subspecialties.
Tables 9-8 through 9-12 present theories that focused on interaction. Although some of the
interaction theorists continued to address the needs of the patient, all the interactionist theorists
TABLE 9-8 INTERACTION THEORISTS—A VIEW OF NURSING
Theorists Definitions
King A process of action, reaction, and interaction whereby nurse and client share information
about their perceptions of the nursing situation and agree on goals
Orlando Interaction with patients who have a need or response to suffering individuals or those
anticipating helplessness
Assistance to individual to avoid, relieve, diminish, or cure sense of helplessness
Paterson and Zderad A human dialogue, intersubjective transaction, a shared situation, a transactional
process, a presence of both patient and nurse
Peplau Therapeutic interpersonal, serial, goal-oriented process
A health-focused human relationship
Travelbee An interpersonal process, an assistance to prevent, cope with experiences of illness and
suffering, and to find meaning in these experiences
Wiedenbach Sensing, perceiving, validating patients need for help, ministering help needed in a
deliberate, goal-oriented way
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166 PART FOUR Reviewing and Evaluating: Pioneering Theories
focused on the processes of care and on the various interaction episodes between nurses and
clients. Their theories were based on interactionism, phenomenology, and existentialist philosophy.
See Table 9-13 on page 168 for a summary of the major components of the interaction theories.
What did we learn from the interactionists?
• Nurse–patient interaction is fundamental to providing care.
• Nursing is a deliberate process that can be elucidated.
• Nursing encompasses help and assistance.
• Nursing is an interpersonal process occurring between a person in need of help and a per-
son capable of giving help.
• The nurse, to be able to give help, should clarify her own values, use the self in a therapeu-
tic way, and be involved in the care.
TABLE 9-10 INTERACTION THEORISTS—GOALS OF NURSING
Theorists Goals of Nursing
King Help individuals maintain their health so they can function in their role
Orlando Relieve distress, physical and mental discomfort
Improve sense of well-being
Paterson and Zderad Develop human potential, more well-being for both patient and nurse
Peplau Develop personality, making illness an eventful experience
Forward movement of personality and other ongoing human processes in the direction of
creative, constructive, productive personal and community living
Travelbee Cope with an illness situation and find meaning in the experience
Assist patient to accept humanness
Wiedenbach Meet the needs of an individual experiencing need for help
TABLE 9-9 INTERACTION THEORISTS—FOCUS OF NURSING
Theorists Focus of Nursing
King Nurse–patient interactions that lead to goal attainment in a natural environment
Orlando Care for the needs of the patients who are distressed, with consideration for perception,
thought, and feeling through deliberate action
Paterson and Zderad Patient is a unique being
Patient’s perception of events
Both patient and nurse are the focus
Peplau Nurse–patient relationship and its phases
Orientation, identification, exploitation, and resolution
Harnessing energy from anxiety and tension to positively defining understanding, and
meeting productively the problem at hand
Travelbee Interpersonal relations, finding meaning in suffering, pain, and illness
Self-actualization
Wiedenbach Patient’s perception of condition, care, action
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CHAPTER 9 Nursing Theories Through Mirrors, Microscopes, or Telescopes 167
• Care is not a mechanistic act but a humanistic act.
• The humanistic interactionist nurses used existential philosophy, symbolic interaction, and
developmental theories to develop their conceptions of nursing.
• Patient-centered care is based on developing a relationship with patients.
• Illness is defined as an inevitable human experience; if one learns to find meaning in it, it
will become a growing experience. In this, these theorists differ from the previous group
of theorists who defined illness as a deviation that must be corrected.
• Nursing is defined as caring, assisting (all other health care professionals), and helping
patients to find meaning and actions that increase human potential and improve well-
being.
• Nurses need systematic knowledge to help them in assessing, diagnosing, and intervening.
• The nursing process is well developed by these theorists.
• Properties, antecedents, and consequences of interactions are advanced by this group of
theorists, and all the theories reflect the relationships that are formed to relieve distress, as
well as those formed to enhance trust.
TABLE 9-11 INTERACTION THEORISTS—NURSING PROBLEMS
Theorists Nursing Problems
King When nurse and patient do not perceive each other, the situation, or communicate
information, transactions are not made, goals are not attained
Orlando Distress due to unmet needs
Paterson and Zderad Persons with perceived needs related to the health/illness quality of living
Peplau Unsuccessful or incomplete learning of life tasks
Energy used in tensions and frustrations due to unmet needs, opposing goals—giving
rise to conflict, aggression, anxiety
Discomfort, anxiety, doubt, guilt, obsession, compulsion
Travelbee Lack of support in nurse–patient relationship
Not finding meaning in illness, transitory discomfort, anguish, malignant despair,
apathetic indifference
Wiedenbach Person with need for help (unmet needs due to physical or inadequate environment)
TABLE 9-12 INTERACTION THEORISTS—NURSING THERAPEUTICS
Theorists Nursing Therapeutics
King Goal attainment, transaction, perceptual validation
Orlando Deliberate nursing process not automatic
Paterson and Zderad Humanness—use of nurse’s self, existential nurturing, being, relating, meeting,
maximum participation
Peplau Development of problem-solving skills through the interpersonal process (educational,
therapeutic, and collaborative)
Travelbee Use of nurse’s self, original encounter, emerging identities, empathy, sympathy, rapport
Wiedenbach Ministration of help, validation, rational, reactional, and deliberate
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168 PART FOUR Reviewing and Evaluating: Pioneering Theories
• These theories mark the beginning of a movement that led toward the patient becoming an
equal partner in the nursing process.
• The interactionist nurse considers uniqueness, dignity, and worth values of patients as
important in the development of wellness. The view of an autonomous individual with
individually established norms was beginning to emerge. Help, it was emphasized, was to
be tailored to individual needs.
• Properties of interaction as validation (Wiedenbach), as meeting the needs of patients
(Orlando), as being totally present, and as relating to others (Paterson and Zderad) are
delineated and defined by this group of theorists.
• The theories concede that perceptions of the patient are important in assessing illness and
its meaning.
• The major nurse–patient interaction relationship goal is derived from their observation that
the person in need of help becomes distressed; the purpose is to prevent or deal with this
distress.
• The interactionist theorists remind us that nurses are human beings who need to participate
in self-reflection to understand their own values. Without such understanding, nurses will
not be able to care, give care, establish connections, and help patients relieve their distress.
• The theorists tentatively introduced the notion of effect of environment on patients. To
them, unmet needs of the patient develop because of:
~ Physical limitations (from incomplete development, temporary or permanent disability,
or restrictions in environment)
~ Adverse reactions to inadequate environment (Orlando)
• This group of theorists reintroduced the significance of nurses’ intuition and subjectivity
in the nursing act.
• Some common assumptions guided the development of the interactionist theories. These are:
~ The integrity of an individual has to be maintained.
~ Individuals have self-awareness and are therefore able to identify their needs.
~ Individuals strive toward actualization.
~ Events in life are human experiences inevitable and essential in helping to move to the
next stage in development.
TABLE 9-13 INTERACTION THEORISTS—A SUMMARY
Concepts Defining Properties
Focus Nurse–patient interactions
Illness as an experience
Human being Interacting being
A set of needs
Can validate needs
Human experience with meanings
Patient Helpless being
A human experience with meaning
Orientation Illness/disease
Role of nurse Deliberate helping process
Self as a therapeutic agent
Use of the nursing process
Decision making Primarily health care professional
Validated by clients
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CHAPTER 9 Nursing Theories Through Mirrors, Microscopes, or Telescopes 169
~ The nurse cannot separate herself as an individual from the act of care—the nurse is an
integral part of care.
~ Within the historical context of the discipline’s development interaction theorists pro-
vided nursing with a new perspective on viewing the nursing care act:
~ There is a reciprocal assessment process.
~ Patient perspective is significant in health care.
~ Situation determines needs and care.
~ Patients are helpless and suffer due to illness.
A number of concepts were identified by the interaction theorists as central to nursing. These
concepts continue to be significant components of the discipline of nursing. These concepts are
integral to nurses’ roles and actions in planning, providing, and evaluating care:
Sensing
Perceiving
Validating
Existential transactions
Goal orientation of interaction
Nurses’ self-development
Interaction theories neither addressed nor focused on:
A more complete view of a human being (human beings are interacting beings with a
minimal focus on biopsychocultural focus) as a biophysiological and a genetic being
A view of the environment, although the centrality of environment was tangential in some
of the theories
The Third School of Thought: Outcomes
The third set of questions that nurse theorists asked was related to the central question—
the “whys” of nursing care. Although not ignoring the “what” and “how” questions, this group
of theorists attempted to conceptualize the outcomes of nursing care and then described the
recipient of care. The image of nursing as portrayed by this group of theorists is that of concern
over the outcomes and end results of the caring processes. Two of the most influential theorists
in this group are Dorothy Johnson (1968) and Martha Rogers (1970). They graduated from
Harvard and Johns Hopkins, respectively, but did most of their work at opposite ends of the
North American continent—Los Angeles and New York, respectively. This East/West school of
thought is referred to in this book as the outcomes school of thought. (Other theorists who
belong to this school of thought are Levine and Roy, and their theories are discussed at length in
Chapter 13.)
Johnson influenced theoretical thinking in nursing, and her theory will influence nursing
more so in the future than it did in the past as the goals of nursing become more congruent with
stability than with change (Hall, 1983). Rogers, on the other hand, has helped to shape nursing
research based on theoretical thinking. Neither theory is as developed as that of Sister Callista Roy
who, as nursing director of Mount St. Mary’s (Los Angeles, California) had the faculty resources
to implement her theory into courses and content, thereby helping in turn to operationalize the the-
ory further. Both Johnson and Rogers, with faculty members of the University of California, Los
Angeles, and New York University, respectively, have also partially operationalized their theories,
but not to the same extent. Roy’s publications on the uses of theory in practice have enhanced the
use of her theory in several schools of nursing. Myra Levine, who views the goals of nursing as
conservation of energy, also belongs in this group.
This group of theorists (Tables 9-14 through 9-19) conceptualized the goal of nursing care as
bringing back some balance, stability, and preservation of energy, or enhancing harmony between
the individual and the environment. They based their conceptualizations on system, adaptation,
and developmental theories. They directed their focus on the outcomes of care. Their view of a
human being and the nursing client incorporated the need theorists’ conceptualization of the
human being experiencing need deficit, having problems, and needing nursing care. (The goals of
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170 PART FOUR Reviewing and Evaluating: Pioneering Theories
TABLE 9-15 OUTCOMES THEORISTS—FOCUS ON NURSING
Theorists Focus of Nursing
Johnson Man as a behavioral system with subsystems, each having a structure, a function, and
functional imperatives (drive, set, behavior) and each requiring protection, stimulation,
and nurturance
Levine Four principles guide conception of human being (energy, personal, structural, and social
integrities) and their organismic responses (fear, inflammation, stress, sensory)
Nursing is conservation of energy and integrities
Rogers Life processes of human beings, unitary person–environment energy fields, complementarity,
resonance, and helicy
Roy Focal, contextual, and residual stimuli and their effect on the cognator and regulator
mechanisms, in turn affecting four adaptive modes: physiologic, self-concept, role function,
and interdependence
TABLE 9-16 OUTCOMES THEORISTS—GOALS OF NURSING
Theorists Goals of Nursing
Johnson Behavioral system balance, subsystems that function efficiently and effectively
Levine Conservation of energy and integrities (personal, structural, social), restoration of well-being and
independent activity
Nursing is conservation of energy and integrities
Rogers Promote symphonic interaction and harmony between man and environment
Strengthen coherence and integrity of human field
Roy Promote person’s adaptation in physiologic needs, self-concept, role function, and interdependence
TABLE 9-14 OUTCOMES THEORISTS—A VIEW OF NURSING
Theorists Definitions of Nursing
Johnson External regulatory force acting to preserve the organization and integration of patient’s
behavior at an optimal level when behavior is a threat to social, physical health, or illness
Levine Patient advocacy, devotion to humanity and self-respect of patient, perception and support
for personal and individualized needs, compassion, commitment, and protection
Rogers Humanistic science for maintaining and promoting health, preventing illness, caring for and
rehabilitating the sick and disabled
Roy Theoretical system of knowledge viewing client as biopsychosocial being (ill or potentially
so) who adapts to changing environment
Nurse acts through nursing process to promote adaptation
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CHAPTER 9 Nursing Theories Through Mirrors, Microscopes, or Telescopes 171
subsystems of behavior in Johnson’s theory and adaptive modes by Roy have parallels in the hier-
archy of needs by Henderson, nursing functions by Abdellah, and universal needs by Orem.)
Although they spoke of harmony with the environment, stability, conservation of energy, and
homeostasis as potential outcomes, the consequences are at a high level of abstraction, limiting
the utility of these theories in outcomes measures. The outcomes theories provide nursing with a
well-articulated conception of a human being as a nursing client and of nursing as an external reg-
ulatory mechanism (Table 9-19).
A Fourth School of Thought: Caring/Becoming
Caring theories emerged in the 1980s and were influenced by existential philosophy and by
principles of equity in relationships. The questions that guided the development of caring theories
are “What do nurses do?” (care for patients), and “How do nurses do what they do?” (by caring
for patients). These are somewhat similar to those questions that prompted the development of
interaction theories. (Theories that are central to this school of thought are not analyzed in this
volume.)
Therefore, caring human/becoming theories have many similarities to interaction theories.
However, caring theories elucidate the act of caring in interactive situations, based on values that
honor and respect human capacity, spirituality and dignity, hope, trust, and altruism in giving and
receiving care. According to Jean Watson (1979, 1988, 1999, 2002), the very act of caring for oth-
ers is considered caring for the self. Rosemarie Parse’s (1981, 1995, 1998) central conception of
nursing is the transformation of the nurse and the client during the act of providing and receiving
care (Cody, 2000; Cowling, 1989). The process of care is defined as a process of becoming for
both clients and nurses; however, transformation is only possible if each is open to it (Baldurs-
dottir and Jonsdottir, 2002). Patients and nurses are human beings who are coexisting and
coconstituting rhythmic patterns with their environments, and choosing meaning and bearing
TABLE 9-17 OUTCOMES THEORISTS—NURSING PROBLEMS
Theorists Nursing Problems
Johnson Structural functional stress in one subsystem (insufficiency, discrepancy) and between subsystems
(incompatibility, dominance)
Levine Response to fear, response to stress, inflammatory response, sensory response
Rogers Disruptions in organization and structure of interacting human–environment fields
Roy Ineffective coping mechanisms causing ineffective responses that disrupt the integrity of the
person
TABLE 9-18 OUTCOMES THEORISTS—NURSING THERAPEUTICS
Theorists Nursing Therapeutics
Johnson Inhibition, constriction, supplementation, protection, nurturing (supportive/maintenance, teaching,
counseling, and behavior modification)
Levine Therapeutic—alter course of adaptation
Supportive—maintain course of adaptation
Rogers Repatterning of human environment fields or assistance in mobilizing inner resources
Roy Manipulation of focal, residual, and contextual stimuli with patient’s zone of positive coping
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responsibilities for their actions. They are actors and reactors simultaneously, and every caring act
transforms both to different levels of being.
Caring human being theories, although evolved from interaction theories, Parse’s in particu-
lar, are based on Rogerian views of uniting human beings and on the ideas of energy and connec-
tion between people and their environments (Watson and Smith, 2002).
Tables 9-20 to 9-25 present theories of caring. Although these theories address nurse–patient
interactions, the process of caring occurs between two independent human beings who connect
equally in a relationship that transforms them both.
Caring theories have taught us that:
• The fundamental act of caring is central in processes that bring patients and nurses
together.
• Caring is central to the discipline of nursing.
• Nurses giving the care, if done right, emerge out of the relationship transformed because
caring for another human being affects them profoundly.
• Meanings of health–illness situations are determined individually and modified collec-
tively.
• Choices, values, interpretations, and meanings are rights of both patients and nurses.
Understanding each other’s perspectives is part of the caring act.
• The moment of nurse–patient encounter involves connection and dialogue on how the
relationship is formed and what the consequences are.
• Although the nurse and patient have a historical context, it is the current moment that
shapes their interaction and the consequences of their interaction.
• Nurses and persons/communities are transformed by their encounters.
172 PART FOUR Reviewing and Evaluating: Pioneering Theories
TABLE 9-19 OUTCOMES THEORISTS—A SUMMARY
Concepts Defining Properties
Focus Energy
Balance, stability, homeostasis presentation
Outcomes of care
Human being Adaptive and developmental being
Patient Lack of adaptation
Systems deficiency
Orientation Illness, disease
Role of nurse External regulatory mechanism
Decision making Primarily health care provider
TABLE 9-20 CARING THEORISTS—A VIEW OF NURSING
Theorists View of Nursing
Watson Nursing is a human science consisting of knowledge, thought, values, philosophy, commitment,
and action with passion in human care transactions.
Parse Nursing helps human beings towards becoming through choosing ways of cocreating their own
health and finding meanings in situations.
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CHAPTER 9 Nursing Theories Through Mirrors, Microscopes, or Telescopes 173
TABLE 9-21 CARING THEORISTS—FOCUS OF NURSING
Theorists Focus of Nursing
Watson Transpersonal caring relationship. A moral commitment to protect and enhance human dignity.
Allow human beings to determine and find their own meaning.
Parse Unitary being with freedom to choose and decide. Nursing guides unitary human beings in
finding meaning in situations, in choosing ways to cocreate their health and to deal with
illness. Nursing guides in authentic living in the day and dayness of a human being’s life.
TABLE 9-22 CARING THEORISTS—GOALS OF NURSING
Theorists Goal of Nursing
Watson Mental and spiritual growth for human beings (nurses and clients), finding meaning in one’s
own existence and experience.
Parse Cocreating meaning and finding ways of being. Transforming through coconstituting new ways
in deliberate ways through the human universe process.
TABLE 9-23 CARING THEORISTS—NURSING PROBLEMS
Theorists Nursing Problem
Watson Imbalance caused by deficit in human transcending; disharmony among the mind, body and
soul, between person and world.
Parse A pattern of human–universe rather than a disease or a problem, process related to
man-living-health tied to meaning, rhythmicity and contranscendence. Discontinuity and
interruption.
TABLE 9-24 CARING THEORISTS—NURSING THERAPEUTICS
Theorists Nursing Therapeutics
Watson Use of entire self in affirming the subjective significance of a person. Detecting and responding
to true feelings of human beings.
Parse Practice methodology: illuminating meaning, synchronizing rhythms and mobilizing
transcendence through being truly present with a person or a group.
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174 PART FOUR Reviewing and Evaluating: Pioneering Theories
THEORIES’ PRIMARY FOCUS
Nursing theories are further classified in this text according to their primary focus. In classifying
theories for analysis, it is assumed that each classification system adds more understanding to
each theory. Correspondence between each of the classification systems is neither presented nor
discussed in this text. You, as a theory student, may wish to consider the relationship between the
different classification systems and critically consider how classification systems may enhance
understanding of each of the theories.
In reviewing the theories for classification, I have included in the analysis central domain
concepts, the central questions the theory addresses, and those areas that seem to be most devel-
oped. Each of these was used to guide the theory classification. Four central foci appear to reflect
the theories: clients, person–environment interactions, interactions, and nursing therapeutics.
Although theories may appear to have more than one focus, my decision to place a theory within a
particular focus in this text was based on my decision to select a primary focus for the sake of
analysis and discussion.
Johnson, Roy, and Neuman focused their theoretical development on the client or the client
system. These theories provide a comprehensive analysis of the client as seen from a nursing per-
spective. Although each of these theorists also discussed how health is defined within their theo-
ries, these concepts do not appear to be as central in these theories. Hence, Johnson’s, Roy’s, and
Neuman’s works were classified as client-focused theories, and also as outcome theories, and they
appear in Chapter 13 as such. These theories have been instrumental in changing the definition of
human beings from biomedical beings to psychosocial beings.
Rogers’ central focus is on the relationship between clients and their environment. In fact,
clients in Rogers’ theory are the environment, and one cannot be assessed in isolation from the
other. Rogers’ theory is one of the most supportive of the centrality of environment in the mission
of the discipline of nursing; however, because its focus is on the outcome of promoting harmony
with the environment, it could also be classified as an outcome theory.
The properties, components, and nature of the interactions between clients and nurses were
the focus of several theoretical formulations. King, Orlando, Paterson and Zderad, Travelbee, and
Wiedenbach concentrated on nurse–patient interactions and considered them the focus of nursing.
These theories are evaluated in Chapter 12.
What nurses should do and under what circumstances these actions should be delivered were
the focus of theoretical formulations in Levine’s and Orem’s theories. These theories are therefore
evaluated as theories that could provide nurses with frameworks for intervention. However,
TABLE 9-25 CARING THEORISTS—A SUMMARY
Focus Human–universe health process, meaning, mutual relations, unity of body, mind and spirit,
humanity.
Human being Man-living-health; continuously becoming and continuously in relationship with their
environment.
Patient Unique human being with ability toward transformation and transcendence, disharmony
between spirit, body, mind, soul. Felt and experienced a sense of incongruence.
Orientation Health, human becoming for both the patient and nurse.
Role of nurse Connect with clients, be present, extract meaning.
Decision making Mutual between health care provider and client.
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CHAPTER 9 Nursing Theories Through Mirrors, Microscopes, or Telescopes 175
because Orem’s theory’s dominant focus is on hierarchy of needs, I have placed her in Chapter 11
as a needs theorist. Unlike client-oriented theories, which are more effective in providing nurses
with a framework for assessment, intervention theories provide nurses with guidelines for inter-
vention. However, it is important to note that each of the theorists provided recommended points
of entry for interventions.
IMAGES, METAPHORS, AND ROLES
The preceding analyses suggest that nurses focus on different aspects of care at different times or
for different purposes. Nursing is not exemplified by one group of theories more than another at
all times. Rather, the situation may dictate when nursing should focus on needs, interaction, or
outcomes. Similarly, focus on clients, interactions, environment, or interventions may require
different theories. Newman (1983) makes the following point:
One of the factors determining the applicability of a theory is the temporal frame of reference.
For example, if one is viewing a relatively short time-frame, the adaptation model might
apply, whereas in a longer time-frame, phenomena would be apparent that could not be
explained by adaptation alone. (p. 391)
Nurses play different roles at different times and project different images, and nursing theo-
ries have helped to suggest these different images and roles that nurses play. Need-oriented nurses
are actively doing and functioning; they rely on problem solving, they carefully plan their inter-
ventions, and they evaluate their work mainly (but not only) by the activities performed.
Interaction-oriented nurses rely on the process of interaction and include themselves in
the sphere of other actions; they use themselves therapeutically, and evaluate their actions pri-
marily in terms of interactions. Interaction-oriented nurses rely more on counseling, guiding,
and teaching—helping clients find meanings in their situations—and less on doing and func-
tioning. Among the interactionists are the existentialists, who focus on the support and devel-
opment of the human potential. That potential includes, for both the nurse and the client, the
goal of authentic being, the process of creating options, and an openness to present and future
experiences.
Outcomes-oriented nurses focus on the goals of maintaining and promoting energy and har-
mony with the environment and on enhancing the development of healthy environments. Outcomes
nurses do not include themselves as therapeutic agents; they enact the healing roles but do not nec-
essarily consider authentic being as essential in the healing processes. The roles and images of
nurses as reflected in the different groups of nursing theories are summarized in Table 9-26.
Care-oriented theorists focus on the personal development or transformation of both the
nurse and the patient (Parse, 1995; Watson, 2002). Care theorists include equally the self-reflections
of patients and nurses as they transform each other into different and more self-examined human
beings.
AREAS OF AGREEMENT AMONG AND BETWEEN THEORISTS AND
SCHOOLS OF THOUGHT
Nursing theories have been considered in terms of their contrasting and competitive views. In the
first section of this chapter, an attempt was made to address how these views may complement
each other as theories and as different schools of thought. In this section, areas of agreement
among the various schools of thought are identified.
• Nursing theories offer a beginning articulation of what nursing is and what roles nurses
play.
• Nursing theories offer a view of the philosophical underpinnings in nursing (e.g., interaction,
phenomenology, and existentialism).
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176 PART FOUR Reviewing and Evaluating: Pioneering Theories
TABLE 9-26 ROLES AND IMAGES OF NURSES IN DIFFERENT CATEGORIES
OF THEORIES
Theorists Roles Nurses Play Image
Needs Theorists
Abdellah Problem solver and performer of They provide an image of a nurse who is
21 physiologic and psychosocial active and busy working and a patient
activities for the patient who is striving for independence. The
Henderson Complementing, supplementing nurse’s work is focused on doing a
knowledge deliberate and well-planned activity.
The will to perform daily activities
Orem Temporary self-care agent for universal
health deviation and development of
self-care needs
Interaction Theorists
King Goal attainer or else! They provide an image of a nurse as a
Teach, counsel, guide, give care, gather present-oriented, situational, a humanist,
information, set mutual goals a process-oriented professional whose
Orlando Deliberate, repetitive, and situational interest is the interaction and, for some,
interactions also the person. The nurse, to some, is
Paterson and Zderad Existentialist and phenomenological also important in the interaction.
nurturer of the human potential
(self and patient)
Peplau Freudian helper
Stranger who works hard to become
a surrogate
Travelbee Meaning finder (more than a dictionary
meaning) and existentialist
Wiedenbach Deliberate helper who focuses
on extrasensory perception and
does not forget to validate the
process
Outcomes Theorists
Johnson The external manipulator: external They provide an image of the nurse as goal
regulatory force to preserve setter, a futurist, environmentalist, who
organization and integration of has extrasensory and energy preservation
patient’s behavior powers.
Controller
Levine Conservator of all
Rogers The environmental nurse, the symphony
player: promotion of person–environment
interaction
The healer without touch
Roy The pace setter: external regulatory
force to modify stimuli affecting
adaptation to create four modes of
adaptation
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CHAPTER 9 Nursing Theories Through Mirrors, Microscopes, or Telescopes 177
• Nursing theories provide descriptions of how to help patients become comfortable, how to
deliver treatment with the least damage, and how to enhance high-level wellness.
• Nursing theories offer a beginning common language and a beginning agreement about
who nursing care recipients are.
• It is obvious that we should not view the recipients only through biologic glasses (as
biologic systems) or psychological glasses (as id, ego, and superego), but rather through
holistic glasses. Nursing clients are more than the sum total of their psychological, socio-
logical, cultural, or biologic parts.
• Recipients of care respond to events in a holistic way.
• The recipient is a member of a reference group set, and interventions are only meaningful
if the whole unit is considered.
• Recipients have needs, and nursing assists them in meeting those needs.
The theories have other themes in common. These emerge when one considers images evolv-
ing from the theories when compared with nursing realities. In this process, several concepts
emerge as central to nursing. These are addressed in the following conclusion.
CONCLUSION
The discipline of nursing deals with people who are assumed to be in constant interaction with
their environment and yet have unmet needs, are not able to care for themselves, or are not
adapting to the environment due to interruptions or potential interruptions in health. Nursing
focuses on therapeutics to help in meeting the needs of the person and to enhance adaptation
capability, self-care ability, health, and well-being. Nursing theories capture and reflect differ-
ent visions of this domain; they mirror different aspects of nursing realities as they are and as
they ought to be. The mission of nursing, the processes by which nursing care is provided, and
the images of nursing portrayed in these theories continue to be shared by nurses around the
globe. Considering the theories in the categories presented in this chapter may lead to many
productive explorations and explanations of the processes of clinical judgment and clinical
decision making.
TABLE 9-26 ROLES AND IMAGES OF NURSES IN DIFFERENT CATEGORIES
OF THEORIES (Continued )
Theorists Roles Nurses Play Image
Caring/Human Becoming Theorists
Watson Coparticipant and time investment Centered healing person, aware, reflective
with embodiment of caring. Spiritual and humanist caring.
person helping people gain .
self-knowledge. A person with
self-control and ability to self-heal
(Baldursdottir and Jonsdottir,
2002; Watson and Smith, 2002).
Parse Understands patient’s lived experience, A present-oriented, situational, process-
brings out the best in patients to be oriented and interactive.
able to make choices (Cowling,1989;
Cody, 2000).
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178 PART FOUR Reviewing and Evaluating: Pioneering Theories
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REFLECTIVE QUESTIONS
1. What are the advantages and disadvan-
tages of classifying nursing theories?
2. What categories do you consider as
more productive in creating a critical
discourse about the theoretical heritage
of nursing?
3. As you assess the current climate and
structure of health care systems, what
group of theories may provide frame-
works for better quality care? Which
group of theories may be antithetical or
complementary to the needs of patients
in the 21st century?
4. Compare and contrast the societal and
professional contexts for any two of the
four sets of theory categories.
5. How else would you categorize the theo-
ries presented in this chapter and why?
6. Identify and discuss metaphors about
nurses that reflect the different theories.
In what ways do these metaphors stereo-
type or enhance nurses’ roles?
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C H A P T E R 10
A Model for Evaluation of Theories:
Description, Analysis, Critique, Testing,
and Support*
A critical review of evidence before and while translating it into practice, and a critical assessment
and evaluation of theories before and while utilizing them in practice or research are activities that
nurses have always engaged in. Quality care, as well as coherent research programs, requires crit-
ical analyses and judgment of theories. Nurses evaluate theories to apply to practice, to develop
curricula, to operationalize for research, or to use in daily decision making. These evaluations may
be deliberate, systematic, criteria-based, objective, conscious, and elaborate, or they may be sub-
jective, experiential, quick, and based on a limited set of criteria. Both types of evaluations are
essential; neither type is sufficient by itself.
Evaluation of theory is an essential component of nursing practice and of knowledge develop-
ment to:
1. Decide which theory is more appropriate to use as a framework for research, teaching,
administration, or consultation
2. Identify effective theories in exploring some aspect of practice or in guiding a research
project
3. Compare and contrast different explanations of the same phenomenon
4. Enhance the potential of constructive changes and further theory development
5. Identify epistemological approaches of a discipline through attention to the sociocultu-
ral context of the theorist and the theory
6. Critically examine and question the ontological beliefs in a discipline
7. Identify competing and complementary schools of thought in a discipline
8. Effect changes in clinical practice, define research priorities, and identify content for
teaching and guidelines for nursing administration
9. Utilize coherent and integrative frameworks to communicate to the public the rationales
and goals of nursing practice
10. Identify strategies that could be used to advance the development of theories
11. Define and articulate the discipline’s demand and perspective
12. Be a critical consumer of theories, as well as a critical consumer of evidence-based
practice
Before going any further in reading this chapter, you should take a few minutes to identify
one or two theories (nursing or nonnursing) that you have used in your work or personal life.
Whether you are a critical care nurse, a primary care provider, or a researcher who may be
studying biomarkers of pain responses, you can reflect on frameworks from which your care or
questions emanate. For example, you may identify role theory as a framework for your research
on women’s daily activities in a nursing home and their health; endorphin theory linking stress
with exercise; or Maslow’s theory in understanding a patient’s needs. The next set of questions
to ask and reflect on are: Why did you select these theories to apply in your work? Why not
other theories that may provide a different set of equally plausible explanations? To complete this
*This chapter is adapted, with considerable changes, from an earlier manuscript written by A.I. Meleis and published in
Chaska, N. (1982). The nursing profession: Time to speak. New York: McGraw-Hill, 1982.
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180 PART FOUR Reviewing and Evaluating: Pioneering Theories
exercise, you should be able to identify the criteria you used in making a decision about what
theory to use.
Over a 30-year span of teaching, I have asked students, faculty, clinicians, and administrators
in the United States, as well as in many other countries, the questions outlined in the preceding
text. In reviewing the answers and analyzing their content, I noticed the emergence of a number of
criteria for selection and use of theory. Now, compare your criteria with those identified in
Box 10-1.
SELECTING THEORIES FOR UTILIZATION
Although these criteria are neither all-inclusive nor representative of all nurses, definite themes
evolve that are consistently supported by much anecdotal evidence. The decision to use one theory
and not another involves both subjective and objective processes. The decision process could be
considered as falling on two continua, each ranging from low to high. Therefore, a decision could
be both highly objective and highly subjective, low on subjectivity and on objectivity, or could be
one of numerous other combinations of levels of objectivity and subjectivity.
The subjectivity in the selection of a theory is as important as is the objectivity in the selec-
tion. Although we can select a theory by using a number of well-defined criteria, and through a
systematic evaluation process, using well-defined and agreed-upon criteria, make the process
highly objective, if the theory’s assumptions are not congruent with our own, if we have concerns
with the theorist’s level of experience, or if we are not comfortable with other work done by the
theorist, the decision process becomes subjective. Conversely, a selection may be based on one’s
having worked with the theorist or her disciples and that in itself becomes the deciding factor in
continuing to use the theory. Neither of these processes of decision-making is sufficient. Another
set of questions are related. The first one is: How did you use that particular theory and frame-
work? A highly objective decision with low subjectivity could result in theory use that is not as
BOX 10-1 CRITERIA USED FOR SELECTING THEORIES
Personal: Individuals who use this criterion discuss their personal comfort in using the theory, their intu-
itive choices, and the theory’s congruency with their philosophical view of life.
Mentor: There are those who use a theory because they were mentored by a theorist, or they were
exposed to the teaching of a theorist who profoundly influenced and transformed them. They spoke of per-
sonal influence, respect, personal contact, and educational experience.
Theorist: Many select and utilize a theory as a framework for their research or practice based on who the
theorists are, their standing in the field, their status, and how well they are recognized.
Literature support: Others identified the availability of extensive writings about the theory that gave them
assurance of the level of significance of the theory and the status it holds.
Sociopolitical congruency: Another criteria used for selecting theory is the congruency between the
theory implementation process and the sociopolitical as well as economic climate at the time of the choice.
These people spoke of a climate that supports one theory over another because, for example, there was no
need to institute structural changes in the organization, or the theory required minimal preparation of mem-
bers of an organization. Within this category are those who indicated that the theory was imposed by
administration.
Utility: The ease by which a theory was understood and applied prompted this group of users to indicate
that utility was the prime factor.
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CHAPTER 10 A Model for Evaluation of Theories: Description, Analysis, Critique, Testing, and Support 181
true to the theory’s premises and propositions, and the converse is also true. Using a particular
theory to describe components of care or to provide an explanation of the use of a particular vari-
able in research is different from testing, refuting, or supporting theories (Norman, 2004).
The objective evaluation and critique of theories is as complex as the subjective evaluation.
To simplify any evaluation, we must break it down into components. For example, when a
research project is critiqued, the analysis is done along structural criteria, such as the introduction,
conceptual framework, research questions and hypotheses, methodology, results, discussion, con-
clusions, and limitations. The critique is then completed by looking for clarity, significance, time-
liness, and documentation, among other criteria. To analyze and critique theories objectively,
numerous criteria have been recommended by a number of authors. In fact, analysis and critique
of theories have preoccupied many nurse metatheorists over a period that even preceded diligent
theory development efforts.
Two disciplines have profoundly influenced the evaluation of nursing theory: sociology and
psychology. The result has been a synthesis of criteria from these disciplines––at times too empir-
ically based and at other times too critical of the theories that were developed by nurses––and
those driven by our own nursing phenomena. When we adhered to some of these criteria, we
tended to discount nursing theories, relegating them to the category of individual subjective philo-
sophical expositions. Although some of these criteria are appropriate for the discipline of nursing,
many were not and did not reflect the nature of nursing and the goals of our discipline. Others
have emerged that directly relate to and represent nursing. The rationale for developing a different
set of criteria is embedded in the nature of nursing care, the assumptions on which the discipline
of nursing is built, and the quality of its scientific and humanistic bases. The domain of nursing
encompasses human experiences and interactions, and deals with complex sets of contextual vari-
ables; therefore, the criteria for theory evaluation must consider ways by which its theories reflect
and represent these contexts.
Each one of the evaluation models offered in nursing literature addressed one aspect of a the-
ory to the exclusion of others. For example, Johnson (1974) focused on a congruence of theory
mission with goals relegated by society to nurses (social congruence, utility, and significance).
Earlier, in an unpublished manuscript on requirements of an effective model, Johnson (1970)
offered a set of requirements that focused on the mission of nursing practice: goals of action,
patience, the actor’s place and role, source of difficulty, intervention focus, and mode and conse-
quences of care. Although Johnson also addressed the necessity of explicit and consistent struc-
ture (assumption and values) and content (nursing’s unique goal, ability to be generalized,
restrictiveness, continuity, and specificity), other utility criteria were not included, such as
research utility and potential for theoretical propositions. Johnson pioneered the development of a
set of objective requirements for effective models in nursing and the use of internal and external
requirements. Her evaluation model was not published, however, and was therefore limited in
exposure and refinement.
Barnum (1998) suggested that passing judgment on theories happens both subjectively and
objectively. Judgment may be “simply a matter of personal taste” (p. 171), just as is judgment of
art that is based on personal taste, and/or it could be based on clear criteria. The criteria selected
by Barnum (1998) are both internal and external. These evaluative criteria are appropriate for
internal criticism (internal construction of theory) and external criticism (which considers theory
in its relationships to human beings, nursing, and health). The criteria for internal criticism are
clarity, consistency, adequacy, logical development, and level of theory development. The criteria
for external criticism are reality conversion, utility, significance, discrimination, scope of theory,
and complexity (Barnum, 1998, pp. 171–185). These criteria represent one framework for cri-
tiquing theories that could be used independently or in conjunction with the descriptive and ana-
lytical criteria offered in the model proposed in this chapter.
A similar framework was offered by Ellis (1968), whose insights endure and transcend time,
and who delineated seven criteria for what she considered significant theories. Significant theo-
ries, according to Ellis, have a broad scope, are sufficiently complex to consider different proposi-
tions reflecting the wide scope, and contain propositions that are testable and useful. Significant
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182 PART FOUR Reviewing and Evaluating: Pioneering Theories
theories are also those that have explicit values and in which implicit values are carefully delin-
eated. These theories must have well-defined and meaningful terminology, and they provide
opportunities for further generation of information (Ellis, 1968). Hardy (1974) borrowing heavily
from the discipline of sociology, organizing her criteria around the concept of “adequacy”: mean-
ing, logic, operationalization, empirical evidence, and pragmatism. She also believed that ade-
quate theories should have the ability to be generalized, should contribute to understanding, and
should be able to predict. It is indeed a challenge to find theories in any discipline to meet all these
criteria simultaneously; however, these criteria provide serious theory developers with milestones
toward which they should strive.
Lest theory developers become discouraged by the rigorous criteria, Duffey and Muhlenkamp
(1974, p. 571) offered the following modest set of questions by which theories can be evaluated:
• Does the theory generate testable hypotheses?
• Does the theory guide practice?
• How complete is its subject matter?
• Did the theorist make her biases explicit?
• Does the theory have propositions and are relationships explicit?
• Is the theory parsimonious?
Chinn and Kramer (2004, pp. 91–119) offer a set of questions that should guide the evalua-
tion of integrated knowledge that incorporates theories. These sets of questions are driven by
their definition of theory as “a creative and rigorous structuring of ideas that projects a tentative,
purposeful, and systematic view of phenomena” (p. 91). They use a series of questions to guide
the reviewer toward describing a theory, and then another set of questions to guide the reviewer
on a journey of critical reflection of theory. To review and describe a theory, they propose these
questions:
• What is the purpose of this theory?
• What are the concepts of this theory?
• What are the relationships in this theory?
• What is the structure of this theory?
• What are the assumptions of this theory?
To reflect and critique the theory, they pose a series of whys? In each of the preceding points,
the major ideas to consider are clarity, simplicity, generalizability, and accessibility.
Fawcett (2005a, 2005b), dissatisfied with previously developed evaluation criteria because of
the seeming overlap between criteria for evaluating theories and those more appropriate for evalu-
ating conceptual frameworks, offered, and continued to update, one analytical and evaluative
framework for conceptual models, and a separate one for theories. Fawcett’s framework for con-
ceptual models separates questions for analysis from those intended for evaluation. For analysis,
Fawcett proposed a consideration of the historical evolution of the model, and the unique focus of
the nursing model and the context of the model. For the evaluation, she proposed evaluation (judg-
ment based on criteria) of the origins of the model, the degree of comprehensiveness of content,
the logical congruence of its internal structure, the ability of the model to generate and test theo-
ries, the degree to which it is credible as demonstrated in its social utility (use, implementation),
social congruency, and significance to society. A final criterion for evaluating nursing models is in
terms of its contributions to the discipline of nursing (Fawcett, 2005a, pp. 51–59). Although these
were proposed as criteria for evaluating conceptual models, the same criteria could be used in ana-
lyzing and evaluating theories. However, Fawcett (2005a, pp. 441–450) proposed another set of
criteria for theory critique that she believed to be more congruent with her definition of theory.
Critique of theories was also divided into analysis and evaluation. For theory analysis, she pro-
posed criteria to similar to those of other metatheorists, such as consideration of the scope of the
theory, the context of theory, and its attention and consideration of major concepts in nursing and
the content of the theory. Fawcett also proposes an evaluation of theories to complement the
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CHAPTER 10 A Model for Evaluation of Theories: Description, Analysis, Critique, Testing, and Support 183
analysis described in the preceding text. The content of theories, she says, could be evaluated in
terms of the congruency of its significance, internal consistency, the extent to which the theory is
stated clearly and concisely (parsimony), and the potential testability of its propositions. Theories
must also be evaluated through the adequacy of their empirical evidence and their utility for prac-
tice (pragmatic adequacy) (Fawcett, 2005a, pp. 441–450).
Fawcett also differentiates between the evaluation of grand and middle-range theories and
provides similarities and differences in the types and level of questions to ask of the two levels of
theories. The levels of theories may be differentiated by the kind of methods used, tests per-
formed, measurements utilized, and their empirical adequacy. For grand theories, Fawcett
(2005b) believes that questions should focus on congruency between methods and philosophical
claims, and on the adequacy of the inductive descriptions of data and its congruency with the
concepts and propositions of the theory. For middle-range theories, the questions focus more on
the observability of concepts, potential for measurement, and the congruency between the theo-
retical assertions and the empirical evidence. Fawcett (2005b) provides a strong convincing argu-
ment against differentiating criteria that are based on whether theories used quantitative or
qualitative data. I would further propose that theories that withstand the tests of time and
repeated research findings could neither be classified based on the type of data nor differentiated
only by research data. This argument will become even more apparent as you review the evalua-
tions of the theories offered in the next few chapters and as you review and study strategies for
theory development in Part Five.
Whall (2005) defines theory as a “group of concepts interrelated via propositional statements
which are based upon a group of underlying assumptions” (p. 5). As such, she proposes that analy-
sis and evaluation use three major criteria: (a) critical review of basic considerations of theory, in
which adequacy is examined; (b) internal analysis and evaluation, in which review of complete-
ness, consistency, and assumptions are examined; and (c) external analysis and evaluation, in
which the connection between theory, research, practice, and education are carefully examined
and reviewed (pp. 11–13). Whall also differentiates between the separate review and analysis of
each theory level (micropractice, middle-range, and grand nursing models). Each level drives a
different set of questions that the reviewer must use. However, analysis and evaluation of all levels
of theory must address basic structure, internal analysis and evaluation, and external analysis
(Whall, 2005, pp. 5–20).
Table 10-1 compares and contrasts the criteria for evaluating theories, as proposed by four
metatheorists. I encourage you to review as many of these proposals for evaluation as possible. As
you can see in Table 10-1, there are some similarities and some differences in how each metatheo-
rist conceptualized the criteria of analysis and evaluation of theories. The criteria reflect the level
and sophistication of our knowledge at different stages of the development of nursing as a scien-
tific discipline. In reviewing the different criteria, several trends emerge:
• Theories are described, analyzed, and tested.
• Internal and external criteria exist for evaluating theories.
• The internal descriptive criteria include assumptions, concepts, relationships, and defini-
tions.
• The internal critical criteria include some areas of agreement, such as consistency, clarity,
and logical development.
• Evaluation criteria consider the fit between the theory and external criteria (human beings,
society, prevailing paradigms) and not only the intrinsic criteria.
• A more accepting attitude has evolved, shifting away from the rigor of empiricism to the
more realistic rigor of potential for testability.
• There is wider acknowledgment of the complexity of evaluation criteria (the two sides of
simplicity, the many meanings of complexity, etc.) and, therefore, wider acceptance of
multiple criteria.
• There is less prejudice toward descriptive theories.
Common themes in description and analysis are presented in Table 10-2.
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184 PART FOUR Reviewing and Evaluating: Pioneering Theories
TABLE 10-1 COMPARISON OF CRITERIA FOR EVALUATING THEORY
Chinn & Kramer
Barnum (1998) (2004) Fawcett (2005) Whall (2005)
Analysis &
Internal Description Evaluation of
Criticism of Theory Nursing Models Criteria for Practice Theory
• Clarity • Purpose Analysis Basic consideration: definition
• Consistency • Concepts • Origins adequacy; empirical adequacy;
• Adequacy • Definitions • Focus statement/prepositional adequacy.
• Logic development • Relationships • Content Internal analysis and evaluation:
• Level of theory • Structure Evaluation completeness and consistency;
development • Assumptions • Origins assumptions of theory.
• Content External analysis and evaluation: analysis
• Logical congruency of existing standards; analysis of nursing
• Generation practice and education; analysis of
• Credibility research.
External Critical Analysis & Evaluation
Criticism Reflection of Theories Criteria for Middle-Range Theory
• Reality • Clarity Analysis Basic consideration: definitions and
convergence • Simplicity • Scope relative importance of major concepts;
• Utility • Generalizability • Context the type and relative importance of
• Significance • Accessibility • Content major theoretical statements and/or
discrimination • Importance Evaluation propositions.
• Scope of theory • Significance Internal analysis and evaluation:
• Complexity • Internal consistency assumptions, science positions;
• Parsimony concepts; internal consistency and
• Testability congruency; empirical adequacy.
• Empirical adequacy External analysis: congruence with
• Pragmatic adequacy related theory and research internal
and external to nursing; congruence with
the perspective of nursing, the domains,
and the persistent questions; ethical,
cultural, and social policy issues.
Criteria for Conceptual Models
Basic paradigm concepts included in the
model: person, nursing, health, and envi-
ronment (definitions, additional under-
standings, and interrelationships);
des criptions of other concepts in the model.
Internal analysis: assumptions, definitions
of any other components of the model;
relative importance of basic concepts or
other components of the model; internal
and external consistency; adequacy.
External analysis: relationship to nursing
research, nursing education, nursing
practice, to the existing nursing diag-
noses and interventions systems.
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CHAPTER 10 A Model for Evaluation of Theories: Description, Analysis, Critique, Testing, and Support 185
FRAMEWORK FOR EVALUATING THEORIES
The model proposed here considers these trends, draws on many of the previously delineated cri-
teria, and further acknowledges that even when systematic criteria are advanced to ensure objec-
tive analysis and critique, objectivity is not guaranteed or required in critiquing theories for one’s
use in research or practice. Furthermore, individuals may differ on how they use the critique crite-
ria, and the perceptions of the meaning of each of these criteria may be influenced by individual
variations and by context variations. It is also acknowledged here that some criteria may be con-
flicting; that to enhance simplicity, complexity may suffer; and that to advocate a wider scope,
accuracy for deviant cases or opposing situations may be jeopardized and generalization may not
be as desirable as it once was.
The proposed model defines evaluation as encompassing description, analyses, critique, test-
ing, and support. By using this model, a reviewer acknowledges extant evaluations that have been
completed by nurse theorists, researchers, and clinicians, among others. The model is also based
philosophically more on a historical view of science than on an empirical view. Therefore, the
model proposes to analyze the central questions that are solved by the theory. It considers the back-
ground of the theorist in the development of the theory and the sociocultural context of the theory
(the theorist’s education, previous work, etc.), the evaluator as an agent for knowledge develop-
ment, and the discipline’s level of development. In other words, human processes are considered an
integral part of theory description, analysis, critique, testing (Laudan, 1977), and support (Meleis,
1995).
Description
Before embarking on theory evaluation, the reviewer should recognize and identify the
boundaries of the review. Boundaries include degree of exposure to theory, length of time devoted
to understanding theory, and type of work done with theory (e.g., having taught theory, used it in
practice, used it in research, worked with the theoretician). In doing so, the reviewer attempts to
separate objective and subjective rationales.
An initial thorough reading after scanning the central work of a theorist helps to identify the
central questions the theorist is attempting to answer. For example, a central question for develop-
mental theorists is how human beings mature. More often than not, it is not entirely clear in nursing
theory what questions the theorists are attempting to answer. The central questions of the theory are
answered in the form of theory propositions. Propositions are the crux of a theory. From proposi-
tions, questions emerge that guide exploration and research. Identifying propositions at the outset
helps make the job of delineating assumptions and concepts easier. It is not a linear process, but a
cyclical one, in which concepts may be identified, followed by pertinent propositions, followed by
TABLE 10-2 COMMON THEMES IN DESCRIPTION AND ANALYSIS
Common Themes Metatheorists
Adequacy Barnum, Whall
Clarity Barnum, Chinn, & Kramer
Consistency Barnum, Chinn, & Kramer, Whall
Complexity/simplicity Barnum, Chinn, & Kramer, Whall
Generality/scope of theory Barnum, Chinn, & Kramer
Significance Barnum, Chinn, & Kramer; Fawcett, Whall
Internal & external evaluation/criticism Barnum, Whall
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186 PART FOUR Reviewing and Evaluating: Pioneering Theories
more concepts and pertinent assumptions, and so on. This entire process of identifying assump-
tions, concepts, and propositions addresses the structural components of the theory. Table 10-3
offers a summary of theory description.
Structural Components
A theory begins with a set of “givens” that have been either empirically tested or accepted by
a number of other theories or previous research. These givens are the theory assumptions. They
could evolve from a philosophical standpoint, from ideological positions, from ethical considera-
tions, from cultural heritage, from social structure, or from previously tested and supported
hypotheses. Assumptions also represent one’s values. Assumptions of a theory are not subject to
testing by the same theory; rather, they lead to a set of propositions that are to be tested. They are
the basis from which we can determine the viewpoint of the theorist. In nursing theories, assump-
tions are made about nursing, human behavior, life, death, health, and illness.
Early writing in theory provides implicit assumptions; these are statements not identified as
explicit assumptions by the theorist. Explicit assumptions are identified by authors as their
assumptions. Implicit assumptions are embedded in the writings; they are statements not identi-
fied as assumptions, yet they are central for the development of theory propositions or answers to
questions. They are statements considered by the reviewer to be significant in the development of
the theory. Assumptions may reflect the values of a person or a culture. These assumptions then
have attached to them a level of valuation that needs to be carefully examined. “It is assumed that
people want to take care of themselves.” A Western value is implied here. The idea, for example,
that a patient has the right to learn about the gravity of his illness is an implicit assumption in our
Western society, whereas the reverse is an implicit assumption in Middle Eastern cultures. A
proposition built on this assumption responds to the question of what is the most effective way to
impart the information about a grave diagnosis to the patient. Another proposition would question
whether a relationship exists, for example, between certain strategies for giving information about
diagnosis and rate of recovery. The rationale for the proposition is understood only when the
assumptions underlying it are delineated.
As theorists in nursing become more systematic in their theory development efforts, more
explicit assumptions are stated, and fewer assumptions are left implicit. The plethora of literature
that has discussed theory critique and theory development should be credited with the constructive
changes demonstrated in the updated, further developed, or new theories evolving in nursing. Roy,
for example, in further developing her theory, followed a more systematic approach in which she
identified assumptions and carefully related many of the concepts to the assumptions, thereby pro-
viding her theoretical propositions with better potential for testability (Roy and Roberts, 1981).
TABLE 10-3 THEORY DESCRIPTION
Criteria Unit of Analysis
Structural components Assumptions
Concepts
Propositions
Functional components Focus
Client
Nursing
Health
Nurse–patient interactions
Environment
Nursing problem
Nursing therapeutics
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CHAPTER 10 A Model for Evaluation of Theories: Description, Analysis, Critique, Testing, and Support 187
When identifying the internal structure of a theory, one should use a description that involves
a careful search of the inherent assumptions; at the same time, one should not overlook the
implicit ones. The more effective theories are those in which authors explicitly state the assump-
tions that guide their thinking. The more explicit the premises of the theory, the less ambiguity
arises when interpreting its conditions and goals.
The internal structure of a theory could be further described by delineating the concepts on
which it is built. Descriptive properties used in relation to concepts are clarity, conceptual defini-
tions, observable properties, and boundaries; concepts are also described as being primitive (i.e.,
concepts that originated in this particular theory) or derived (i.e., concepts that were derived from
other theories). Hage (1972) provided criteria to help determine whether concepts in a theory are
primitive or derived. The introduction in a theory of a concept with no definition—because the
concept has an agreed-on meaning, has simple definitions, has an intuitively obvious definition, or
has been defined elsewhere––designates a primitive concept. The definition of the derived concept
is that it occurs within the theory and is based on primitive terms. The definitions of primitive
terms are outside the theory (Hage, 1972, pp. 111–115).
The usage of primitive and derived concepts in this book differs from Hage’s usage. Primi-
tive concepts are those concepts introduced in the theory as new and therefore defined within the
theory. Derived concepts are concepts from outside the theory that have taken on a different
meaning within the theory. For example, in Meleis (1975), role is a derived concept, and role
supplementation is a primitive concept—that is, it is a new concept with a new definition (see
Chapter 17).
Concepts are also evaluated along the abstract–concrete dimension. The degree of generality
of a concept determines its abstract–concrete level. The more general a concept is, the more it
transcends time and geography, and the higher its level of abstraction. Concepts have also been
classified along the general variable–nonvariable dimension (Hage, 1972). Nonvariable concepts
in nursing are sex, ethnic background, religion, and marital status. Examples of variable concepts
(general variables) are sex-role orientation, level of well-being, degree of cultural identity, and
level of sick role. It becomes apparent that each nonvariable could be converted into a general
variable.
There are several advantages to having general variables (Hage, 1972). General variables
allow more precise classification and allow for variations that are more congruent with variations
occurring in reality. Classification of a patient as male or female yields some significant data and a
certain degree of predictability of the structure and function of a few of the biological systems.
However, sex-role orientation, a general variable, may help us to more precisely describe clients
and predict their patterns of rehabilitation.
Just as assumptions and concepts are delineated, sometimes simultaneously and at other
times cyclically, theory propositions also should be delineated and described. A proposition is a
descriptive statement of the properties and dimensions of a concept or a statement that links two
or more concepts together. Propositions provide the theory with the powers of description, expla-
nation, or prediction. A theory that has more assumptions than propositions is a theory with lim-
ited power. It indicates that we have to agree to too many conditions for a few descriptions or
predictions. If we consider the relationship of assumptions and propositions in a ratio form, an
inverse relationship (with the number of propositions being higher than the number of assump-
tions) allows for more explanatory power.
There are different types of propositions, with each having a different purpose. Existence
propositions are constructed around one phenomenon and therefore describe and assert the exis-
tence of only this one phenomenon. Propositions with the power of explanation, on the other
hand, link concepts; therefore, they are expected to have two or more concepts. They are formu-
lated to explain and assert something pertaining to the reality embodied in the theory. These are
relational propositions, which encompass many types of propositions, such as those that simply
describe the existence of a relationship, those that describe the direction of such a relationship,
and those that can predict the relationship, the direction of the relationship, and the conditions
under which that relationship may or may not occur.
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188 PART FOUR Reviewing and Evaluating: Pioneering Theories
Further description of a proposition could be done along dimensions specified by Zetterberg
(1963, pp. 69–71). This is best illustrated by using an example of a two-concept proposition
derived from Johnson’s subsystem theory:
The higher the level of met functional requirements of the affiliative subsystem of behaviors
of Middle Eastern immigrants, the greater the recovery rate.
A reversible proposition would have “and vice versa” at the end of the statement, thus,
requiring two testings––one with the condition of “met functional requirements” and prospec-
tively considering recovery rate, and the other beginning with different levels of the recovery rate
and then retrospectively considering levels of “met functional requirements.”
A second dimension is whether the proposition is deterministic or stochastic. Nursing has a
predisposition toward more stochastic propositions that incorporate a probability condition, rather
than “if X then always Y,” which is deterministic and improbable in a humanistic science. A sto-
chastic proposition, albeit a probabilistic one, would be:
The higher the level of met functional requirements of the affiliative subsystem of behaviors,
the more probable is a greater recovery rate.
A third dimension is whether the proposition is sequential or coexisting. A sequential propo-
sition assumes that one variable occurred before the other variable. Propositions in nursing lend
themselves more to coexisting propositions when describing existing relationships and to sequen-
tial propositions when engaged in theorizing about interventions and the consequences of inter-
vention. This dimension characterizes theorizing that is central and essential to nursing.
A fourth dimension is demonstrated in the relationships between concepts. This relationship
may be sufficient (if X, then Y, regardless of anything else) or contingent (if X, then Y, but only if Z)
(Zetterberg, 1963, p. 71). Humanistic sciences cannot strive to produce sufficient propositions.
Propositions in nursing theory include numerous variables and probabilistic relationships.
The last dimension identifies whether the relationship is necessary or can be substituted. A
necessary relationship is “if X, and only if X, then Y.” A substitutable relationship is “if X, then Y;
but if Z, then also Y.” Like other concepts in nursing, greater recovery rate is contingent on a num-
ber of variables and not only on “met functional requirements of one subsystem”; therefore, a sub-
stitutable proposition is more appropriate. To increase the explanatory power of such a proposition
and then the predictive power, all other concepts related to recovery rate could be identified. For
example:
The higher the level of met functional requirements of the affiliative subsystem of behaviors
of Middle Eastern immigrants, the greater the recovery rate. The higher the level of met
functional requirements of the aggressive subsystem of behaviors, the greater the recovery
rate.
Therefore, propositions in nursing may be reversible, stochastic, coexisting, contingent, and
substitutable. Attention to each dimension provides a way to describe the propositions and to
deliberately develop propositions along these dimensions; this may help in enhancing the power
of contextual explanations, if that is what the theorist wishes to do. This labeling also allows
appropriate assessment of the propositions and their power of explanation and predictability. The
clarity and systematization of propositions are also considered when we analyze the selected
ordering and sequencing of propositions.
This first level of description is structural. The next level involves a description of a theory in
terms of its function. This level considers the concepts of the nursing domain.
Functional Components
Unlike a structural analysis of a theory, a functional assessment of a theory carefully consid-
ers the anticipated consequences of the theory and its purpose. A functional analysis is focused on
the relationship between the theory’s assumptions, concepts, and propositions and those of the
domain. (Again, refer to Table 10-3 for a summary of theory description.)
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CHAPTER 10 A Model for Evaluation of Theories: Description, Analysis, Critique, Testing, and Support 189
Concepts of the Domain
Theory is described around questions central to the discipline of nursing, including the
following:
• Who is acted on? This is the major question that begins to address the function of theory.
Does the theory identify its focus as the client, family, community, or society, or does the
theory consider the target as being one to the exclusion of others? The target of action here
denotes both the target of assessment and the target of intervention; the target in nursing
should be the client (in the broadest sense) in health or illness.
• What definitions does the theory offer for nursing, client, health, nursing problems, envi-
ronment, and nurse–patient interactions? Are definitions explicit and clear?
• Does the theory offer a clear idea of what the sources of the nursing problem are, whether
the sources lie within or outside of the individual?
• Does the theory provide any insights in the form of intervention for nursing? Are the vari-
ables to be manipulated well delineated? Is it clear what the points of entry are for a nurs-
ing intervention? Is the focus of intervention justifiable within the theory? Points of entry
could vary from manipulating outside stimuli (Johnson, 1968) to interactions and transac-
tions between client and nurse (King, 1971), to behaviors within systems (Auger, 1976).
• Are there guidelines for intervention modalities? Are they specified? Is there potential for
the evolution of such intervention modalities?
• As a nursing theory, does it provide guidelines for the role of the nurse?
• Are the consequences of nurses’ actions articulated in the theory? Are they intended or
unintended, positive or negative, anticipated and delineated? Is there a plan for dealing
with such consequences?
These criteria are generally consistent with those offered by others, including Dickoff, James,
and Wiedenbach (1968) and Barnum (1998).
Analysis
Analysis is defined as a process of identifying parts and components and examining them
against a number of identified criteria. Analysis includes concept and theory analysis.
Concept Analysis
Concept analysis is a useful process in the cycle of theory development, as well as in theory
evaluation. Concept analysis may occur at many different points in the process of evaluation and
development. Wilson (1969) proposed several steps and techniques in analyzing concepts. These
steps do not necessarily have to be completed in this order.
1. Definition, identification, and description of the different dimensions and components of
the concept. For example, we proposed “transitions” as a central concept in nursing; we
have defined the concept as “those periods in between fairly stable states, a passage from
one life phase, condition, or status to another” (Chick and Meleis, 1986, pp. 238–239).
We have identified some of its components and dimensions as process, disconnectedness,
perception of transition, and patterns of response.
2. Comparison of the concept to others with similar properties and dimensions to establish
its boundaries (Norris, 1982; Walker and Avant, 1995). Transition, for example, can be
differentiated sufficiently from the general concept of change to make it useful in alerting
nurses to relevant aspects of the life contexts of clients. In this case, transition is seen as a
special case of the general phenomenon of change (Chick and Meleis, 1986).
3. Description of some of the antecedents to the concept and of some of the consequences
(Lindsey, Piper, and Stotts, 1982), and matching some of these descriptions with what
occurs in nursing practice. Examples of antecedents of transition are illness, recovery,
loss, and birthing; examples of consequences are distress, role performance changes, and
disorientation.
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190 PART FOUR Reviewing and Evaluating: Pioneering Theories
4. Development, description, and analysis of exemplars or model cases. This step may
include empirical results that are related to the concept.
5. Development, description, and analysis of contrary cases and their comparison with nor-
mative cases. Situations in which the concept appears only occasionally or appears under
a new set of conditions are called borderline cases and are also useful in analyzing con-
cepts. (See Chapter 15 for a more comprehensive discussion of concept analysis as a
strategy for concept development.)
The process of concept analysis may include semantic analysis, which is analysis of linguistic
meanings of the label given to the concept; analysis of logical derivation, which is the logical pro-
gression of identifying, supporting, and labeling a concept; and context analysis of the concept,
which includes the conditions under which the concept is manifested. Any inferences about the
concept should be analyzed for their sources, whether they are logically or empirically derived.
Each one of these steps is a test of the occurrence of the concept. These tests are both concep-
tual and clinical, but they are not tests as defined by empiricists. They are, however, equally neces-
sary tests and equally important steps in the process of testing concepts that involve the
development of empirically valid and reliable research instruments.
Theory Analysis
Whereas concept analysis is a process that could occur early in the process and cycle of the-
ory development and theory testing, theory analysis is a later process. Table 10-4 compares theory
TABLE 10-4 ANALYSIS
Analysis Criteria Units of Analysis
Concepts Differentiation from others Definitions
Semantic
Logic
Context
Antecedents
Consequences
Exemplars
Theories The theorist Educational background
Experimental background
Professional network
Sociocultural context
Paradigmatic origins References, citations
Assumptions
Concepts
Propositions
Hypotheses
Laws
Internal dimensions Rationale
System of relations
Content
Beginnings
Scope
Goal
Context
Abstractness
Method
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CHAPTER 10 A Model for Evaluation of Theories: Description, Analysis, Critique, Testing, and Support 191
analysis and concept analysis. Theory analysis involves considering important variables that may
have influenced the development of the theory and its current structure. In analyzing theories, con-
sider several criteria: the theorist, paradigmatic origins, and internal dimensions. These criteria pro-
vide a better understanding of choices of central theory questions, goals of theory, the theory
phenomena, and the strategy of theory development; these criteria also set the stage for the critique.
The Theorist. A comprehensive analysis of theories includes a careful consideration of the the-
ory’s author. Areas for exploration include experiential background, educational background,
employment, and reconstruction of the professional and academic networks that surrounded the
theorist while the theory was evolving. Such an analysis may include mentors, students, and spon-
sors when appropriate. This analysis helps in identifying influencing factors on the theory’s incep-
tion and on its further development. Often, clarification in a theory, redefinitions, or extensions are
directly or indirectly related to a new mentor relationship, a new degree, an employment move, or
other variables that contribute to shifts in orientation. Analysis helps to uncover the external and
internal factors influencing a theorist, such as beliefs held by the theorist, and the patterns of rea-
soning and the origins of these patterns. This may lead to a better understanding of the human
parameters involved in theory development, an essential component of a historically contexted con-
ception of science (Silva and Rothbart, 1984).
This segment of analysis could be done in a number of different ways, including a thorough
review of all that has been written by the theorist and all that has been written by others about the
theorist, direct communication with the theorist, and communication with mentors and students. A
review may also focus on only one (or more) aspect of the theorist (Fulton, 1987). Analyzing the
theorist’s background will help to clarify internal dimensions, which follows as the next order of
business in analyzing theories.
Consideration of who the theorists are as people, as nurses, educators, clinicians, and theorists
was the subject of analyses during the 1980s. These analyses took the form of short reviews (for
example, Marriner-Tomey, 1989) or elaborate videotapes (see Chapter 20). These analyses are indi-
cations of the value the discipline places on the contributions of these theorists, the significance of
knowing the theorist behind the theory for further understanding of the theory and for enhancing the
potential for others to model the theorist’s thought processes and strategies in developing the theory.
Paradigmatic Origins of Theory. Theoretical thinking in nursing either evolves from a proto-
type theory or can be traced to theories used in other fields. Examples of such theories are those of
Johnson, who derived her theory from the premises of the systems paradigm (Parsons, 1949;
Riehl and Roy, 1980, pp. 207–216), and Paterson and Zderad (1988), who based their work on
the existentialist philosophy. Therefore, for a careful consideration of this component, the theory
analyst should become conversant with the paradigmatic origins of the theory under considera-
tion and address those origins in the analysis.
To identify the paradigm from which the theory may have evolved or other theories that may
have influenced its development, the review considers the following:
• References, bibliography provided
• Background of theorist, educationally and experientially
• Sociocultural context that may have influenced the theory’s development.
Analysis of the theory in relationship to these components provides answers to three major
questions:
1. Is the theory derived from and built on a specific paradigm?
2. What are the origins of the paradigm?
3. Why was this particular paradigm used?
More specifically, on what prototype theory or paradigm did the theorist build the conceptual
structures? How extensively is the original paradigm or theory used?
Beckstead and Beckstead (2006) offer another approach for determining the epistemic origins
of nursing theories and models of framework. They used the multidimensional scaling (MDS)
approach in an attempt to systematically and objectively determine the nature of paradigms that
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192 PART FOUR Reviewing and Evaluating: Pioneering Theories
influenced nursing theorists from various fields such as psychology, biology, or philosophy. By
identifying the scholars from other fields cited by 20 nurse theorists, they tentatively concluded
that the themes of adaptation and wholeness may be traced to the field of biology and specifically
to general systems theory, and the themes of humanism to Abraham Maslow and Carl Rogers.
More importantly, by experimenting with this evaluative technique, they propose that nursing sci-
ence is derived from both a priori (philosophical) and posteriori knowledge (sense experiences).
Thus, theorists may utilize wider ranges of scholars from different disciplines, to provide a wider
scope of influence; or they may use a smaller and more homogeneous set of scholars, to provide a
more focused influence. Evaluating theories by the MDS approach may shed light on the intellec-
tual inspiration of theorists; however, the nature of this inspiration must be uncovered by the con-
tent analysis of the explicit and implicit assumptions used in the theory.
Other content questions to consider are the following: Is the use of paradigm obvious to the
reviewer, made explicit or implicit by the writer? Does the theorist present the rationale for selection
of the theory or parts of the theory used? From where do theory inadequacies originate: prototype
theory or nursing theory? Do the problems detected reflect those of borrowed theory, or are they
the result of translation? Does nursing theory improve on prototype theory? How congruent or
incongruent is the use of components of prototype theory with nursing theory? How different or
similar are the definitions to prototype theory definitions? Are goals the same? Is justification for
variance included? Are other nursing theories derived from the prototype theory? What are they?
Internal Dimensions. The components of the internal structure act as guidelines to describe a
theory, as discussed in the section, Theory Description. Dimensions described in this section help
in analyzing a theory to enhance understanding of the approaches used to develop it, in delineat-
ing gaps in the theory, and in giving perspective to why some omissions are not necessarily gaps
in the theory but in some instances are merely what the theory intended. This will soon become
clear. The dimensions described next provide the necessary lexicon to describe a theory.
The first dimension to consider is the rationale on which the theory is built. Questions to con-
sider in describing the theory along this dimension include: Are components of the theory united in
a chain-link fashion? Is it a theory of the factor type? Is the theory developed around concepts and
thus a concatenated theory? Or, is it based on certain sets of relationships that are deduced from a
small set of basic principles and are therefore hierarchical in nature? The concatenated theory has
fewer explanations that converge on a central point and therefore embodies existence propositions,
whereas the set of relationships theory embodies an interpretive model (Kaplan, 1964).
The second dimension to consider is that of system of relations. Questions to be asked are:
Do relations explain elements, or do elements explain relations? A monadic approach in theory
construction considers single irreducible units, as opposed to a field approach, which considers its
unit of analysis in terms of a number of other mini-units. An example of the monadic approach is
cell theory, and an example of the field approach is a theory of personality in terms of roles. A
monadic approach is one in which the attributes and properties of the phenomenon are the focus of
the theory. A field approach focuses on the relationships between the phenomena and thus
explains the phenomena through these relationships. Therefore, a theory of a human being as a
subsystem of behavior would be monadic, and a theory of human environmental interaction would
be a field theory.
Content of the theory is a third descriptive dimension (Kaplan, 1964). Content is distin-
guished by the range of laws and group of individuals to which the theory refers. A theory could
be classified as molar or macrotheory, or as molecular or microtheory. Organizational theories in
sociology are macro in content, whereas rule theory is micro. This dimension considers the range
of relationships in the theory and the set of individuals to which the relationships refer. When a
theory considers the human being in totality, it is macrotheory. When the theory address needs
during illness, it is a microtheory. Therefore, Rogers’ work (1970) is an example of macrotheory,
whereas that of Orem (1985) is an example of microtheory.
The point at which a theorist begins articulating ideas and addresses either a theory of extant
nursing practice or one of ideal nursing practice specifies another dimension, namely, that of theory
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CHAPTER 10 A Model for Evaluation of Theories: Description, Analysis, Critique, Testing, and Support 193
beginnings (Kaplan, 1964). A constructive beginning is hypothetical and is intended to build up a
picture of more complex phenomena, whereas a principle theory beginning is more empirically
grounded (discovered). A theory with a constructive beginning tends to be more complete, clear,
and adaptable and tends to consider relationships hypothetically; the latter is more analytical and
addresses the “is” rather that the “ought to be.” It is more perfect and better substantiated.
A theory with a constructive beginning is also called a deductive theory because it empha-
sizes a conceptual structure deduced from another conceptual structure (Duffey and Muhlenkamp,
1974). Its laws are logically interrelated. It is through such deductive logic that some theories are
derived. The major criticism of deductive theories is the lack of empirical support until they are
tested in research. An example of a deductive theory in nursing is Rogers’ (1970) theoretical con-
ceptualization of man in his symphonic harmony with the environment. Her theory evolved from
principles of physics, thermodynamics, and evolution, among others.
The principle theory beginning is also called the inductive beginning. It, on the other hand,
consists essentially of summary statements or empirical relations. An example of an inductive the-
ory is a conceptualization of issues surrounding dying, evolving from Glaser and Strauss’ (1965)
and Benoliel’s (1967) work, even though these have not been formally labeled nursing theories.
Many theorists have addressed the scope of theory and its significance in describing the capa-
bility of the theory. The basic question that considers a theory’s scope is: How many of the basic
problems in nursing or any of its specialties could be addressed by the same theory? The signifi-
cance of scope stems from the notion that theories having wider scope tend to be more general and
last longer (Kuhn, 1970). In addition, the significance of a theory increases as its scope broadens
(Ellis, 1968). Therefore, to answer questions related to scope, we also address generality. Theories
with a wide scope are also called “grand theories,” as opposed to “single-domain theories,” which
could be placed at the other end of a scope continuum.
The major criticism associated with both ends of the scope continuum (i.e., grand theories
and single-domain theories) involves the attempts of grand theories to explain everything sur-
rounding a set of phenomena, which is also why they may be limited in their power to explain
(a major criticism of Parsons’ [1949] attempts at a theory of sociology). Single-domain theories
address only simple, abstract, isolated factors and principles. The empiricist and methodologist
Robert Merton (1964) is credited with advocating middle-range theories, thus avoiding those crit-
icisms. Middle-range theories consider a limited number of variables, have a particular substan-
tive focus, focus on a limited aspect of relationship, are more susceptible to empirical testing, and
could be consolidated into more wide-ranging theories (see Chapters 16 and 17).
In nursing, Jacox (1974), following Merton’s ideas, urged the development of middle-range
theories for limited aspects within the discipline of nursing, such as pain alleviation or promotion
of sleep. A major criticism of middle-range theories is that they lead to fragmentation of a disci-
pline when the discipline has no agreed-on phenomenon. Middle-range theories are more appro-
priate now in nursing, particularly after we have identified and broadly agreed on the boundaries
of nursing knowledge and nursing domain concepts. Situation-specific theories are evolving to
reflect specific contexts, limited scope, and more conditions that limit generalization. There are
more indications that the level of maturity of the nursing discipline allows for more specificity in
the theories.
Questions to ask when considering the goal of a theory are: Why was the theory developed?
What is its aim and intent? Theories are constructed to describe, explain, predict, or prescribe. A
descriptive theory gives information related to phenomena under consideration but does not make
a claim beyond that, nor does it tell us what to expect in the future. When a beginning linkage and
description of relationships between derived concepts are provided, the theory becomes an
explanatory theory. Correlative studies to test explanatory theories provide empirical evidence in
support of these theories. Another goal explicated in some theories is that of prediction. A predic-
tive theory encompasses propositions of an “if . . . then” nature in a consequential manner. The
ultimate goal in nursing is to prescribe; therefore, prescription is another theory goal. Theories
might have all of these goals, or they may explicate only one goal or another. At this time in the
developmental history of nursing theory, it is essential that a theory represent each of the goals.
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194 PART FOUR Reviewing and Evaluating: Pioneering Theories
The context of a theory in which the central phenomenon is addressed is yet another dimen-
sion for theory evaluation. Johnson (1959) called attention to the need in nursing for theories
addressing knowledge of order, knowledge of disorder, and knowledge of control. The knowledge
of order addresses phenomena that are central to objects, events, and interactions in a healthy con-
text. They describe regularities in such phenomena. They describe the normal state and natural
scheme of things. They provide baseline data. An example of such knowledge is provided by
Auger (1976) in her explication of Johnson’s (1968) normal patterns of a person’s behavior within
systems of behavior. Knowledge of disorder recognizes a context or disorder within which nurses
deal. An attempt to develop such knowledge, not yet bound together in a theoretical schema, was
manifested in the first conference on classification of nursing diagnosis (Gebbie, 1976) and in
subsequent conferences. To prescribe a course of action that, when implemented, could change
the sequence of events in a desired way is to have knowledge of control. Examples of theories
addressing such knowledge are Orem’s self-care theory (1985) and Meleis (1975) and Meleis,
Swendsen, and Jones’ role supplementation (1980) theories, among others. Theories could also
address knowledge of process, which included the nursing process and nurse–patient interactions
(Paterson and Zderad, 1988).
Abstractness, another theory dimension, is evaluated by length of reduction and deduction
between its propositions. A highly abstract theory requires more steps to reduce the chain “con-
necting the theoretical terms with the observable ones” (Kaplan, 1964, p. 301). It is a theory with
wide spaces between its proposition and conceptual schema that is highly removed from reality
but still pertains to it. If abstractness is put on a continuum from high to low abstractness, Rogers
and Johnson would be at the high end and Orem at the low end.
Finally, the method of theory development should be carefully assessed. Barnum (1998) pro-
posed that four methods are used in developing theories. One can assess these methods by consid-
ering the reasoning on which the theory is built, the system of action, and the plan for progression.
A dialectical method is exemplified by Rogers’ work (Barnum, 1998) and is based on Hegel’s
dialectical process. It speaks to the fusion of opposites (Newman, 1979). It emphasizes relation-
ship with a whole and, in fact, each whole explains parts and each part is a whole explaining other
parts. A dialectical method encompasses contradictions, apposition, and dilemmas, but order
evolves from the interaction among all of them. Erickson’s developmental theory (1963) is an
example of resolution of conflict and crisis in the process of moving into the next level of develop-
ment. A dialectical method defies Aristotelian logic, which is another method of theory develop-
ment––the logical method. This is a method in which the parts are organized to describe the whole
systematically and categorically. Nursing process is organized in a logical sequence. A theory of
this nature offers a description of each part, and the whole is more than and different from the sum
total of all parts. Barnum (1998) also warns of the misuse of “systems” as a subject matter to clas-
sify a theory as system theory. There are many different ways to use systems theories to develop
the substance of a theory. It is important to differentiate the different foci. Barnum (1998) consid-
ers the theories of Johnson and Roy in this category.
The other two methods of theory development, according to Barnum (1998), are problematic
method and operational method. Both appeal more to common sense, use persuasion in support-
ing ideas, and use their experiences in theory development, and in both the agent is part of the
method. Problem theories (Henderson, 1966; Nursing Theories Conference Group, 1980) are
organized around nursing problems, whereas operational theories (Orem, 1985) are organized
around methods of intervention and differential diagnosis.
Critique of Theory
Critique is defined by Webster’s Third New International Dictionary as “critical examination
or estimate of a thing or situation with the view to determining its nature and limitations or its con-
formity to standards.”* Several criteria are essential in critiquing theory. These are relationships
* By permission. From Webster’s Third New International Dictionary. (1986). Springfield, MA: Merriam-Webster, Inc.
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CHAPTER 10 A Model for Evaluation of Theories: Description, Analysis, Critique, Testing, and Support 195
between structure and function, diagram of theory, circle of contagiousness, usefulness, and exter-
nal components. Each is defined and presented in the following sections.
Relationship Between Structure and Function
In critiquing a theory according to the criteria listed next, the critic considers the relationship
between structure and function (Table 10-5). This is accomplished by making a critical assess-
ment and judgment of the relationship between the different components of the theory, such as
assumptions, concepts, propositions, and domain concepts. In doing so, the critic cannot judge the
logic inherent in the development of a dialectic theory by the same criteria used when judging a
logical theory; rather, the method used dictates the critique. Several criteria could be considered,
such as clarity, consistency, simplicity/complexity, and tautology/teleology.
Clarity. Clarity is defined on a continuum ranging from high to low. It denotes precision of
boundaries, a communication of a sense of orderliness, vividness of meaning, and consistency
through the theory. Clarity is also defined by Chinn and Kramer (2004) as “how well the theory
can be understood and how consistently the ideas are conceptualized” (p. 109). Clarity is demon-
strated in assumptions, concepts, and propositions, as well as in domain concepts. To have clarity
in concepts is to have theoretical and operational definitions that are consistent throughout the the-
ory, are presented in a parsimonious way, and are consistent with theory assumptions and proposi-
tions. Questions such as the following help to determine concept clarity: Are concepts
operationally defined? Do they seem to have content and construct validity? Propositional clarity
is manifested in a coherent and logical presentation of propositions and systematic linkages
between the theory concepts. The criterion of clarity varies within a range from high to low clarity.
Consistency. The boundaries between clarity and consistency are not easily determined. The
degree to which a congruency exists between the different components of a theory describes its con-
sistency. The fit between the different components of a theory describes its consistency. The fit
between assumptions and concept definitions, between concepts as defined and their use in proposi-
tions, and between concepts and clinical exemplars can all be considered determinants of consistency.
Simplicity/Complexity. Another criterion with which to critique a theory is its level of simplic-
ity/complexity. The more phenomena the theory considers, the more potential relationships it
could generate, and the more complex the theory is (Ellis, 1968). Simplicity of a theory is more
desirable if it focuses on fewer concepts and few relationships that may enhance its utility. Com-
plexity of a theory may be a desirable criterion if the complexity enhances the number of explana-
tions and predictions that the theory offers. Therefore, simplicity in the face of complex contextual
reality is as unadvisable as complexity in theory would be when the theory explains a limited
TABLE 10-5 THEORY CRITIQUE—RELATIONSHIP BETWEEN STRUCTURE AND
FUNCTION, DIAGRAM OF THEORY, AND CIRCLE OF CONTAGIOUSNESS
Criteria Units of Analysis
Relationship between structure Clarity
and function Consistency
Simplicity/Complexity
Tautology/Teleology
Diagram of theory Visual and graphic presentation
Logical representation
Clarity
Circle of contagiousness Geographical origin of theory and geographical spread
Influence of theorist versus theory
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196 PART FOUR Reviewing and Evaluating: Pioneering Theories
number of relationships. Chinn and Kramer (2004) advocate simplicity in a theory that has been
tested and as a means for generating ideas and hypotheses. Levels of theory simplicity and com-
plexity correspond with the stage of theory development. Some nursing situations require a higher
degree of complexity and less empirical accessibility. Other situations require a limited number of
elements and thus reflect simplicity.
Tautology/Teleology. The clarity, consistency, and simplicity/complexity of a theory could also be
described through tautology and teleology. A general assessment of tautology is done by considering
the needless repetition of an idea in different parts of the theory. Tautology decreases a theory’s clarity.
A careful consideration of the extent and the care by which causes and consequences are kept separate
ensures that the theorist avoids teleology. Teleology occurs when the definition of concepts, conditions,
and events uses consequences rather than properties and dimensions. When defining concepts by con-
sequences only, the theorist introduces new concepts to define existing ones. This practice leaves the
original concept undefined. Teleology is another dimension in the relationship between structure and
function. The critic, therefore, should consider questions such as: Does the theory have logical coher-
ence? Are definitions of nursing phenomena concise? Is it a teleological theory?
Diagram of Theory
The clarity of theories and models is further enhanced by visual representation of the theory.
Major questions to be addressed in relation to this component are: Was the theory visually and
graphically presented? Did the graphic presentation enhance understanding of different compo-
nents of the theory? More specifically: How clear is the visual representation? Is it an accurate
representation of the text? Does it include major concepts? Are linkages clear? Are linkage direc-
tions indicated? Is representation logical? Are there overlaps? Are there gaps? Is representation a
substitute for words and explanation or is it a supplementation? Is the diagram clear and well
defined? Is there a correspondence between diagram and concepts and propositions in the text?
Do the diagrams enhance understanding of the text?
Circle of Contagiousness
The final test of any theory is whether it is adopted by others (see Table 10-5). The units of
analysis here are geographical location and type of institution. Theories in nursing have been used
within the geographical areas from which they emanated. Rogers’ theory is used at New York Uni-
versity and tested by Rogers’ students; Johnson’s is used in Los Angeles and tested by her stu-
dents. Therefore, when a theory begins to cross several concentric circles from its origin, its circle
of contagiousness increases, and we can infer that the theory is receiving more acceptability, unin-
fluenced by the theorist.
The critic should review the literature, indexes, and citations for answers to questions such
as: Where has the theory been developed and used? Where is it being used both geographically
and institutionally? What is it used for (research, education, administration, clinical practice,
etc.)? How influential was the theorist in prompting the implementation of the theory? Where was
it first introduced? What happened in the interim? Has the theory been considered and used cross-
culturally and transculturally? A critique of the circle of contagiousness of a theory is made in
conjunction with the usefulness of theory.
Usefulness
A critique of the usefulness of a theory encompasses four areas: its potential for usefulness in
practice, research, education, and administration (Roper, Logan, and Tierney, 1996) (Table 10-6).
Usefulness in Practice. A thorough review and assessment of theory has to consider its poten-
tial for operationalization and utilization in nursing practice. A practitioner who is considering
using a theory in some practice area should assess the theory in terms of its function: its goals, con-
sequences, and potential for practice. Therefore, the theory should be able to respond to these ques-
tions or have a framework to help the clinician respond to them: Does the theory provide enough
direction to affect practice? Does it have a framework for prescription? Does the theory include
abstract notions that are not applicable to practice? Does the level of abstraction or understandabil-
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CHAPTER 10 A Model for Evaluation of Theories: Description, Analysis, Critique, Testing, and Support 197
ity render it applicable or inapplicable? Does the theory cover all areas of nursing? Should it? Does
the theory currently apply to practice? Who pays for use of the theory in practice? Is it cost effec-
tive? Is it a timely nursing practice theory? Does it have relevance for the way nursing is practiced
today? Where does the theory fit in terms of nursing process? Is the theory understandable to the
practitioner? What is the assessment of practitioners of the theory as to its uniqueness and its eso-
teric language? How does it relate to diagnosis-related groups (DRGs)? In what ways is the theory
translatable to an existing or a proposed informational technology or system?
Finally, a different question is proposed by Reed (2008) as one test of the pragmatic ade-
quacy of nursing theories. It is related to the extent to which the theory is able to inform nurses
about the human health experience of well-being or adversity. Reed proposes that developing the-
ories may be influenced by adverse circumstances, depending on how science is defined at the
time of the theory’s development. In addition, considering how the theory deals with patients’
experiences with any misfortune, as well as how it provides guidelines for restoring theory, would
be an important evaluative point.
Usefulness in Research. The raison d’être of theories is to guide and be guided by research;
therefore, a critique of a theory should include questions related to the assessment of a theory’s
potential for testability. The concepts and propositions should eventually be related in a consistent
manner to a systematic set of observable or testable data. Otherwise, if a theory remains untested,
its usefulness is in question. Schrag (1967) emphasizes the significance of a theory’s potential for
research, which he calls “the empirical adequacy” of a theory, and this potential is realized
through congruence between “theoretical claims and empirical evidence.” He asserts that credibil-
ity refers to the “goodness of fit between claims and existing evidence, while predictability esti-
mates how well the claims will hold true in the future” (Schrag, 1967, p. 250).
Theories are established on current information; it usually is up to the future to provide evi-
dence that corroborates them. Although the aim of research is not to establish the absolute truth of
the theoretical propositions, it is essential that it begins to indicate a degree of confidence based on
empirical evidence. It is noteworthy that, to the unsophisticated reviewer, any supportive corrobo-
ration between theory and data uncovered through research may be interpreted as giving support to
the entire theory structure, however premature that might be. The reverse could also be true. There-
fore, the type and extent of empirical corroboration should be skeptically considered by answering
several questions, including: What specific theory propositions did the research consider? Were
TABLE 10-6 THEORY CRITIQUE—USEFULNESS
Criteria Unit of Analysis
Practice Direction
Applicability
Generalizability
Cost effectiveness
Relevance
Research Consistency
Testability
Predictability
Education Philosophical statement
Objectives
Concepts
Administration Structure of care
Organization of care
Guidelines for patient care
Patient classification system
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198 PART FOUR Reviewing and Evaluating: Pioneering Theories
these central or peripheral propositions? Was the research undertaken to provide validity to con-
cepts or relationships? Was theory used to test propositions or to interpret findings? Were explicit
theory assumptions considered in designing methodology?
Although it is significant to the theory critic to note that theories are tested on a piecemeal basis,
the critic should still consider finding responses to the following questions: Does the theory build on
previous research? Was research done using the theory? What propositions were being tested? How
reproducible is the research? Can the findings be generalized? What research designs have been
used? Why? How appropriate are they? Can proscriptive and predictive (experimental and quasi-
experimental) studies be designed? Are the research results relevant to other fields? Is the research
used appropriately? Do the theories state what research is to be completed to support central theory
propositions? Has there been empirical verification of its properties? How consistent are its proposi-
tions with other theories and laws? Is there evidence for corroboration (Schrag, 1967)? Finally, one
can detect any spuriousness in the theory’s components as manifested in a logical or research determi-
nation of whether or not dependent variables are potentially related to other, independent variables.
The research potential or testability of a theory should not be critiqued lightly. As Berthold
(1968) and Ellis (1968) stressed, the ultimate criteria for evaluating a theory’s usefulness are
whether it generates predictions or propositions concerning relevant events and whether it stimu-
lates new observations and insights that could subsequently be corroborated. Units of analysis for
testability are theoretical and operational definitions, theoretical propositions, ongoing research,
and completed research.
Usefulness in Education. The beginning evaluation of nursing theories for their potential to
offer guidelines for nursing curricula and programs coincided almost completely with the devel-
opment of most of the theories that we now consider to be nursing theories. In fact, as we analyze
the rationales and the goals of a good number of the nursing theories, we find that nursing educa-
tion invariably prompted their development through the search for a coherent presentation of
what nursing is about, and to guide and structure the curriculum, the biomedical model that dom-
inated nursing curricula. Invariably, a growing uneasiness prompted a shift to a needs orientation,
such as that offered by Henderson (1966) and Abdellah (1969), and with it a rejection of biologic
systems and disease orientation as frameworks. Unfortunately, the shift to a nursing conceptual-
ization was premature because it occurred simultaneously with the theory being developed, and,
therefore, many faculty members suffered from the pitfalls of attempting to operationalize a the-
ory while still developing it.
The National League for Nursing criteria for accrediting and adopting a conceptual frame-
work to guide curricula was both a blessing and a menace to nursing curricula and to theory devel-
opment. The blessing was the reorientation of faculty to nursing theory; the menace emanated
from the prematurity of the use of nursing theories in nursing education. Nursing theories could
provide the major premises on which a curriculum is built, yet I believe that it was not feasible to
develop an entire program on just one conceptualization of nursing. For example, theories about
teaching and learning, about the learner, and about the environment are complementary to nursing
conceptualizations in defining and structuring curricula.
Usefulness in Administration. Use of nursing theory in administration is considered in terms of
the structure and organization of care. Theories ought to provide the potential for guiding and
describing nursing care. Nursing theories are expected to guide the care of clients and are not
expected to provide the administrator with guidelines for administration or for leadership style.
Analysis shows how useful theory can be in providing guidelines in patient care on a large scale.
Some questions to consider are: Does it help the patient classification system? How congruent is
the mission of nursing as articulated by theory with the mission as articulated by different nursing
organizations? Does the theory provide any specific guidelines for theory implementation on an
organizational scale? Does it provide assistance in determining criteria for quality control?
Other criteria for the evaluation of theories for nursing administration were identified by
Buchanan (1987). These include the congruency of theory with professional standards, such as
licensing requirements, as well as standards stipulated by such accrediting bodies as the American
Nurses Association and the American Hospital Association. Theories selected by administrators
should also be congruent with the legal structure governing nursing functions in different countries.
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CHAPTER 10 A Model for Evaluation of Theories: Description, Analysis, Critique, Testing, and Support 199
External Components
Finally, the theory should be assessed against several external criteria. These are: personal
values, other professional values, social values, and social significance (Table 10-7).
Personal Values. Ellis (1968) and Johnson (1987) emphasized the importance of recognizing val-
ues inherent in theories and in making them explicit. Review of values occurs as the assumptions of a
theory are uncovered and described. A critical consideration of values should account for those values
of the theorist and the critic. In the latter, the fit between the theorist’s and critic’s personal and profes-
sional values should be considered. It is through such careful assessment that biases can be delineated.
Congruence with Other Professional Values. A similar assessment of the values espoused in the
theory should be made of the values of other professions. Health care professionals will be able to
enhance patient care through collaboration and complementarity of value systems. Awareness of such
complementarity or competition in professional values enhances the potential of the development of a
collaborative working schema to close the professional value gaps (Johnson, 1974).
Congruence with Social Values. Beliefs, values, and expectations of different societies and cul-
tures within societies shape and direct the type of theory that is most useful. Although self-help, self-
care (at its different levels), and individuality are goals congruent with some cultures’ value systems,
they are the antithesis of those espoused in others. Therefore, theories with such goals and conse-
quences would be incongruent and inappropriate to some societies and should be avoided. Careful crit-
ical assessment of societal values and theory values is an integral part of a thorough theory critique.
Questions should be addressed such as: Is the role of the nurse within the model congruent with the
role of the nurse as perceived by society? Are actions and outcomes congruent with societal expecta-
tions of nursing (Johnson, 1974, 1987)?
Social Significance. In our attempt to enhance nursing science and articulate the discipline of
nursing, we must not neglect the significance of its practice to humanity and society. The philanthropic
Bacon’s profound words of the 18th century still hold true today:
Lastly, I would address one general admonition to all; that they consider what are the true
ends of knowledge, and that they seek it not either for pleasure of mind, or for contention, or
for superiority to others, or for profit, or fame, or power, or any of these inferior things, but for
the benefit and use of life; and that they perfect and govern it in charity. For it was from lust of
power that the angels fell, from lust of knowledge that man fell; but of charity there can be no
excess, neither did angel or man ever come in danger by it. (Bacon, in Ravetz, 1971, p. 436)
A critic should ask philosophically whether the goals and consequences of theory make a
substantial and valued difference in the lives of people. (Consider questions from the perspective
of clients and from the perspective of other health professionals.) The critic should also ask
whether intended and unintended consequences are carefully considered (Johnson, 1974, 1987).
TABLE 10-7 THEORY CRITIQUE—EXTERNAL COMPONENTS OF THEORY
Criteria Units of Analysis
Personal values Theorist implicit/explicit values
Critic implicit/explicit values
Congruence with other professional values Complementarity
Esotericism
Competition
Congruence with social values Beliefs
Values
Customs
Social significance Value to humanity
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200 PART FOUR Reviewing and Evaluating: Pioneering Theories
Theory Testing
The development of theory and the continuance and advancement of a theory for the purpose of
providing evidence in practice requires theory testing, as well as a replication of that testing. The def-
inition of theory testing has been the subject of many discussions and dialogues in nursing (Chinn,
1984, 1986; Silva and Sorrell, 1992; Clift and Barrett, 1998). It has also been equated with the evalua-
tion of theories and considered the most significant goal in developing, accepting, and using theories.
Theory testing is different from theory based research. Theory testing provides evidence, advances
predictions, and adds substantially to theory building (Norman, 2004); theory-based research affirms
its utility in conceptualizing the research questions and variables. Both provide different types of sup-
port for theories. Theory testing is considered here as only one component of a comprehensive evalu-
ation of theories in the discipline. To equate testing with evaluation and to consider it the only
significant goal for theory development is to ignore all the descriptive, analytical, and critical com-
mentaries on theories that have been published and that have added to our understanding of theories
and are significant for knowledge development. (Refer to writings in Advances in Nursing Science,
Nursing Outlook, American Journal of Nursing, and Journal of Advanced Nursing during 1970–1990
for extensive examples of writings describing, analyzing, and critiquing theories and theoretical
thoughts.) To equate testing with evaluation is also to reduce theoretical knowledge to the context of
justification and to exclude the context of discovery with its process orientation.
Theory testing is a systematic process of subjecting theoretical propositions to the rigor of
research in all its forms and approaches, and consequently, the use of the results to modify or
refine the research propositions. Theory testing presumes the complete cyclical relationship
between theory, research, and theory. Theory testing is neither a static process nor an end result.
The dynamic testing process begins with theory development and continues with testing and more
development of theory, pausing long enough to reflect and go through the cycle again.
Theory testing is not a single entity. It has many dimensions, needing many different approaches.
Silva and Sorrell (1992) reviewed tests of nursing theories and identified three alternative approaches:
• Tests to verify theories through critical reasoning
• Tests to verify theories through the description of personal experiences
• Tests to verify theories through application to nursing practice
Earlier, in a review of 62 studies in which the use of theories by Johnson, Roy, Orem, and Rogers
guided the studies, Silva (1986) found three ways in which theory testing was used. In 24 studies,
there was a minimal use of the theory other than in identifying it as a framework for the study. She
labeled 29 of the studies as insufficient, simply using the theories as a way to organize their review of
literature or to select their instruments. Only nine of the 62 studies qualified in the third category of
adequate use of theories. These were studies in which the hypothesis testing and findings were inte-
gral to the theory and actually provided evidence to modify, accept, or reject theory propositions.
Silva proposed that this third category, which she labeled adequate use of the theory, is an inte-
gral part of problem identification, analysis, and interpretation. It is the type of test that should be the
goal of nurse scientists in the development of knowledge in the discipline. She further attributed the
lack of empirical testing to the pressure on nurse investigators to use a conceptual framework for
their studies without clear guidelines on what is involved in testing, to the use of highly abstract the-
ories, to the lack of precise measures, to the subsequent “lack of tolerance to methodological imper-
fections,” and finally to an inability to systematically retrieve theory-based research (Silva, 1986).
Testing of theory in nursing is more complex than mere proposition testing. Considering the
types of theories nurses have and will develop—that is, theories that attempt to explain responses of
clients, environments, and nursing therapeutics to enhance the health of clients—it would be inad-
visable to limit the investigative processes and goals to a limited definition of testing. Meleis
(1995) proposed the consideration of theory testing through six principles. Each of these six prin-
ciples could be used to judge the appropriateness of the tests used for the theory. The principles
are gender sensitivity of the testing, the extent to which a diverse population was used, whether or
not the theory was tested on populations that are considered vulnerable and marginalized, whether
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CHAPTER 10 A Model for Evaluation of Theories: Description, Analysis, Critique, Testing, and Support 201
the questions and the methods reflect cultural competence, whether the theory testing was done
nationally or internationally, and finally, what philosophy of health care provided a framework for
the testing (curative care or primary health care). Throughout the history of theory testing in nurs-
ing, at least six approaches are utilized. These are:
1. Testing the utility of nursing theory: Research developed to evaluate the use of theory in
practice, teaching, or administration falls under this category. Units of analysis for this
category are the individual nurse, teacher, student, or administrator. The intent of this
type of research is to determine the feasibility of the use of theory by the group of indi-
viduals using that theory. This research tests the learner’s ability to recall, comprehend,
evaluate, and use the theory. Results of such tests relate to and enhance adult learning
theories or cognitive theories rather than nursing practice theories (e.g., Jacobson, 1984).
A variation of this category is testing the difference between the use of the different
existing theories. Jacobson (1984), for example, used a semantic differential scale to
define some of the differences among the King, Orem, Rogers, Roy, and Wiedenbach
theories as perceived by users. Eight factors emerged to account for 49% to 56% of the
variation between the theories as perceived by users. The factors are sophistication,
dynamism, clarity, usefulness, focus, utility, scope, and scientific rigor. This approach to
testing a model was critiqued conceptually and methodologically (e.g., Nicoll, Meyer,
and Abraham, 1985). In their view, nursing models are to be evaluated individually in
terms of their content. An external evaluation, from their perspective, is incongruent with
the nature of models as specific to a certain context and thus ineffectual in advancing
nursing knowledge.
Tests designed to compare the feasibility of implementing different theories are useful
if they are problem- and context-specific. For example, using Johnson’s theory and King’s
theory to assess and diagnose the nursing care needs of an immigrant patient undergoing a
kidney transplant, and then comparing the processes and contents of assessment, could
help in understanding learners’ abilities to use the theories and to compare the efficiency
and effectiveness of the theories in defining the priority needs of the patient.
2. Testing propositions from other disciplines: Research in this category is designed to test
propositions from theories that were developed in other disciplines. Nursing literature
has numerous examples of this type of research. Tests related to theory utilization also
fall under this category because they are designed to address propositions related to edu-
cational theory. Other examples are research to test propositions evolving from systems
theory, adaptation theory, role theory, and stress theory. Maslow’s theory (Davis-Sharts,
1986) is an example of a theory derived from other disciplines.
3. Testing propositions from other disciplines as they relate to nursing: Research in this cat-
egory involves, more specifically, testing propositions as they relate to a nursing phenom-
enon or testing propositions that are of interest to nursing. Examples of this research
include studies designed to test role strain in nursing faculty (Meter and Agronow, 1982;
O’Shea, 1982) and in women (Woods, 1985a, 1985b), based on role theory, and studies
to test concepts from other disciplines (Wewers and Lenz, 1987).
4. Testing nursing concepts: Research in this category is designed to develop a measurable
concept by identifying corresponding variables. The objective of testing in this category
is to develop a valid and reliable means by which the concept is tested. Validity means
that the instrument, the tool, or the means by which the concept is measured indeed
measures that concept, and the extent to which it is used provides data compatible with
other relevant evidence (Diers, 1979). Reliability means that these instruments consis-
tently measure the same concept. The development of valid and reliable instruments,
tools, or means by which concepts could be measured is one of the priorities in the devel-
opment and testing of nursing theories. Examples include Lush, Janson-Bjerklie,
Carrieri, and Lovejoy (1988); Nield, Kim, and Patel (1989); Carrieri, Janson-Bjerklie,
and Jacobs (1984); and Derdiarian and Forsythe (1983).
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202 PART FOUR Reviewing and Evaluating: Pioneering Theories
5. Testing nursing propositions: Research in this category is designed to test theoretical
propositions that are derived from nursing theories. There are three major types of propo-
sitions tested in nursing:
• Existence propositions: These relate two or more concepts to demonstrate their exis-
tence. Research designed to test existence propositions merely demonstrates that the
two concepts exist concurrently. Descriptive studies of levels of self-care of oncology
patients are one example; others may relate levels of self-care to degree of anxiety.
Correlational tests are the most suitable analytical models for this type of research.
• Predictive propositions: Tests designed to explore predictive propositions demonstrate
the effect of one concept on another. Such propositions are modeled after the question:
What will happen if . . . ? For example, studies designed to test interactional theory
propositions asked: What will happen if patients are given an opportunity to express
their feelings of anxiety before surgery (Dumas and Leonard, 1963)?
• Prescriptive propositions: Research designed to test nursing interventions use princi-
ples from evaluation research. The objective is to find out how effective is the interven-
tion in bringing about the desired goals. Examples are Smith (1986), who tested
Rogers’ principle of integrality, and Mentzer and Schorr (1986), who tested Newman’s
proposition linking situational control and perception of duration of time.
6. Testing through interpretation: Theory may also be tested by using it as a framework for
interpretation. This may support, refine, or extend a theory.
Theory Support
One other evaluative component for theories is the extent to which the theory is supported.
This component of evaluation addresses the extent to which the theory has garnered support, has
attracted a dedicated and loyal audience, and for which there is an identifiable community of
scholars who are using the theory in their own work and in a variety of situations.
Theory support is a broader concept than testing, more friendly to alternative ways of theory vali-
dation, and more congruent with the nature of the discipline (Meleis, 1995). It is not only the validation
of a theory that should be considered in evaluating theory––we need to think of support and affirma-
tion of parts of theories, and we need to think of components of theories. Even if we cannot generalize
from a theory about individuals’ health and illness situations and experiences, it is still extremely use-
ful to understand the experience of the few who experience health and illness in certain unique ways,
particularly in sciences that deal with human experiences and with practice-oriented issues. What
other criteria can affirm or support a theory? Accounts, exemplars, and stories can be used as tests of a
theory’s credibility and could bolster a theory’s validity. Theory support includes increased advocacy
for central statements, goodness of fit with some central problems in the discipline, and new insights
about nursing phenomena. Support for a theory could also be obtained through networks formed to
evaluate the theory’s potential and capability, and by determining what other criteria can affirm or sup-
port a theory. Scholars in the discipline of nursing—and I mean by scholars both scientists and clini-
cians—can provide support for theories through a number of approaches. The following are different
ways by which the extent of support for a theory could be determined:
1. Supporting nursing theory through philosophical analyses
2. Supporting nursing theory through conceptual analysis
3. Supporting nursing theory through existing data
• Analytical synthesis of single utilization studies
• Component-based meta-analyses
• National and regional databases
4. Supporting nursing theory through new data
• Narrative studies based on clinicians’ experiences, assessment of clients’ situations,
and therapeutics used
• Interpretive studies based on clients’ experiences
• Predictive studies of stress and wellness
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CHAPTER 10 A Model for Evaluation of Theories: Description, Analysis, Critique, Testing, and Support 203
• Studies to support the utility of nursing therapeutics and through further development
of predictive theory studies
CONCLUSION
Theory development and evaluation are cyclical, continuous, and dynamic processes. One cannot
exist without the other. Theory evaluation includes description, concept analysis, theory critique,
theory testing, and theory support. These processes are based on the view that science is a human
process that includes not only valid findings but also observations, agreements, and useful solu-
tions to problems. It is also important to consider the experiences, the lens, and the level of credi-
bility that the theorists were able to garner.
Theory evaluation is central to the development of theory; it is the responsibility of every cli-
nician, academician, and administrator. If each does her share, we are then assured of the continu-
ous growth of a body of knowledge to guide research and practice.
The theory evaluation model provided here is not designated to be used as a whole for every
theory the evaluator wishes or plans to use. Different parts of it could be used for different evalua-
tion purposes. One evaluator could not complete a full theory evaluation by using all components
of the model. An evaluator may choose to focus on description, analysis, critique, or testing, or on
one part of any of these components. Teaming nurses, faculty, and clinicians for a more thorough
evaluation may enhance the results (Dean and Mountford, 1998). A careful analysis of the theorist
and her contributions is also as valuable in advancing knowledge as is testing one proposition of a
theory. Each offers members of the discipline different findings. Analyses focused on the theorist
provide strategies for the development of theories and theorists, as well as forces and constraints
that promote scholarship. Tests focused on accepting or rejecting propositions or generating
propositions help in explaining, describing, and predicting substantive content of the field.
Despite the many critics who have been skeptical of Kuhn’s attempts to delineate criteria that
govern choices of good theory and have labeled them as futile, and because “the decision of a scien-
tific group to adopt a new paradigm cannot be based on good reasons of any kind, factual or other-
wise” (Shapere, 1966), Kuhn continued to assert that, indeed, we can delineate such criteria and that
accuracy, consistency, broad scope, simplicity, and fruitfulness in research are essential as objective
criteria for judging competing theories (Kuhn, 1977, p. 321). However, Kuhn also maintained that
“every individual’s choice between competing theories depends on a mixture of objective and sub-
jective factors, or of shared and individual criteria” (p. 325). The subjective factors are based on idio-
syncratic factors and are therefore dependent on individuals’ preferences and personalities. Both
subjective and objective factors have a place in our understanding of the philosophy of science.
The discussion provided here acknowledged subjective criteria and emphasized objective
criteria. It provided criteria for theory description, analysis, critique, testing, and support, in an
attempt to decrease the margin of subjectivity and to enhance that of objectivity. The goal is not
to avoid subjectivity altogether, but to continue in the attempts to develop and refine components
of theory evaluation and of the criteria used in these evaluations. The model of theory critique
(Fig. 10-1, p. 204) is designed not only to provide the basis for understanding the internal struc-
ture of theory but also the social, intellectual, and structural context that surrounds its develop-
ment. It delineates a comprehensive framework for all the norms and parameters against which
theories ought to be analyzed and critiqued.
When using the delineated criteria for evaluating theories, it is important to note that theories
may be superior in some points and evolving in other aspects. No one theory will satisfy or be able to
address all criteria. Styles of inquiry and personal preferences for theory design affect the configura-
tion and function of theory. Throughout the analysis, one should not lose track of the ultimate purpose
of theory, which is to systematize data and provide its users with a unique insight into the matter at
hand. In addition, we should not underestimate the test of time. Ultimately, it is the temporal dimen-
sion that will determine which theory is adequate and useful and therefore survives and dominates. It
is ultimately the strength of support that a theory receives and the extent to which the theory is useful
that leads to an expansion of understanding and enhanced interpretations of situations.
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204 PART FOUR Reviewing and Evaluating: Pioneering Theories
FIGURE 10-1 ◆ A model of theory evaluation.
REFLECTIVE QUESTIONS
1. For what reasons should members of the
discipline evaluate and critique theories?
2. What might be three critical outcomes
that could result from evaluating theories
and three critical outcomes of not evalu-
ating theories? Give specific examples of
both approaches.
3. Can you identify and describe three theo-
ries that you have used in your work?
Now, write down and present to your col-
leagues why you selected each of the the-
ories, and ways by which you evaluated
them prior to or while using them. Step
back from all three and describe themes
in the selection and utilization process.
4. Compare and contrast your selection
criteria with the criteria discussed in this
chapter.
5. Select one theory to evaluate. Identify
implicit or explicit values that may cre-
ate ethical dilemmas for nurses and/or
for patients and their families. Would
you use this theory in spite of, or
because of, these values?
6. Compare and contrast the different eval-
uation elements of theories, description,
analysis, critique, support and testing.
Which of these illuminate your under-
standing of theory? Which are essential
for further development?
7. Select and define the most essential cri-
teria for theory evaluation. Indicate why
these particular criteria are the most
essential.
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CHAPTER 10 A Model for Evaluation of Theories: Description, Analysis, Critique, Testing, and Support 205
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C H A P T E R 11
On Needs and Self-Care
The needs theorists were the first group of nurse theorists who thought of giving nursing care a
conceptual order. Virginia Henderson is a historical figure and a pioneer in addressing patients’
needs. Dorothea Orem is a contemporary figure. Her ideas about a hierarchy of needs for patients
and the activities that nurses perform provided an organizing framework that built on Henderson’s
work. Her central thesis is a framework that facilitates the assessment of needs, as well as the pro-
vision of care that enhances self-care. Orem’s theory is reviewed and evaluated in this chapter as a
premiere example of needs theories.
DOROTHEA OREM
Theory Description
Orem’s theory has been one of the most widely discussed and nationally and internationally
used theories in nursing. Self-care, although an ambiguous concept and one that has many differ-
ent meanings, is invariably credited to her name. The impetus of Orem’s ideas, as is the case for a
number of other theorists, was to define content for nursing curricula. The seeds of her theory
were first published in 1959, in a guide for developing a curriculum for practical nurses (Orem,
1959). As a member of a curriculum subcommittee at Catholic University (1965–1968), Orem
recognized that work needed to continue in developing a conceptualization of nursing. Five of the
subcommittee members continued to work with another six colleagues for about a decade (1968–
1979) to formalize a theory of the process of nursing. In the process, Orem published the first for-
mal articulation of her ideas (1971), and the group articulated the process of nursing theory
development and identified universal elements in nursing that are congruent with Orem’s theory
(Nursing Development Conference Group, 1973, 1979). The second edition of Orem’s book
appeared in 1980, in which she refined and extended the theory that appeared in the first edition
(Orem, 1980). She continued to develop her theoretical framework in subsequent editions to her
major book (Orem, 1991, 1995, 2001a). The major changes in her theory are the advancement in
the development of the conceptual components of the three theories, and more specificity in pro-
posing substantive areas in the practical science of self-care. In addition, Orem reformulated the
nature of self-care requisites and provided a practice guide to reflect each of the requisites
(Denyes, Orem, and SozWiss, 2001).
In her major book at the beginning of the 21st century, in which she provides structure and con-
tent not only for the theory of self-care deficit, but for her vision of nursing as a “direct human serv-
ice,” she outlined six themes as a framework. The major one from which she developed the
Self-Care Deficit Theory of Nursing (SCOTN) is “why persons need and can be helped through
nursing.” The second is that there is a “tridimensional relationship” between a person needing nurs-
ing care, a relationship with society, an interpersonal relationship, and a relationship with technol-
ogy. The third theme is that human beings are of a “unitary nature,” functioning as persons in their
own situations. The fourth theme is very central to her theory: it is that actions are all deliberate, and
they are performed to achieve desired ends. The fifth theme is that “methods of helping or assisting”
are the foundation for uncovering and developing nursing systems. The sixth very important theme
for Orem’s thinking is that nursing has both practical and theoretical science components with each
having a structure and substance (Orem, 2001a, vi–ix). There is also a theme of intentionality in
Orem’s work and theoretical development of nursing (Burks, 2001).
The original set of questions that prompted the development of Orem’s self-care theory is
very similar to most other theorists’ questions. What is nursing? How is it differentiated from
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208 PART FOUR Reviewing and Evaluating: Pioneering Theories
medicine? What knowledge base should be included in nursing? More specifically, Orem’s ques-
tions were (Orem and Taylor, 1986):
• What do nurses do?
• Why do they do what they do?
• What are the outcomes of their care?
These questions and Orem’s answers to them over the years classified her work as a theory of
nursing therapeutics, in addition to classifying it as a “needs” theory. Orem’s theory provides a
framework for intervention. Orem herself believed that:
. . . self-care deficit theory of nursing will fit into any nursing situation because it is a general
theory, that is, an explanation of what is common to all nursing situations, not just an explana-
tion of an individual situation. (Orem, in Fawcett, 2001)
The SCOTN has been extended by specifying three separate theories of self-care, self-care
deficit, and nursing systems. The connections among the three theories forms the whole of the
self-care deficit theory. The theory of nursing systems subsumes the theory of self-care deficit,
which subsumes the theory of self-care (Orem, 2001a, p. 141). Orem identified four themes (pos-
tulated entities) in all the theories. These are the person within a particular space/time, attributes
of persons, motion or change, and products in each. These entities differentiate among the three
theories (Orem, 1991, p. 68). And central to all three theories is that people function and maintain
life, health, and well-being by caring for themselves.
The first theory—the theory of self-care—is based on the fundamental idea of Orem’s theory of
self-care deficit. Self-care is a human regulatory function that is performed by individuals or is per-
formed for them by others (dependent care). The purpose of self-care is to maintain life, to keep the
essential physical and psychic functions going, and to maintain the integrity of a person’s functions
and development within the framework of conditions that are essential for life (Orem, 2001a). This
central focus is based on the presumption that individuals learn self-care practices through experi-
ence, education, culture, scientific knowledge, growth, and development. A relationship exists
between deliberate self-care actions and the development and functioning of individuals and groups.
The second theory, the essential constituent of self-care deficit nursing theory is “self-care
deficit.” It is the most comprehensive element, and is the core of her ideas. The central idea of this
theory is a conceptual image of individuals who are completely or partially unable to know or to
engage in providing care that ensures functioning and development for themselves or for their
dependents. This theory is based on two sets of presuppositions. The first revolves around the per-
son’s ability to manage and engage in providing self-care and dependent care and to take actions
to maintain and manage health and functioning. The second revolves around what societies are
capable of offering to help with services for individuals who are in a state of dependency.
The third theory, the theory of nursing system(s), describes therapeutic self-care requisites
and the actions or systems involved in self-care within the context of their contractual and inter-
personal relations in human beings with self-care deficits (Orem and Taylor, 1986, p. 44). It pre-
supposes that experienced nurses provide intentional care for individuals whose care needs exceed
their ability to provide such care for themselves. All three theories together become a general the-
ory of nursing, the Self-Care Deficit Theory of Nursing (Orem, 1995).
Advancing knowledge in nursing requires a focus on the three theories of self-care, which is
defined as “the practice of activities that individuals initiate and perform on their own behalf in
maintaining life, health, and well-being” (Orem, 1985, p. 84). Self-care is not limited to a person
providing care for himself; it includes care offered by others on behalf of the person (dependent
care). Care may be offered by members of the family or outsiders until a person is able to perform
self-care. Self-care is purposeful and contributes to human structural integrity, functioning, and
development (Orem, 1985, p. 86). As such, Orem negated some who criticized this theory’s appli-
cability to other cultures that are more family- and community-focused. Developing the theoreti-
cal and practical knowledge about self-care requisites is in essence considered as the fundamental
science for self-care. It requires qualitative and quantitative standards for the content and regulation
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CHAPTER 11 On Needs and Self-Care 209
of the requisites, identification of barriers to meeting the self-care requisites, availability of what
self-care agents should know and be aware of, and evidence and exemplars of effective experi-
ences in meeting the requisites (Denyes, Orem, and SozWiss, 2001). The purposes to be attained
are universal, developmental, and health-deviation self-care requisites. Self-care deficit is the rela-
tionship between the action capabilities of an individual and the demands for self-care. Deficit,
which should be considered a relationship rather than a disorder, is a relationship between the
actions an individual takes or should take, and his capability to do so (Orem, 2001a).
The three types of self-care requisites are universal, developmental, and health deviation. The
universal self-care requisites are found in all human beings and are associated with their life
processes and general well-being. There are eight universal self-care requisites, which in other
theories may be considered human needs: (1) maintenance of sufficient intake of care, (2) water,
(3) food, (4) care associated with elimination, (5) maintenance of balance between activity and
rest, (6) prevention of hazards, (7) promotion of functioning, and (8) development and mainte-
nance with social groups (Orem, 2001a). Developmental requisites are related to the different
stages that human beings undergo, such as adolescence, pregnancy, and aging, among other stages
in the life cycle. Examples of developmental self-care requisites are those related to needs for
understanding of habits of introspection and reflection about self; meaningful engagement in pro-
ductive work; understanding values, emotions, actions, and impulses; and the promotion of posi-
tive mental health (Orem, 2001a). The third set of requisites result from or are attached to
deviations in the structural or functional aspects of human beings (Orem, 1991, p. 125). The
health deviation self-care requisites arise from disease, genetic and constitutional defects, and
human structural and functional deviation. Actions for treatment require seeking medical assis-
tance, being cognizant of deleterious effects of disease, medical care, learning to live with condi-
tions and complying with prescribed medical regimes, and therapeutic and rehabilitative measures
(Orem, 2001a). Orem operationalized each one of these requisites. The focus of nursing is on the
identification of self-care requisites (Box 11-1), the designing of methods and actions to meet the
requisites, and “the totality of the demands for self-care action” (Orem, 1985, p. 88).
The totality of self-care actions that are to be performed for some duration to meet human
self-care requisites by using valid methods and related sets of operations or actions is termed the
therapeutic self-care demand (Orem, 1985, p. 88). Therapeutic self-care demand is based on
deliberate action (Orem, 2001a, p. 150). “Deliberate actions of persons are based on their judg-
ments about what is appropriate under existent conditions or circumstances” (Orem, 1991, p. 79).
Nurses use “compound actions,” meaning that their actions need to be coordinated, performed
simultaneously, or related. The agent who performs the action must have “sensory knowledge”
and an “awareness” of the situation; the agent “reflects” on that knowledge and “makes deci-
sions.” Actions are performed in phases (Orem, 1991, pp. 79–86).
The provider of self-care, whether self or other, is considered a self-care agent. It is an entity
to be described in terms of development and operability—which are influenced by such variables
as genetics, and cultural or experiential backgrounds—and in terms of adequacy. The latter could
be evaluated by considering self-care capabilities and self-care demand (Orem, 1987). The agent
is a person who takes action, whether this person is the patient or the nurse (Orem, 2001a).
Nursing care is therapeutic self-care designed to supplement self-care requisites in the
absence of capabilities to do so. There are three fundamental nursing sciences:
• Wholly compensatory: The nurse is expected to accomplish all the patient’s therapeutic self-
care or to compensate for the patient’s inability to engage in self-care, or when the patient
needs continuous guidance in self-care. This is the science of self-care (Fawcett, 2001, p. 35).
• Partly compensatory: Both nurse and patient engage in meeting self-care needs. This is
the science of development and exercise of self-care agency.
• Supportive developmental system: The system requires assistance in decision making,
behavior control, and acquisition of knowledge and skills. Under this system, patients are
able to perform self-care with assistance (Orem, 1985, pp. 152–156). This is the science of
human assistance for persons who have self-care deficits.
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210 PART FOUR Reviewing and Evaluating: Pioneering Theories
Orem’s theory is based on explicit and implicit premises (Orem, 1983, 1987, 2001a) (Box
11-2) that “do not express a singular belief in a clear way at either the philosophical or more gen-
eral level of discourse” (Smith, 1987, p. 93).
Orem provides nursing with a number of primitive concepts (Box 11-3, p. 212) that are
defined theoretically and operationally, the esoteric nature of the terminology being one of the
obstacles that may have influenced the initially slow use of the theory in practice (Anna, Chris-
tensen, Hohn, Ord, and Wells, 1978). The theory includes both abstract (health, self-care agency)
and concrete (universal self-care needs) variables (Box 11-4, p. 213).
When concepts are defined, their relationships are not entirely clear as, for example, with
health and self-care or illness and self-care deficit. The primitiveness, the overlap, and the unde-
fined boundaries between concepts create multiple interpretations, particularly for those who are
new to operationalizing the theory. The self-care agency is an example of an undefined or primi-
tive concept with multiple meanings. When should an agent be identified? What is the extent of
BOX 11-1 SELF-CARE REQUISITES—OREM
Universal Self-Care Requisites
• The maintenance of a sufficient intake of air
• The maintenance of a sufficient intake of water
• The maintenance of a sufficient intake of food
• The provision of care associated with elimination processes and excrements
• The maintenance of a balance between activity and rest
• The maintenance of a balance between solitude and social interaction
• The prevention of hazards to human life, human functioning, and human well-being
• The promotion of human functioning and development within social groups in accord with human
potential, known human limitations, and the human desire to be normal (Orem, 1985, pp. 90–91)
Developmental Self-Care Requisites
• The bringing about and maintenance of living conditions that support life processes and promote the
processes of development; that is, human progress toward higher levels of the organization of human
structures and toward maturation
• Provision of care either to prevent the occurrence of deleterious effects of conditions that can affect
human development or so as to mitigate or overcome these effects from various conditions (1985, p. 96)
Health-Deviation Self-Care Requisites
• Seeking and securing appropriate medical assistance in the event of exposure to specific physical or
biologic agents or environmental conditions associated with human pathologic events and states, or
when there is evidence of genetic, physiologic, or psychological conditions known to produce or be
associated with human pathology
• Being aware of and attending to the effects and results of pathologic conditions and states
• Effectively carrying out medically prescribed diagnostic, therapeutic, and rehabilitative measures
directed to the prevention of specific types of pathology, to the pathology itself, to the resolution of
human integrated functioning, to the correction of deformities or abnormalities, or to compensation for
disabilities
• Being aware of and attending to or regulating the discomforting or deleterious effects of medical care
measures performed or prescribed by the physician
• Modifying the self-concept (and self-image) in accepting oneself as being in a particular state of health
and in need of specific forms of health care
• Learning to live with the effects of pathologic conditions and states and the effects of medical diagnostic
and treatment measures in a lifestyle that promotes continued personal development (1985,
pp. 99–100)
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CHAPTER 11 On Needs and Self-Care 211
self-care performed by an agent to make it self-care by self or by others? How do you determine
the agent? By whose perception? (Anna, Christensen, Hohn, Ord, and Wells, 1978; Smith, 1979).
These are examples of what an adequate theoretical and operational definition could do to
decrease ambiguity and enhance clarity. Some of the variables are nonvariables (e.g., self-care),
thereby limiting their propositional power (Table 11-1, p. 214).
Limitations of the theory are also demonstrated in other ways, as when definitions are consid-
ered in relationship to health care systems. As the world of health care is shifting from predomi-
nately acute/hospital care to chronic/community/home care, how self-care is conceptualized and
used must also be modified to reflect how society and health care systems define, support, and pay
for nurses who modify and enhance self-care. According to Wilkinson and Whitehead (2009), the
ambiguity of the definition of the self-care concept becomes more acute when health care delivery
systems and political structures are not supportive of self-care management by individuals, fami-
lies, and communities. A more congruent consensual definition is needed before self-care can be
fully utilized.
Orem’s propositions are summarized in Box 11-5 on page 215. Propositions developed by
Orem (1985, 2001a) correspond to her three proposed theories and their central ideas. These have
progressed from existence propositions, to relational and predictive propositions, attesting to the
stage of development of the theory (Orem, 1995). Despite the complexity of the construct of self-
care, Orem’s theory has become part of the lexicon of health care and is beginning to be adopted
by patients and health care professionals alike.
BOX 11-2 ASSUMPTIONS—OREM
Explicit Assumptions
• Nursing is a deliberate, purposeful helping service performed by nurses for the sake of others over a
period of time.
• Persons (human agency) are capable and willing to perform self-care for self or for dependent members
of the family.
• Self-care is part of life that is necessary for health, human development, and well-being.
• Education and culture influence individuals.
• Self-care is learned through human interaction and communication.
• Self-care includes deliberate and systematic actions performed to meet known needs for care (Orem,
1980, pp. 34–38).
• “Human agency is exercised in discovering, developing, and transmitting to others ways and means to
identify needs for and make inputs to self and others” (1987, p. 73).
• Each person possesses “powers and capabilities, personal dispositions, talents, interests, and values”
(Orem, 2001a, vii).
Implicit Assumptions
• People should be self-reliant and responsible for their own care needs, as well as for others in the
family who are not able to care for themselves.
• People are individuals with entities that are distinct from others and from their environment.
• “Nursing is a form of action-in-interaction between two or more persons. The person is an essential
substantial unity” (Taylor, Geden, Isaramalai, and Wongvatunyu, 2000, p. 105).
• “Successfully meeting universal and developmental self-care requisites is an important component of
primary prevention of disease and ill health” (Ailinger, Lasus, and Braun, 2003, p. 198).
• “A person’s knowledge of potential health problem is a prerequisite for promoting healthy self-care
behaviors to prevent disease” (Ailinger, Lasus, and Braun, 2003, p. 198).
• “Self-care and dependent care are both behaviors learned within the context of the group and within a
sociocultural context” (Taylor, Renpenning, Geden, Neuman, and Hart, 2001).
• “The culture and class can influence professional judgments” (Lauder, 2001, p. 550).
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212 PART FOUR Reviewing and Evaluating: Pioneering Theories
Theory Analysis
The Theorist
The late Dorothea Orem, born in Maryland, in 1914, earned her diploma and bachelor of sci-
ence degree in the 1930s, and her master of science degree in 1945, from the Catholic University
of America, Washington, DC. She earned honorary doctorates in 1976 from Georgetown Univer-
sity, Washington, DC, and in 1980, from Incarnate Word College, San Antonio, Texas. She estab-
lished a private consulting company, Orem and Shields, Inc., in Chevy Chase, Maryland, perhaps
to accommodate the diverse practice arenas that are using her theory and that need her assistance.
She was involved in nursing practice, nursing service, and nursing education at different levels of
education (practical, diploma, baccalaureate, and graduate). She taught at two schools of nursing:
the Catholic University of America and the Medical College of Virginia, Richmond (Foster and
Janssens, 1980). Dorothea Orem passed in June 2007, after a long life (93 years) of dedication to
articulating the essence and meaning of nursing.
The impetus of Orem’s theory was an attempt to conceptualize a curriculum for a diploma
program by isolating and specifying nursing actions. In this work, she introduced the ideas related
to self-care (1959). She continued her theory development activities as a member of two crucial
overlapping groups, the Nursing Model Committee of the Catholic University nursing faculty and
the Nursing Development Conference Group (NDCG) (Nursing Development Conference Group,
BOX 11-3 CONCEPTS—OREM
Self-care
Deficits
Capabilities
Demands
Dependent care
Dependent care deficit
Nursing systems
Wholly compensatory
Partly compensatory
Supportive educative
Self-care requisites
Universal self-care
Developmental self-care
Health-deviation self-care
Therapeutic self-care demands
Self-care agency
Nursing agency
Dependent care agency
Human and environment
Basic Conditioning Factors (BCFS)
Internal
External
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CHAPTER 11 On Needs and Self-Care 213
1973, 1979). She incorporated the ideas evolving from these two collaborative groups into her
own text in different forms until 1991, when she integrated and acknowledged their work in her
own major book on self-care.
Orem’s work benefited from these collaborations, and she continued in the same collabora-
tive tradition with other groups who worked on the further development of self-care requisites.
Among these various groups are the International Orem Society for Nursing Science and Scholar-
ship, which was founded at the beginning of the 1990s and which started by publishing newsletters
that further developed into a journal, Self-Care, Dependent Care and Nursing. Faculty from the
University of Missouri-Columbia, under the leadership of Susan Taylor, have continued to extend
and refine her theory, seeking Dorothea Orem’s consultation and guidance (Denyes, Orem, and
SozWiss, 2001; Taylor, 2001; Taylor, Renpenning, Geden, Neuman, and Hart, 2001; Cox and Tay-
lor, 2005). In addition, the establishment of the Institute for Self-Care at George Mason University
promoted a more general concept of self-care as central in nursing and made a contribution to the
measurements of Orem’s basic condition factors (Moore and Pichler, 2000). Another important
milestone related to Orem’s conceptualization is the federal support given by Wayne State Univer-
sity for predoctoral and postdoctoral fellows promoting studies in self-care (Artinian, Magnan,
Sloan, and Lange, 2002). Orem continued to refine her ideas through the Orem Study Group (Faw-
cett, 2005), and Orem scholars continue to publish their work in Self-Care, Dependent Care and
Nursing, the official journal of the International Orem Society (Clarke, Allison, Berbiglia, and
Taylor, 2009).
Paradigmatic Origins
Orem’s theory has been classified as a systems theory by Riehl and Roy (1980), as an interac-
tion model by Riehl-Sisca (1989), as developmental by Fawcett (1989), and as a needs theory in
BOX 11-4 THEORIES—OREM
Self-care deficit theory of nursing: “A general theory descriptive and explanatory of what nursing is and
should be.”
1. A theory of self-care
A. Self-care
B. Self-care agency (SCA)
(1) Foundational capabilities and dispositions (FCD)
(2) Power components of self-care agency (PC)
(3) Self-care operations: the phases of deliberate actions
C. Self-care requisites (see Table 1: Denyes, Orem, and SozWiss, 2001, p. 50)
(1) Essential enduring requisites: regulatory of human functioning and development
— Universal self-care requisites
— Developmental self-care requisites
(2) Situation-specific requisites: existent or predicted internal or external conditions of
functioning and development
— Health deviation self-care requisites: regulation or control of human structural or
functional disorders
— Developmental self-care requisites: mitigating or overcoming deleterious effects of
developmental disorders and disabilities
2. A theory of self-care deficit
3. A theory of nursing system
A theory of dependent-care (Taylor, Renpenning, Geden, Neuman, and Hart, 2001)
Dependency, Dependent-care agency, Dependent-care agent, Dependent-care demand
Dependent-care deficit, Dependent-care system, Dependent-care unit, Social dependency
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214 PART FOUR Reviewing and Evaluating: Pioneering Theories
TABLE 11-1 DEFINITION OF DOMAIN CONCEPTS—OREM
Nursing Nursing is art, a helping service, and a technology (Orem, 1985, pp. 144–146).
Actions are deliberately selected and performed by nurses to help individuals or groups
under their care to maintain or change conditions in themselves or their environments
(p. 5).
Encompasses the patient’s perspective of health condition, the physician’s perspective, and
the nursing perspective. Universal, developmental, and health deviation self-care requisites.
Goal of nursing To render the patient or members of his family capable of meeting the patient’s self-care
needs (1985, p. 54).
“1. To maintain a state of health; 2. To regain normal or near normal state of health in the
event of disease or injury; 3. To stabilize, control, or minimize the effects of chronic poor
health or disability” (1980, p. 124).
Health “Health and healthy are terms used to describe living things . . . [it is when] they are
structurally and functionally whole or sound . . . wholeness or integrity . . . includes that
which makes a person human, . . . operating in conjunction with physiological and psy-
chophysiological mechanisms and a material structure (biologic life) and in relation to and
interacting with other human beings (interpersonal and social life)” (1980, pp. 118–119).
“A state of being whole and sound” (1985, p. 176).
Well-being is a perception of contentment, happiness, and pleasure, by spiritual
experiences and through a sense of personalization (1985, p. 179).
Environment Environment components are environmental factors, environmental elements,
environmental conditions, and developmental environment (1985, pp. 140–141).
Limited view of environment to its usefulness as a helping method. Therefore defined
under Nursing Therapeutics. Although environment is mentioned in a diagram (1985,
p. 85) and in the definition of nursing (1985, p. 53), it is not defined.
Human being Has the capacity to reflect, symbolize, and use symbols (1985, p. 174).
Conceptualized as a total being with universal, developmental needs and capable of
continuous self-care (1985).
A unity that can function biologically, symbolically, and socially (1985, p. 175).
Nursing client A human being who has “health-related or health-derived limitations that render him
incapable of continuous self-care or dependent care or limitations that result in ineffective
or incomplete care” (1985, pp. 34–35). A person who is deficient in universal, developmen-
tal, or health-related self-care requisites. . . . A human being is the focus of nursing only
when a self-care requisite exceeds self-care capabilities (1985, p. 35).
Nursing problem Deficits in universal, developmental, and health-derived or health-related conditions.
Nursing process A system to determine (1) why a person is under care, (2) a plan for care, (3) the
implementation of care.
Nurse–patient relations Not defined.
Nursing therapeutics Deliberate, systematic, and purposeful action.
Total compensatory, partly compensatory, or educative supportive care in universal,
developmental, and health-deviation self-care deficits, using several helping methods;
acting or doing for others, guiding, supporting, providing a developmental environment,
teaching (1985, pp. 88–90).
Focus “The special concern of nursing is the individual’s need for self-care action and the
provision and management of it on a continuous basis in order to sustain life and health,
recover from disease or injury, and cope with their effects” (Orem, 1985, p. 54).
Dependency or incapacities due to health/illness situation (1983, p. 208).
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CHAPTER 11 On Needs and Self-Care 215
this book. Orem used concepts from all these paradigms, a process that may lead to the conclusion
that the theory evolved over time from a synthesis and integration of all of them. Her definition of
health as a state of wholeness, her conception of the integrity of the person, and the use of systems
of nursing may have evolved from systems theory. These, however, are isolated concepts, more
like terms, not derived conceptually or defined in terms of the original paradigm. A system model
implies a feedback mechanism between nurse and patient, and such bidirectional movement is not
congruent with this theory, in which the nurse–patient relationship is predicated by the one-way
transfer of agency (Melnyk, 1983, p. 173).
Similarly, Orem views a person with self-care deficits as socially dependent; the capability to
engage in self-care and to meet universal self-care needs appears to characterize a more integrated
BOX 11-5 PROPOSITIONS—OREM
Person and Nursing Client
• Human beings have capabilities to provide their own self-care or care for dependents to meet universal,
developmental, and health-deviation self-care requisites. These capabilities are learned and recalled.
• Self-care abilities are influenced by age, developmental state, experiences, and sociocultural background,
as well as by other variables.
• Self-care deficits are to balance between self-care demands and self-care capabilities and are an indication
of a state of social dependency.
• Self-care or dependent care is mediated by age, developmental stage, life experience, sociocultural
orientation, health, and available resources.
• Human beings are persons/selfs, agents, organisms, users of symbols, and objects (Orem, 1997).
• “Mature and maturing individuals have requirements and responsibilities for self-maintenance,
self-management, care of dependents, and the fulfillment of their human potential” (Orem, 2001a, viii).
• “The formulation of a requisite requires evidence of persons’ states of human functioning and human
development and factors that condition these states. Within the framework of the self-care deficit
nursing theory these factors are named basic conditioning factors (e.g., age, health state, and the
developmental state)” (Denyes, Orem, and SozWiss, 2001, p. 49).
• “Five areas of a science of self-care are self-care, self-care agency, self-care requisites, therapeutic
self-care demand, and self-care practices/self-care systems” (Denyes, Orem, and SozWiss, 2001, p. 50).
• “Self-care requisites are principles to guide the selection, choice, and conduct of regulatory actions in
the care of self” (Denyes, Orem, and SozWiss, 2001, p. 51).
• “Self-care requisites that are unique to an individual because of a life situation or prevailing internal or
external conditions and circumstances are specific and not generalizable” (Denyes, Orem, and SozWiss,
2001, p. 51).
• “Self-care systems and dependent-care systems are produced by individuals through the exercise of
human powers and capabilities named self-care agency and dependent-care agency” (Denyes, Orem,
and SozWiss, 2001, p. 54).
• Orem (2001): see p. 143–149.
Nursing Therapeutics
• Therapeutic self-care includes actions of nurses, patients, and others who regulate self-care capabili-
ties and meet self-care needs.
• Nurses assess the abilities of patients to meet their self-care needs and their potential for refraining
from performing their self-care.
• Nurses engage in selecting valid and reliable processes or technologies or actions for meeting self-care
demands.
• Components of therapeutic self-care are wholly compensatory, partly compensatory, and supportive–
educative.
Based on Orem (1985), Orem and Taylor (1986), and Orem (2001a).
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216 PART FOUR Reviewing and Evaluating: Pioneering Theories
development. These are concepts reflecting a developmental view of human beings, yet their lack
of centrality in the theory, lack of definition, and absence of developmental stages and deliberate
progression to more complex entities deny the theory a developmental origin. In fact, classifying
the theory as either a systems or a developmental theory would highlight gaps in defining con-
cepts and propositions central to the two paradigms but tangential to Orem’s theory.
The paradigmatic origin of the theory is more appropriately the needs theory of Henderson
(1991) or the functional theory of Abdellah, Beland, Martin, and Matheney (1961). Henderson
(1991) identified 14 needs (Pearson, 2008). Universal self-care needs are similar to the needs
identified by Henderson, although the uniqueness of Orem’s theory lies more in the expectation of
that person’s capability to engage in his own self-care. Health-deviation requisites are an exten-
sion and not a refinement of Henderson’s concept of nursing. Orem offers a fine example of the
process inherent in theory development, based on other theories in which new concepts evolve and
others are derived. It is an example to be emulated as nurses refine and extend other theories.
Orem’s theory has been designated as being based on “moderate realism” by Banfield (1997,
2001) in doctoral dissertation research from Wayne State University (cited in Taylor, Geden,
Isaramalai, and Wongvatunyu, 2000; Biggs, 2008). This view of the philosophical underpinnings
has been endorsed by Orem (Fawcett, 2001) and further explicated by others (Taylor et al., 2000).
Tenets of moderate realism are that human beings are powerful agents to act on their own behalf,
that there is an objective world outside an individual, that knowing is partial but constantly evolv-
ing, and that there is a tendency toward determinism and causability. However, according to
Wallace (1996), a realistic philosopher, even with a focus on determinism and causability, there is
room for probability and tendencies toward alternative and chance outcomes.
These points were made by Taylor and colleagues (2000) in their analysis of the philosophic
foundation of Orem’s theory. They further concluded that Orem’s proposed nursing science is a
practical science with both speculative and practical knowledge. The focus is on action, hence my
classification of this theory as a nursing therapeutic theory as well as a needs and self-care theory.
Both nurses and patients engage in deliberate actions, and these actions form the bases of the prac-
tical science of nursing (Orem, 2001a). The actions of both nurses and patients have been linked
with Bandura’s (1997, 2000) theory and research on self-efficacy and self-agency. The idea of
linking them stemmed from the assumptions that perception of capacity to act and self-manage is
predicated on the skills, knowledge, abilities, and beliefs in the ability to manage and care for self.
An example of such integration is in the analysis provided by Timmins (2008), in which the author
argued that, in reviewing the effectiveness of conceptual models, the notion of self-care for clients
with cardiovascular problems tends to surface as important, but equally or even more significant is
the relationship between clients and nurses.
Internal Dimensions
Orem’s theories are interrelated and centered around self-care. Their level of development
and interrelationship suggest that they are concepts and part of one theory, a nursing therapeutic
theory of self-care. Orem’s theory of self-care is a descriptive theory developed around an attempt
to clarify the components of care offered by nurses and a conceptualization of the nursing client. It
is a deductive theory with a hypothetical constructive beginning (Orem, 1985, 1991, 1997, 2001a)
that is based on support from clinical experiences. Fawcett (2005) makes the point that Orem
made extensive use of inductive reasoning because Orem used her clinical experiences as exam-
ples to support the notion that self-care limitation is the need for nursing care. However, the theory
evolved deductively from other theories, with support from collaborators in the Nursing Develop-
ment Concept Group (1973, 1979) and from questions that Orem posited in her writing, Guides
for Developing Curricula for the Education of Practical Nurses in 1959 (Orem, 1959). The gene-
sis of the ideas did not come from practice situations (inductive reasoning); they evolved from
thinking, other theories, group discussions, and the logical and formal development of ideas
(deductive reasoning) supported by clinical exemplars. Orem herself credits her own practice and
reflections on others’ practice for her theory’s beginnings, making it an inductive theory. It is a
concatenated theory with more potential for existence propositions to describe the properties of
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CHAPTER 11 On Needs and Self-Care 217
the various concepts and to delineate the elements of such complex constructs as the exercise of
self-care. It uses a field approach to theory construction. The units are understood in terms of
other smaller units, and the theory of self-care is subsumed by the theory of self-care deficit, and
that, in turn, subsumed by the theory of nursing system.
The theory of self-care deficit is focused on and limited to dealing with individual self-care
deficits, rather than with the entire human being. It deals essentially in what Orem calls the practi-
cal science of nursing, with one of the domain concepts––clinical therapeutics––and the actions
contained in that therapeutic, and it offers one modality for care—the development of self-care
abilities to meet the deficit and to meet the requirements and demands for self-care. The theory
focuses on actions and deals with knowledge of control. It is a theory developed using an opera-
tional method; alternative methods of action are dependent on the nurse’s discrimination and deci-
sion about the needs and the action (Barnum, 1994, pp. 143–144). It is the agent’s perspective that
decides on alternative action. All actions are deliberate, and they depend on the power and capa-
bilities of an individual who is a nurse or a patient. Power has two components, self-care or nurs-
ing-care agency. She identified ten self-care agency power components that make it possible to
perform in self-care. These range from awareness of self as self-care agent to use of physical
energy, body position, and movements to the importance of being motivated, communicating, and
integrating self-care in personal, family, and community living. There are also eight nursing
agency power components that include managing the self as a professional; having the necessary
knowledge, skills, motives, and willingness to provide nursing; possessing the ability to direct
action toward outcomes; and having the ability to be flexible and consistent.
Orem’s theory of self-care provides a comprehensive view and framework for simplistic
nursing therapeutics and components that can be operationalized in different practice areas,
including the community (Aponte and Nickitas, 2007; Hines, et al., 2007), and for dealing with
different types of problems (Gast and Montgomery, 2005).
Theory Critique
Orem’s theory has been operationalized and used in research, practice, and administration. It
lends itself to research for a number of reasons. Orem herself developed propositions linking the
theory concepts and addressing at least two of the central concepts in nursing. Orem also contin-
ued to revise and refine her theory with her mentees and collaborators. However, because the the-
ory provides a framework to organize practice and interventions, it therefore appeals to nurses for
its high relevance to their daily care and is used more to guide practice than for research. It is a
theory about practice and a theory that is for practice, even though it was developed initially to
guide curricula. It provides a framework in which appropriate parts of each of the theories can be
used in isolation or together, depending on the situation. There are several reasons for the rather
speedy adoption of the theory by nursing practice. The language of the theory extends concepts
advanced by Henderson, Abdellah, and, to some extent, Nightingale, using language that is famil-
iar to nurses. As nursing care shifted from a medical model, curricula and practice used a needs
and functional approach, a shift that was gentle and gradual, the kind of progress that is integral to
Orem’s theory. Orem also delineated the technical and professional aspects of nursing practice in
both the Nursing Development Conference publications (1973, 1979) and in her first book (Orem,
1971). This differentiation resonated well with those who were developing curricula, although,
according to Orem, her theory could be used, is used, and should be used as a framework for
diploma, associate degree, baccalaureate, and continuing-education programs (Fawcett, 2001,
2005).
Orem’s theory also incorporates rather than rejects the medical perspective (Johnston, 1983)
and purports to build nursing practice on it. Furthermore, the theory uses medical science lan-
guage, with which most nurses are familiar and many prefer. It presumes a list of needs that evolve
out of a pathophysiological or medical focus, which explains its utility to hospital care. It estab-
lishes a relationship between a sick person and a nurse, but not enough of a relationship between a
well person and a nurse. It also provides limited utility for nurses who care for patients who refuse
to achieve their maximum level of independence (Easton, 1993). The theory is developed around
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218 PART FOUR Reviewing and Evaluating: Pioneering Theories
the ill person and conveys the centrality of individual and institutional care, perhaps the most
appealing feature for the majority of nurses who care for the sick (Taylor, 1990). However, it has
been used for all ages and in all settings. Orem extended the use of the theory to the care of fami-
lies (Orem, 1983; Taylor, 2001), and it was further extended by her colleagues to multiperson and
community situations (Taylor and Renpenning, 2001). It also appeals to those who wish to model
Kinlein (1977), who “hung her own shingle” when she went into private practice. It is perhaps due
to all these reasons, and the operational method in theory development, that we see more literature
documenting the utility of this theory for practice than is true for other theories.
Early use of the theory appears to have been more illness-oriented for both acute and chronic
care, with limited indication of its utility for the wellness setting. It has wide appeal for use in crit-
ical care (Hurlock-Chorostecki, 1999), with chronically ill patients (Burks, 1999), with patients
with diabetes (Allison, 1973; Backscheider, 1971, 1974; Fitzgerald, 1980), in caring for patients
with amyotrophic lateral sclerosis (Taylor, 1988), in psychiatry (Buckwalter and Kerfoot, 1982;
Caley, Dirksen, Engalla, and Hennrich, 1980; Underwood, 1980), in critical and acute-care set-
tings (Mullin, 1980; Noone, 1995; Budinger, 2007; Coyle and Martin, 2007), in preoperative and
postoperative care (Bromley, 1980; Campuzano, 1982; Dropkin, 1981), in hospice care (Murphy,
1981; Walborn, 1980), and with adult and geriatric patients, as well as with children (Anna,
Christensen, Hohn, Ord, and Wells, 1978; Mosher and Moore, 1998; Cox and Taylor, 2005).
Later, researchers and clinicians adapted it to older people living at home (Westerbotn, Fahlström,
et al., 2008), and with hypertensive patients in the community (Akyol, Cetinkaya, Bakan, et al.,
2007). Although mostly it has been considered more appropriate for use with adults (Melnyk,
1983; Kumar, 2007), some extended its use to the care of children and adolescents (Michael and
Sewall, 1980; Norris, 1991; Slusher, 1999; Moore and Beckwitt, 2006; Baker and Denyes, 2008).
The theory was used to individualize care for cancer patients (Morse and Werner, 1988), for
patients with end-stage renal disease (Greenfield and Pace, 1985), for patients on dialysis (Sim-
mons, 2009), for patients with drug problems (Compton, 1989), and in managing anxiety in HIV-
infected patients (Phillips and Morrow, 1998). The theory was also used in caring for gerontologic
patients in community health nursing settings (Clark, 1986). It has been used as a framework for
community health care (Taylor and McLaughlin, 1991; Taylor and Renpenning, 2001) and for
identifying the best ways to communicate information to parents about children’s vaccinations,
thus increasing knowledge and empowering self-care for parents (Wilson, Baker, Nordstrom, and
Legwand, 2008) and demonstrating its utility for community care. The theory also has institutional
utility (Bonamy, Schultz, Graham, and Hampton, 1995). The clarity of the theory is questionable in
light of its complexity, but the diversity of its utility, as demonstrated in a variety of subspecialties,
has made it appealing to clinicians and, more recently, to researchers as well. It provides nurses
with collegial visibility (Bennett, 1980), and once nurses acquire the language of the theory
through staff development programs, they tend to use it (McLaughlin, 1993; Walker, 1993).
Nurse administrators have found the theory amenable to implementation in a number of
institutions, and a great number of chief nurses (16 of 24) of Department of Veterans Affairs
medical centers reported using either Orem’s theory alone or in combination with the work of
other theorists (Bonamy, Schultz, Graham, and Hampton, 1995). Orem (1989) herself proposed a
framework for nursing administration (Orem, 2001a). Miller (1980) challenged nursing adminis-
trators to create a climate that would enhance the use of theory, although she did not give much
guidance or exemplars for implementation on a large scale involving nursing administrators. She
offered a model for nursing practice based on Orem’s theory, demonstrating its utility for care in
acute illness, convalescence, and restored health. The model was based more on a developmen-
tal, health–illness continuum than on Orem’s theory. Others have described the utility of the the-
ory as “a guide for the nursing activities within a hospital nursing service” (Coleman, 1980, p.
323); in organizing nursing care in independent practice (Backscheider, 1974); in psychiatric
units (Underwood, 1980); particularly, in nurse-run clinics (Allison, 1973); in five pilot units at
the Toronto General Hospital (Reid, Allen, Gauthier, and Campbell, 1989); and in a Veterans
Affairs medical center (Bonamy et al., 1995). It was also used effectively as a framework for a
hospital-based utilization review process (Harrison-Raines, 1993). It is used internationally in
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CHAPTER 11 On Needs and Self-Care 219
Canada (Lanigan, 2000), the United Kingdom, and Australia, among other countries (Fawcett,
2005; Walker, 1993).
The theory evolved from interest in curricula for diploma and baccalaureate programs and the
need to differentiate between technical and professional education. Therefore, its utility to nursing
education is enhanced by the theorist’s interest. The curriculum subcommittee of the School of
Nursing, Georgetown University, of which Orem, Backscheider, and Kinlein were members,
developed a curriculum based on ideas of theory (or theory ideas evolved out of curriculum). Not
surprisingly, the theory has been used as a conceptual framework in associate-degree programs
(Fenner, 1979). The framework is also used in the schools of nursing at the University of Southern
Mississippi in Hattiesburg and the University of Missouri at Columbia (Fawcett, 1989, pp. 236–
237), and partially for specific courses in a number of other universities (Fawcett, 2001).
External Components of Theory
Orem’s theory is congruent with the prevailing era of nursing practice that focuses on the sick
and the institutionalized, which has increasingly become the core of health (illness) care at the
turn of the 21st century. As we shift focus to well individuals and to the community, extensions
and refinements will need to be made. The focus on health deficits due to illness creating self-care
deficits will need to be supplemented with a focus on health benefit/assets, centering resources,
and potential (Melnyk, 1983), thereby allowing prevention and health promotion care. Its congru-
ence with prevailing social values is paradoxical. Although the theory promotes the patient as
being responsible for his own self-care and a partner in all decisions pertaining to his care (pre-
vailing values in nursing, specifically, and in Western society, in general), the theory is based on
values that see the patient as dependent, expecting goals to be set for him, goals that involve him
in developing the highest potential for self-care. Furthermore, what if a patient prefers that others
take care of him? Orem herself has a response to this question: Nurses must help the patient to
reconceptualize himself or herself as a self-care agent (Orem, 2001a). Patients need to be aware of
the need and learn to care for self.
The theory enjoys a wide circle of contagiousness that extends to practice, research, and
administration, and includes many geographical areas such as Asia, Europe, and the Americas.
There are indications and testimonials to its cross-cultural utility (Wang, 1997). However, some
have determined that a fundamental constraint in using the theory is related to the values of the
individualism principle, which is more prevalent in U.S. cultures (Behi, 1986) as compared to
other cultures that expect families and communities to continue to provide care for patients until
healing and recovery are complete. In spite of these concerns, researchers and clinicians from dif-
ferent countries used Orem theories as-is or modified them to reflect the practices of a particular
country. Examples include descriptions of management strategies for medications among older
people in Sweden (Westerbotn, Fahlstrom, et al., 2008). The findings demonstrated that older peo-
ple are capable of medication self-management, provided they have good cognitive ability and are
able to get help from some close individuals. In a Taiwanese study, Yun-Fang Tsai (2007) found
that institutionalized older people used some creative strategies to manage their depressive sys-
tems. Orem’s ideas also were formed as a framework for studies in Turkey (Akyol, Ceinkaya,
Bakan, et al., 2007), the United Kingdom (Lauder, Kroll, and Jones, 2007), and the Netherlands
(Moser, van der Bruggen, et al; 2008).
Therefore, while used in many countries, it continues to need adaptation for use with other cul-
tures; for example, values of patients in Japan include group care and the inseparability of the environ-
ment and the individual. Conversely, the theory is usable in some societies in which, although hospital
patients are not expected to be self-care agents, family members are expected to and actually do
become the self-care agents, as in many Middle Eastern countries. The nurse’s role in these countries
is to educate and support family members who assume the care. When these patients come to the
United States alone, without their families or other self-care agents, they are unreceptive to
nurses’ attempts to promote self-care skills. However, the theory still has global utility. It has been
used in Sweden to determine the effectiveness of using a nurse-led clinic to promote self-care for
home dialysis patients and to compare the results with a comparison group receiving regular care.
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220 PART FOUR Reviewing and Evaluating: Pioneering Theories
Self-care in the nurse-led clinic included reflective listening, timed exchange information, indi-
vidualized care, motivational dialogues, information giving, education about kidney function, pro-
viding test results, and communicating about the effects of medications and other aspects of
self-care. The results demonstrated that the nurse-led group had more instances of self-care dialy-
sis as compared with those receiving traditional care (Pagels, Wang, and Wergström, 2008). The
theory was also used in China to determine the level of self-care behaviors of school-aged chil-
dren who were diagnosed with heart disease (Fan, 2008), in Germany to describe its utility in
developing a nurse-led education program for patients with leg ulcers to meet their therapeutic
self-care demands (Herber, Schnepp, and Rieger, 2008), and in Taiwan to define self-care strate-
gies to manage sleep disturbances among older residents in nursing homes (Tsai, Wong, and Ku,
2008).
Orem’s proposed theory may indeed make a substantial and valued difference in the lives of
people whose self-care abilities are curtailed due to acute or chronic conditions, but it may not
make the same difference in enhancing prevention and promoting health and well-being.
Theory Testing
Orem herself did not believe that nursing research should be focused on testing her theory as
much as on developing knowledge related to the different components of the theories of self-care,
self-care deficit, and systems of care. Taylor and colleagues (2000) reviewed six published
research reports that used self-care deficit theory or components of it and performed an analysis of
these reports, concluding that the studies demonstrated five stages in theory development. The
framework of theory development that they used for the analysis was proposed by Orem (1985,
1987, 1995, 2001a). The first stage is description, as exemplified by the further development of
the theory of dependent care (Taylor et al., 2001), as well as descriptions related to other compo-
nents and theories in self-care deficit theory.
Several descriptive studies focused on self-care practices. Allan (1988) examined the use and
interpretation of health information in the practice of self-care activities of women as related to
their weight. She found that women in her study were more concerned about their self-image than
risk factors, and she was able to describe the self-care activities that they used to protect that
image in the face of the reality of failure to maintain their weight. Hsieh, Wang, McCubbin, et al.
(2008) found that self-efficacy, as reflected in self-care theory, was a better predictor for engaging
in osteoporosis preventive behaviors than other behaviors. Miller (1982) used the theory to iden-
tify categories of self-care needs for patients with diabetes, and Storm and Baumgartner (1987)
illustrated through a research case study method the use of self-care theory in the successful dis-
charge of ventilator-dependent patients. Kubricht (1984) described the self-care needs of radiation
patients, and Sandman, Norberg, Adolfsson, Axelsson, and Hedly (1986) described Alzheimer-
type dementia patients and nurses’ needs and actions. Maunz and Woods (1988) described self-
care actions by women. The theory was used to assess the perceived demands or changes in
universal and self-care activities, and the degree of perceived difficulty in attempting to meet these
demands among English- and Spanish-speaking women with HIV infection. For these women, the
universal self-care tasks with the highest burden were caring for their children, engaging in physi-
cal activity, and attempting to fulfill the demands of their work responsibilities (Anastasio,
McMahan, Daniels, Nicholas, and Paul-Simon, 1995). Others found that the higher the level of
disability in Turkish patients suffering from rheumatoid arthritis, the lower their self-care agency
(Tokem, Akyol, and Argon, 2007). Infant birth weight was significantly and directly related to
self-care agency and prenatal care actions (Hart, 1995). The theory was also tested with patients
experiencing taste changes after chemotherapy. Although the sample was small, patients were
provided with strategies to enhance their self-care in managing the effects of taste change. The
majority reported that they tried the provided strategies but also added to the strategies by suggest-
ing more strategies. The authors conclude that providing strategies helped patients anticipate taste
change and thus activated their own self-help strategies (Rehwaldt et al., 2009).
Homeless adolescents were studied to explore their self-care attitudes and behaviors (Rew,
2003). The results supported the utility of self-care agency in caring for self in a vulnerable situation.
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CHAPTER 11 On Needs and Self-Care 221
These homeless adolescents took care and protected themselves by becoming aware of their situa-
tion, by gaining self-respect, and by increasing self-reliance. They learned how to stay alive with
limited resources, and handled their own health through interactions with others they met and by
confronting obstacles.
A second stage is “discrimination and verification of variations in person properties,” as
exemplified by a study by Söderhamn and Cliffordson (2001), in which they investigated the
structure of self-care in elderly populations in Sweden. One component of this stage is instrumen-
tation, as exemplified by the many studies conducted to develop research and health assess-
ment instruments. Orem’s theory has been used as the basis for the development of research
instruments to assist researchers in using the theory (Clinton, Denyes, Goodwin, and Koto,
1977; Denyes, 1982; Kearney and Fleischer, 1979; Kuriansky, Gurland, Fleiss, and Cowan,
1976). Kearney and Fleischer (1979) described the development of a valid and reliable instrument
to measure the exercise of self-care agency (McBride, 1987). The instrument can be used to meas-
ure the level of involvement of patients in self-care, and eventually measurements could be devel-
oped to determine outcomes of the increase in self-care abilities. Hanson and Bickel (1985) and
Weaver (1987) developed, described, and critiqued an instrument to measure patients’ perceptions
of self-care agency. A self-care practice questionnaire was developed and tested by Moore (1995)
for the special purpose of measuring the self-care practice of children and adolescents. The Dan-
ger Assessment Instrument (Campbell, 1986) was developed to measure the danger level of homi-
cide for battered women. Along the same lines, the Performance Test of Activities of Daily Living
(PADL) is another tool developed to measure self-care agency (Kuriansky, Gurland, Fleiss, and
Cowan, 1976).
Several others instruments were developed based on Orem theories. Among them is the
Appraisal of Self-Care Agency Scale (ASAS), containing a single substantive dimension. This
instrument has adequate construct validity and reliability (Sousa, Zauszniewski, et al., 2008).
Another instrument, the European Heart Failure Self-care Behavior Scale was developed from
attempts to quantify patient strategies in managing their heart failure. This scale was tested, and
although it demonstrated reliability, its internal consistency was only moderate (Shuldham,
Theaker, et al., 2007). An updated and revised instrument based on self-care theory was designed
to measure knowledge of facts about osteoporosis, and was retested, validated, and proved reliable
(Ailinger, Lasus, and Braun, 2003).
Another component of this stage is the extension of the theory. Some researchers proposed
extending the theory by incorporating a “sense of coherence” to strengthen prediction of out-
comes for self-care (Baker and Denyes, 2008; Söderhamn, Bachrach-Lindström, and Ek, 2008).
Continuity in the development of instruments is an indication of a potentially cumulative knowl-
edge base.
Another component of the discrimination and verification studies are those focused on basic
conditioning factors. Basic conditioning factors include age, gender, developmental state, health
state, socioeconomic orientation, health care, family systems, and environmental factors, as well
as patterns of living and resource availability (Orem, 2001a, p. 245). Wang (2001) compared two
models of health-promoting lifestyle in rural elderly Taiwanese women and concluded that a num-
ber of the basic conditioning variables affect the outcome of self-care and that self-care agency is
a strong variable in predicting the use of health-promoting lifestyles.
Despite these studies elucidating the various relationships between Orem’s basic condition-
ing factors, there is an apparent lack of consensus in the operational definitions, as well as meas-
urements, and this continues to need much work. For example, in family systems, Moore and
Pichler (2000) determined a lack of consensus among the studies they reviewed. One of the
authors’ recommendations was that factors and measurements need to become more specific.
There is also a lack of clarity in what constitutes adequate self-care (Ricka, Vanrenterghem, and
Evers, 2002). Another component of this stage is human action. Examples are Orem and Vardiman
(1995), as well as a study of self-care requisites by Pickens (1999).
The third stage is nursing cases and their natural history, as exemplified by the publication of
case studies. The fourth stage is concerned with integrating practice knowledge; this is called
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222 PART FOUR Reviewing and Evaluating: Pioneering Theories
“models and rules of nursing practice.” Taylor and Colleagues (2000) gave Hagopian (1996) as an
example. In addition, other studies that were published later, such as those designed to describe
self-care behaviors, would fit in this category (Artinian, Magnan, Sloan, and Lange, 2002). The
fifth stage is designing care for specific populations and describing that care and its outcomes. An
example of this stage is the development and evaluation of appropriate self-care materials that fit
patients’ basic conditioning factors (Wilson, Mood, Risk, and Kershaw, 2003). Another example
of this stage is using the theory to clarify similar concepts, such as activity and rest (Allison,
2007).
Other tests of interventions lend further support to the utility of Orem’s theories. The rela-
tionship between self-care as a nursing therapeutic and nursing outcomes was examined in a num-
ber of studies. For example, Toth (1980) examined the relationship of a structured transfer
preparation on patients’ anxiety; Watkins (1995) tested patients’ comprehension of discharge
instructions based on Orem; Rothlis (1984) explored the effect of self-help groups on perceptions
of hopelessness and helplessness; and Moore (1987) described the effects of various learning
strategies on the development of autonomy and self-care agency among school-aged children.
Using Orem as a framework, it was demonstrated that patients tended to accept responsibility for
self-infusion at home, which increased their independence and sense of freedom (Gardulf et al.,
1995). Dashiff (1988) reviewed research and clinical literature in psychiatric nursing based on
Orem’s self-care deficit theory. She compared the contributions of this literature to the develop-
ment of theory for use in psychiatric nursing with other nursing specialties, and concluded that psy-
chiatric nurses are using Orem’s theory, although with limited indications of research productivity.
Hanucharurnkui and Vinya-nguag (1991) tested the use of Orem’s and King’s theories on expedit-
ing the rate of recovery from surgery and increasing satisfaction of adult patients undergoing sur-
gery. Interventions derived from Orem’s and King’s theories were related to less pain sensation and
distress, using fewer analgesics, more ambulation, and higher satisfaction of patients than with
those who did not receive the theory-driven care. The theory was also used as a framework for a
community-based intervention study in a smoking cessation program, with results pointing to the
need for “tailored” self-care strategies (Williams, Shuster, Merwin, and Williams, 1994) and in the
design, selection, and evaluation of appropriate patient education materials for patients with low lit-
eracy skills (Wilson, Mood, Risk, and Kershaw, 2003).
Other studies tested relationships between propositions. One example is Denyes (1988), who
provided partial support for the relationship between self-care agency and self-care in determining
health outcomes. Hartley (1988) tested the relationship between nursing system and self-care
behavior by examining the congruence between teaching strategies and learning styles of women
and their effect on the accuracy and frequency breast self-examination performance. The study
demonstrated that self-care agency could evolve through the recall of observations or actions of
others: “Knowledge of self-care breast self-examination developed through the use of supportive-
educative nursing system, a system through which efficient and effective learning occurred”
(Hartley, 1988, p. 166). Hart (1995) provided support for the significant relationship between
basic prenatal care actions and self-care agency, which, in turn, was directly related to infants’
birth weight. The relationships among health-promoting self-care behaviors, self-care efficacy,
and self-care agency was investigated using the canonical correlation model (Callaghan, 2003).
The only variable that influenced self-care agency was the variable of spiritual growth.
A self-care model of women’s responses to battering was constructed by Campbell and Weber
(2000). The model included a number of basic conditioning factors that would directly relate to rela-
tional conflict and negatively relate to self-care agency. These would then be indirectly related to
health and well-being. Although the results are congruent with Orem’s proposition of the efficacy of
self-care agency on health, the women’s relationship problems had a stronger effect on them than
did their ability to take care of themselves. Conversely, self-care was found to explain 30% of the
variance in well-being in a population of adult homeless participants in a research study by Anderson
(2001). These studies offer support for the category of self-care and its relationship to health.
An indirect effect of focusing on a nursing theory was reported by Denyes, O’Connor, Oakley,
and Ferguson (1989). A collaborative research project was initiated between nursing service and
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CHAPTER 11 On Needs and Self-Care 223
nursing education, focusing on contraceptive nursing care and self-care of women using primary
care facilities. The results of the research––that women are their own self-care agents––gave
impetus “for revising the clinic’s family planning standards so that they would more fully opera-
tionalize the concepts” (1989, p. 144).
Theory-driven research is most effective and productive when a program of research is estab-
lished, versus a single study approach. Williams and Ramos (1993) demonstrated this in a series
of four studies based on Orem’s theory to describe the self-care needs of people with symptomatic
mitral valve prolapse. The approach resulted in more focused questions that built on each other,
which contributed to building systematic knowledge about the experience of patients suffering
from this disease. The phases of the research included a review of medical records, analysis of
health perception and body image, and a survey of cardiovascular nurses; and it led to the con-
struction and validation of a research instrument.
Biggs (2008) provided a synthesis of the state of the art and science related to Orem’s theory,
and concluded that, in the period between 1999 and 2007, there have been many impressive con-
tributions to the discipline made by researchers, clinicians, and educators pertaining to all areas of
practice. However, Susan Taylor, an important Orem scholar, in an interview conducted by Pamela
Clarke (Clarke, Allison, Berbiglia, and Taylor, 2009) voiced a concern that, in the 50 years since
Orem started to write about her theory, many of the issues in practice and education still remain
the same. She goes further to indicate that if views of theory, practice, and education do not
change drastically, Orem will be relegated to other similar historical figures such as Florence
Nightingale. Pearson (2008) considers Orem an important figure in what he hopes will become a
“Dead Nursing Theorists” Society (in the footsteps of “Dead Poets”), affirming the widespread
use of self-care as evidenced by the extensive use of her theory to support improvements in health
outcomes and enhancing the satisfaction of nurses and patients.
As with all other theories, Orem’s could be used more broadly as a schematic to analyze the
focus of research conducted in nursing and to set a direction for future research in nursing (Smith,
1979). Hoy, Wagner, and Hall (2007) reviewed the literature related to self-care in elders, with
particular focus on health promotion, and concluded that elders’ self-care agency is composed of
actions, capabilities, and processes for health. These included fundamental, power, and perform-
ance capabilities, a process of life experience, and learning process. They also determined that the
interaction between all of these leads to the understanding of the nature of self-care. On the whole,
the theory has been used productively as a guide for practice; however, there is still a paucity of its
outcomes on patient care outcomes (Chang, 1980; Roberts, 1982). In general, theory testing has
been problematic, due to the different levels of its utilization in research (Silva, 1986; Timmins,
2008). One study was designated as experimental, only two as replication, and few explicitly
linked theory variables to practice (Taylor, Geden, Isaramalai, and Wongvatunyu, 2000). Research
driven by Orem’s theory, published in 1986–1991, was evaluated by Spearman, Duldt, and Brown
(1993). They concluded that 32% of the studies used Orem’s theory minimally, and 55% used it
insufficiently; that is, the researchers used the theory superficially as a framework but the theory
was not used in the discussion of the results. Only 13% of the studies used the theory adequately.
Among these are studies that tested propositions relevant to health and health promotion among
adolescents with diabetes (Frey and Fox, 1990), and relevance of the effects of computer-assisted
instruction on avoidance of dust in adult asthmatics (Huss, Salerno, and Huss, 1991).
A test of the potential productivity of a theory is in its potential to stimulate theoretical dis-
courses in the literature. Few dialogues in the literature of theory stimulate critical responses from
a theorist or a metatheorist; however, one example would be a publication about how self-care the-
ory could be used to understand self-inflicted health neglect, or “self-neglect” (Lauder, 2001). The
author proposed that self-care theory is useful in offering insight into how some conditions are
implicated in the development of self-neglect. Orem, while not critiquing the extension, ques-
tioned the misrepresentation of aspects of self-care and implicitly disagreed that self-care illumi-
nates self-neglect. Instead, she proposed that self-care theory, as well as models of deliberate
action and self-care agency, could explain self-neglect (Orem, 2001b). The ultimate test of the
utility of her theory is in the ability to build on it by extending it or developing other theories. An
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224 PART FOUR Reviewing and Evaluating: Pioneering Theories
example is Riegel’s situation-specific theory of self-care for patients with heart failure (Riegel and
Dickson, 2008). Several propositions of this theory were tested and supported, providing evidence
that symptom recognition information and confidence enhanced self-care in patients with heart
failure. The next generation of theories, such as this one, provide explanation and prediction for
desired outcomes in nursing.
CONCLUSION
Nursing therapeutics are those deliberate actions provided by nurses to prevent illness and to
maintain or promote health. Although every developed nursing theory may be used as a frame-
work to develop a model of intervention, Orem’s theory is categorized as a theory whose primary
focus provides a framework for assessing needs of clients and developing intervention in enhanc-
ing peoples’ abilities to manage daily care of themselves and their dependents, and conserve their
energy, and structural, personal, and social integrity. Nurses intentionally use principles of self-care
and conservation to provide supportive and therapeutic care. Her theory, as well as Henderson’s,
generated many dialogues in the literature, reflecting on clinical utility as well as their accessibil-
ity to operational definitions in research programs.
REFLECTIVE QUESTIONS
1. Why do you agree or do not agree with
the identification of nursing needs as a
category for nursing theories? Criti-
cally discuss the rationale for the inclu-
sion of Orem’s theories under this
category.
2. Compare and contrast three major out-
comes of nursing care intervention that
are informed by Orem’s theory.
3. Compare and contrast the conceptual
attributes of “conservation” and “self-
care” and critically describe the differ-
ences and similarities of their external
components.
4. Review the most recent research studies
in which Orem’s theory was identified as
a framework. In what ways do the results
support or refute central theory proposi-
tions?
5. How, if at all, did either of the nursing
therapeutic theories influence the inter-
ventions and/or outcomes of care in your
field of interest?
6. Identify, describe, and critically discuss
research findings related to nursing ther-
apeutics used in your field of practice.
What are the theories that inform these
nursing therapeutics?
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C H A P T E R 12
On Interactions
Several nurse theorists addressed nursing as a process of interaction and nursing care as a human
relationship. Some, such as Ida Orlando, developed the focus of the nursing process in nursing.
I selected the following theorists to represent the central domain concepts related to interaction:
Imogene King, Ida Orlando (Pelletier), Josephine G. Paterson and Loretta T. Zderad, Joyce
Travelbee, and Ernestine Wiedenbach. The theories of King, Orlando, Travelbee, and Wiedenbach
may also be used as the frameworks to describe and explain significant questions and the knowl-
edge base related to the nursing process.
IMOGENE KING—A THEORY OF GOAL ATTAINMENT
Theory Description
King’s theory evolved in the mid-1960s, when she raised questions about how nurses make
decisions in their daily practice and how to define the nursing act, leading her to focus and
develop the concept of the “human act” (King, 1997). King also attempted to describe the essence
of nursing and the interactional patterns and goals that govern the nurse–patient relationship. Like
other nurse theorists of her generation, she asked fundamental questions to explain what nursing is
(King, 1981, 1990a); to differentiate it from other disciplines; and to question nursing educational
programs that are designed to differentiate them (King, 1986a, 1986b). The development of her
conceptualization progressed from the idea that nursing could be provided through a framework
that contains a synthesis of ideas (a frame of reference that she entitled, in 1971, “Toward a The-
ory for Nursing”) to the development of a theory (prompting the title to shift to “A Theory for
Nursing” in 1981 and 1996b). In a curious way, the difference between the first tentative title and
the second is analogous to nursing’s tentativeness about theory in the 1970s and the determination
to theorize in the 1980s. The difference between King’s two books can be found in the last chapter
of the second book, where she articulated her theory “for” nursing. Her theory is that nursing is a
process that is interactional in nature between two human beings engaged in a human act. These
interactions lead to transactions resulting in goal attainment (King, 1990a, 1992a).
At the beginning of the 1990s, King also entitled her work, “general systems framework” and
then derived from it a “theory of goal attainment” (King, 1992a, 1992b, 1996a, 1996b, 1997a,
1997b). King provided nursing with four sets of concepts as part of her conceptual framework for
nursing (King, 1988a). These concepts are central to the field of nursing and provide the basis on
which she developed a theory of goal attainment, beginning with an assumption that nurses as
human beings interact with patients as human beings, and both are open systems that also interact
with the environment. Therefore, the personal systems (nurse and patient) interact with each other
in an interpersonal system (small and large groups) and with the environment, which she called
the social systems (institutional organizations). The relationships between these systems led to the
development of the theory of goal attainment, with a distinct set of concepts, some of which were
derived from the conceptual framework. Other theories may evolve from the conceptual framework.
To understand the theory fully, it should be read in conjunction with the conceptual framework. The
goal of the development of this conceptual system of relations is to delineate concepts for our disci-
pline, to derive theories, to provide a structure for educational programs, to use as a framework for
nursing practice and to deliver care to individuals, families, and communities (King, 1997b).
The theory deals with the central questions of interaction between nurses and clients (King,
1996b) and the processes of decision making, and it extends arguments and guidelines for ethical
decision making (King, 1999). King considered questions related to the nature of the process of
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230 PART FOUR Reviewing and Evaluating: Pioneering Theories
interaction that lead to the achievement of goals and the significance of mutual goal setting in
achieving nursing care goals. By emphasizing the collaborative role of the patient in decision-
making and in making and providing choices, she acknowledges the importance of empowering
patients (Whelton, 2008). The theory evolved from several explicit assumptions to provide the
basis for action (Box 12-1). One of the modifications in her assumptions is that individuals are
spiritual (King, 1997a). The explicit assumptions are congruent with the contemporary and future-
oriented views that nursing holds and aspires to maintain, particularly as she explicitly stated an
assumption about the continuous transaction of individuals with internal and external environ-
ments (King, 1997c). All King’s assumptions speak to the significance of patient involvement in
their care, as well as in the decision-making process; the importance of collaboration; the human-
ity of the nurse–patient encounter; and the dynamic changes in environments (King, 1999). The
theory provides guidelines for ways to decrease the confusion occurring in the health care system
as patients try to deal with a myriad of options, as they exercise their right to having choices and
making informed decisions.
It is important to note, too, that King’s assumptions encompass the nurse’s perceptions,
goals, needs, and values—not only those of the patient—and these are expected to influence the
interaction process and, indeed, the outcomes. Although King designated the nurse as a central
concept in nursing theory, she did not go as far as Paterson and Zderad did in focusing on the sig-
nificance of the consideration of the continuous growth of the nurse in every interaction. The the-
ory assumptions explicitly address the rationality of human beings, and King’s theory proceeds to
develop consistent concepts related to clients who can perceive, interpret, and solve problems.
Austin and Champion (1983) argued that, as such, the theory is not useful to some situations in
nursing (e.g., when patients are comatose or psychotic), and I might add, as options increase
and/or as evidence of the particular decision is yet to be conclusive. How decisions are made dur-
ing times of uncertainty remains problematic. However, Whelton (2008) makes the case of its util-
ity for patients who are in palliative care.
BOX 12-1 ASSUMPTIONS—KING
Explicit Assumptions
• The central focus of nursing is the interaction of human beings and environment, with the goal being
health for human beings (King, 1982, p. 143).
• Individuals are social, sentient, rational, reacting, perceiving, controlling, purposeful, action-oriented,
and time-oriented beings (King, 1981, p. 143).
• The interaction process is influenced by perceptions, goals, needs, and values of both the client and the
nurse (1981, 1992).
• Human beings as patients have rights to obtain information; to participate in decisions that may influ-
ence their life, health, and community services; and to accept or reject care (1981).
• It is the responsibility of health care members to inform individuals of all aspects of health care to help
them in making “informed decisions” (1981).
• Incongruities may exist between the goals of health caregivers and recipients. Persons have the right to
either accept or reject any aspect of health care (1981, pp. 143–144).
• Human beings are in continuous transaction with their internal and external environments (1997c, p. 21).
• Individuals are spiritual (1997a, p. 16).
Implicit Assumptions
• Patients want to participate actively in the care process.
• Patients are conscious, active, and cognitively capable to participate in decision making (Austin and
Champion, 1983, p. 56).
• All individuals should be respected as human beings of equal worth and who have their own set of val-
ues (King, 1999, p. 296).
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CHAPTER 12 On Interactions 231
There are inconsistencies in the different lists of concepts provided by King (Box 12-2). In
one instance, she listed human being, environment, health, and society as the abstract concepts.
She also identified personal, interpersonal, and social systems as the major concepts (King, 1981,
p. 142; 1997a, 2001). She defined interaction, perception, communication, transaction, role,
stress, growth and development, time, and space as they represent the theory of goal attainment.
Although King clarified the relationship between the latter set of concepts in the interpersonal
system, it is not clear how these “major concepts in the theory” relate to human beings, environ-
ment, health, and society (King, 1988a). Perception appears to be a central concept in her theory
(Bunting, 1988), including perceptions of patients, which must be honored and accepted, and the
importance of nurses’ perceptions (Clarke, Killeen, Messmer, and Sieloff, 2009). This was further
developed by Alligood and May (2000) into a theory of personal system empathy. King and
Whelton (2001), however, criticized this theory for its inaccurate reflection of King’s ideas, for lack of
BOX 12-2 CONCEPTS: A CONCEPTUAL FRAMEWORK FOR NURSING—KING
Personal Systems
Perception Growth and development
Self Time
Body image Space
Interpersonal Systems
Role Transactions
Human interaction Stress
Communication Coping
Coping (1997a, p. 16)
Social Systems
Organization Decision making
Power, authority, status Control
Goal attainment
Concepts: A Theory of Goal Attainment
Interaction Time
Perception Space (Personal)
Communication Goal attainment
Transaction Effective nursing care
Self Appropriate information
Role Satisfaction
Stress (stressors)
Growth and development
Concepts: A Theory of Administration
Organization Decision making
Power Perception
Authority Communication
Status Interaction
Role Transaction
Control
Conceptual system (instead of conceptual
framework, conceptual model or paradigm)
(King, 1997a, p. 162; 2001, p. 281)
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232 PART FOUR Reviewing and Evaluating: Pioneering Theories
support for the need of another theory without the use of King’s entire theory, and for its lack of
expansion of her theory. I highly recommend reviewing this exchange of ideas and subsequent
related publications by others.
King offered, in the conceptual framework, almost every concept that nurses may have his-
torically used in nursing care (see Box 12-2). It is not entirely clear how the goal attainment the-
ory evolved from the myriad concepts that appear in the conceptual framework; however, King
indicated that the selection was based on those she believed represented “a broad conceptualiza-
tion of knowledge” (King, 1997a). In the goal attainment theory, King restricted concepts to the
interaction system central to the nursing act. Most of her concepts are derived, except for goal
attainment, health transaction, effective nursing, appropriate information, and satisfaction. She
also added the concept of coping to the personal system (King, 1997a). Although the derived
concepts are defined conceptually and have the potential for operational definition, they have not
been delineated as central concepts, nor were they defined theoretically or operationally. How-
ever, the theory purports to have as a goal nurse–patient interactions that enhance goal setting
and lead to goal attainments of outcomes, which are a measure of effective nursing care (King,
1996b).
Other concepts not defined are satisfaction and effective nursing care, and although these are
seemingly central to patient outcomes, they are defined neither conceptually nor operationally.
Much later, Plummer and Molzahn (2009) explicated how quality of life and life satisfaction are
interconnected and explained by one’s ability to set and attain goals. To attain goals, appropriate
information should be given; what is “appropriate,” what is considered “information,” and who
decides what is appropriate or what is considered information are only a few of the questions that
point out the lack of theoretical definitions and lack of boundaries between concepts (Table 12-1),
and the incongruence between assumptions, concepts, and statements (Uys, 1987). King updates
concepts to reflect more contemporary health care language. For example, as she indicated, she
changed quality nursing care to effective nursing care, to quality assurance, to continuous quality care,
to outcomes, and now to evidence-based practice (King, in Fawcett, 2001).
Incompleteness and inconsistency are evident in how King views health. Health is defined in
terms of ability to function in a social role (King, 1986a), and it includes genetic, subjective, rela-
tive, dynamic, environmental, functional, cultural, and perceptual components (King, 1990b).
Magan (1987) questioned ways by which the levels and quality of that functioning could be
assessed, a critique that could inspire a more effective and productive conceptualization of health.
Explication of health in terms of morbidity and mortality data and accidents is more congruent
with a disease orientation than with a role-functioning orientation. King’s views of health and ill-
ness are also problematic. As Magan puts it:
The difficulty with a consistent understanding of health in King’s framework is further com-
plicated by her assertion that health and disease do not constitute polarities, while she also
maintained that illness is an interference or disturbance in health. (Magan, 1987, p. 119)
The inconsistencies in King’s definition of health are manifest in viewing health and illness
as nonpolar and not dichotomies, and illness as an interference or disturbance, and at the same
time viewing health in terms of a dynamic life experience. Doornbos (2000), using King’s theory
to develop and test a derivative theory of family health, defined King’s driven family health as
adaptability, cohesion, satisfaction, and conflict using instruments to test adaptability, cohesion,
and satisfaction with the level of functioning. By doing that, she helped to advance an explication
of health à la King. Quality of life, implicitly considered in King’s theory to be imbedded in well-
being and life satisfaction, is similarly not well defined (Plummer and Molzahn, 2009).
King offers strategies to measure health (King, 1988b) and examples of how her theory can
be tested through a set of propositions that link perceptions, transactions, goal attainment, satis-
faction, and effective nursing care; these are more congruent with educational goals rather than
research goals. The propositions are relative and tend to be deterministic (Zetterberg, 1963). They
are based on a cause-and-effect approach and are designed for prediction, not description, which
could be equally effective in further development of theory. Propositions link some of the defined
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CHAPTER 12 On Interactions 233
TABLE 12-1 DEFINITION OF DOMAIN CONCEPTS—KING
Nursing “A process of human interaction between nurse and client whereby each perceives the
other in the situation and, through communication, they set goals, explore means, and
agree on means to achieve goals” (King, 1981, p. 144), “and their actions indicate move-
ment toward goal achievement” (1987, p. 113). “A process of action, reaction, interaction
and transaction” (1971, p. 89 and 1981, p. 2). Nursing services are called on when
individuals cannot function in their roles.
Goal of nursing “To help individuals to maintain their health so they can function in their roles” (1981, p. 3).
“To help individuals to attain and restore health or die in dignity” (1981, p. 13). The goal
of nursing is then to maintain, restore, and promote health (1992). The goal of nursing is
“to help individuals and groups attain, maintain, and regain a healthy state” (King, 2001,
p. 283). Or, to help individuals die with dignity (King, 1971).
Health “A dynamic life experience of a human being, which implies continuous adjustment to
stressors in the internal and external environment through optimum use of one’s resources
to achieve maximum potential for daily living” (1981, p. 5 and 1983, p. 186).
Ability to function in social role.
Process of growth and development (King, 1990b, 1992).
Environment The internal environment of human beings transforms energy to enable them to adjust to
continuous external environmental changes (1981, p. 5). The external environment is the
formal and informal organization. “A social system is defined as an organized boundary
system of social roles, behaviors, and practices developed to maintain values and the
mechanisms to regulate practice and rules” (1981, p. 115). The nurse is part of the
patient’s environment.
Human being Rational, sentient, social being, perceiving, thinking, feeling, able to choose between
alternative actions, able to set goals, to select means toward goals, to make decisions,
and to have a symbolic way of communicating thoughts, actions, customs, and beliefs.
Is time oriented and reacting. Reactions are based on perceptions, expectations, and
needs (1981, p. 19).
Nursing client A unique, total, open system with perception, self, body image, time, space, growth, and
development throughout the life span and with experiences of changes in structure and
function of body influencing perception of self (1981, pp. 19–20).
Person as open system exhibits permeable boundaries permitting an exchange of matter,
energy, and information (1981, p. 69).
A person who cannot perform daily activities and cannot carry the responsibilities of their
roles (1976).
Nursing problem Inability to meet needs for daily living (1981, p. 5).
Inability to function in their roles (1981, p. 3).
The central problem is nonmutual goal setting and lack of agreement on goals and means
leading to unattained goals (1981, p. 144). “Felt needs” as perceived by patient or real
needs as perceived by nurse (1968, p. 29).
Nursing process A focal concept in King’s theory called transactional process. The goal of nursing is to help
patients attain their goals. The mechanism for that is the nursing process. Through this
process, nurses interact purposefully with clients (1981, p. 176). The purpose is information
sharing, setting of mutual goals, participation in decisions about goals and means, imple-
menting plans and evaluations. It is based on a knowledge base.
(continued )
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234 PART FOUR Reviewing and Evaluating: Pioneering Theories
concepts (transactions, interactions, role performance), but they also link the undefined concepts,
such as health and outcomes.
Theory Analysis
The Theorist
Imogene King is well known for more than her theory; she is one of the pioneers who pro-
moted a theoretical base for nursing (King, 1964, 1975, 1976). She is, like a number of other the-
orists, a graduate (EdD, 1961) of Teachers College of Columbia University. In 1945, she
graduated from St. John’s Hospital School of Nursing in St. Louis and received a bachelor’s
degree in nursing education in 1948 and a master of science in nursing in 1957 from St. Louis
University. She completed a postdoctoral study in systems research, advanced statistics, research
design, and computers (King, 1986a, 2001). She considered her life in terms of many opportuni-
ties. In one of her last essays, published after she passed (King, 2008), she was asked whether
“adversity” played a role in her life or her theory. Her answer was a resounding “no,” and she con-
cluded by suggesting that this “concept of adversity” should be replaced with challenges and
opportunities. She acknowledged that her theory evolved due to many opportunities, giving the
example of how a chance meeting with Dr. Hildegard Peplau (another early giant theorist) led to
Peplau reading and providing a constructive critique of King’s early draft of a manuscript of her
theory. This led to revisions and publication in 1971. In many ways, King’s theoretical tenets did
not waver far from this early manuscript.
A clinician, an administrator, but primarily an educator with multiple honors and awards,
including the Jessie Scott award for leadership, which was presented by the American Nurses
Association at the 100th anniversary convention in 1996 and an honorary doctor of science in
1998 (King, 2001), she was inducted to the American Nurses Association Hall of Fame and the
Teacher’s College, Columbia University Hall of Fame. She was also named a Living Legend by
the American Academy of Nursing. She has been a professor at the College of Nursing, University
of South Florida at Tampa, the dean of the School of Nursing at Ohio State University, Columbus,
and professor of nursing at Loyola University in Chicago. Besides being an author, she was an
effective speaker whose joy in presenting and describing her theory was readily apparent to her
audiences. Her commitment to students was continuously demonstrated whenever they sought her
council. Dr. King passed in December 2007 (Stevens and Messmer, 2008; Clarke, Killeen, Messmer,
and Sieloff, 2009).
Paradigmatic Origins
King used the language of systems theory to introduce her ideas, and she credits Bertalanffy
(1968) and his science of wholeness and system elements in mutual interaction to the beginnings
of her ideas (King, 1990a). Fawcett classified her as a systems theorist (2005, p. 94) with a recip-
rocal interaction worldview (2005, p. 93). King classifies her ideas as emerging from systems
TABLE 12-1 DEFINITION OF DOMAIN CONCEPTS—KING (Continued )
Nurse–patient “A process of perception and communication between person and environment and
relations between person and person, represented by verbal and nonverbal behaviors that are
goal-oriented” (1981, p. 145).
Variables affecting interactions are knowledge, needs, goals, past experiences, and
perceptions of nurse and patient. The interaction process also includes reaction and
transaction (1981, p. 145).
Nursing therapeutics Transactions: informing, sharing, setting of mutual goals, participation in decisions about
goals and means (1981, p. 176).
Goal-oriented nursing record (1983, pp. 183–186).
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CHAPTER 12 On Interactions 235
theory (King, 1990a), and George classified her as an adaptation theorist (1980, p. 186). Her con-
ceptual framework evolves from all paradigms that have been used in nursing; for example, the
developmental (growth and development), systems (structural–functional view of role, open sys-
tems, social systems, and energy), adaptation (continuous adjustment to stressors), psychoanalyti-
cal (self), and stress (energy response to environment) paradigms. The theory of goal attainment
derives a great deal from symbolic interactionism, and what King offers helps in the understand-
ing of the nursing process and the process of interaction; this prompts a classification of her theory
as an interactionist theory.
Although King personally stated that she never used the symbolic interactionist school of
thought (Fawcett, 1989, p. 116), the influence of interactionism is marked. Several indications of
parallelism between King’s theory and symbolic interactionism are the descriptions of a person as
a social being, actor, and reactor, who is constantly structuring and restructuring his perception of
the world, thereby communicating through symbols. Nurse–patient interactions occur within the
perceptual repertoire of both. The present meaning of any situation and the perceptions of time
and situations of both nurse and patient are significant to the interaction, to the choices, options,
and discussions (King, 1981, p. 148). In addition, King’s use of roles (although more congruent
with a structural–functional approach) and the personal element of perception and interpretation,
are also indications of an interactionist approach. King recognized that a functionalist view of role
is related to the study of social systems, but . . .
[t]he interactionist view of role is basic to understanding individuals in organizations when
role is thought of as a relationship with another person or group of individuals, it is related to
interpersonal systems. . . . The interactionist view relates to social interaction. (1981, p. 90)
Therefore, the entire focus of theory, and the central question around process, interaction, and
goal attainment, makes it more congruent with a symbolic interactionist approach. However,
whether or not the refinement of the theory may be more enhanced if the backdrop is interaction,
rather than the inconsistent and mixed use of both system and interaction paradigms, is a question
that continues to require an answer (Burney, 1992). Finally, both the paradigmatic origin and the
theory suffer from the limitation of viewing a person as a social being rather than as a biopsy-
chosocial being, or a wholistic being.
These limitations may be an artifact of claimed paradigmatic origins as systems (Bertalanffy,
1968) or even a limitation of the concepts of Dewey, who King, in 1992a, credited as providing
the philosophical underpinnings for “transaction,” which is a key concept in her theory. Whelton
(1999) provided the most comprehensive analysis of a possible different philosophical core of
King’s theory. She indicated that King’s framework is consistent with the philosophical assump-
tions of the Greek philosopher Aristotle (Whelton, 1999, 2008). Such a view is congruent with
King’s initial question of what it means to be human and what the properties of the human act are.
Whelton (1999, 2008) provides a new major insight on King’s theory by isolating “human nature”
as the core of her theory and intimating that, by considering Aristotle’s teachings, there is far more
complexity and richness in making King’s view of human capacity more dynamic and encom-
passing of personal, interpersonal, and social interactions. By providing a critical analysis of a dif-
ferent paradigmatic origin of King’s theory, Whelton (1999) provides an answer to the question
that may have prompted King to develop her theory, which was “what is human nature?” (King,
1997a), and she also shifts the emphasis from interaction to a focus on the person and his or her
human acts.
Internal Dimensions
The microtheory of goal attainment was developed from a field approach centering on con-
cepts rather than on propositions, and is therefore concatenated in structure. It is a mental image,
with a constructive beginning deduced from a conceptual framework, the concepts of which were
also deduced from other paradigms, systems, symbolic interactionism, or Aristotelian logic. Its
scope is limited to the process of interaction, focusing on the perceptions of clients for the purpose
of goal attainment. It deals with the interactions of one nurse with one patient. Despite the fact that
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236 PART FOUR Reviewing and Evaluating: Pioneering Theories
King extensively discusses the social system, her theory, evolving from the interpersonal system,
is limited to nurse–patient interactions, as it ought to be. She later expanded it to incorporate the
family and their perceptions (King, 1983a, 1983b, 1990b) and discussed the use of the theory in
the community (King, 2001). Others have also expanded it to include families (Doornbos, 2000;
Temple and Fawdry, 1992) and the community (Sowell and Lowenstein, 1994).
The microtheory of goal attainment purports to predict processes inherent in goal attainment
and provides descriptions of the concepts and properties of the interpersonal system. The theory
was classified as providing a description of the nursing process (nursing transaction); it mainly
explains how and when to use transactions to achieve mutually agreed-on goals. It is a single-
domain theory about decision-making processes, with an average level of abstractness for the dif-
ferent concepts. King developed her theory using a logical method of development. The parts of
the interactional system (interaction, transaction) lead to goal attainment.
Theory Critique
The literature provides numerous examples of the utility of King’s theory for practice,
research, education, and administration. Theory development progressed from a conceptual
framework using a variety of unrelated concepts to a theory of nursing in the interpersonal system.
King herself completed one research project and operationalized her theory for practice (King,
1981, 1986a) as well as for educational programs (King, 1986b). Propositions emanating from the
theory are presented in Box 12-3.
King’s theory is parsimonious, with distinct concepts and limited relationships, but teleolog-
ical because interaction is defined by interaction and transaction (King, 1981, p. 145). Goal attain-
ment appears to be a process of transaction toward effective nursing care, and it is a product
equated with effective nursing care and satisfaction (King, 1981, pp. 147 and 153).
Considering that interaction has emerged as one of the central concepts in nursing, King’s
contribution is substantial to nursing knowledge (King, 1987b). The theory’s clarity is enhanced
when considered as a theory to describe and answer questions related to nurse–patient interactions
for the purpose of setting goals. The nursing care process has been conceived by other theorists as
a process involving assessment, diagnosis, intervention, and evaluation (King, 1986a). She called
BOX 12-3 PROPOSITIONS—KING
1. If perceptual accuracy is present in nurse–patient interactions, transactions will occur.
2. If nurse and patient transact, goals will be attained.
3. If goals are attained, satisfactions will occur.
4. If goals are attained, effective nursing will occur.
5. If transactions are made in nurse–patient interactions, growth and development will be enhanced.
6. If role expectation and role performance, as perceived by nurse and patients, are congruent,
transactions will occur.
7. If role conflict is experienced by nurse or patient or both, stress in nurse–patient interactions will
occur.
8. Nurses with special knowledge and skills communicate appropriate information to patients, mutual
goal setting and goal attainment will occur.
9. Knowledge of oneself will bring about a helping relationship with patients.
10. Accurate perceptions of time and space in nurse–patient interactions lead to transactions.
From King, I. M. (1981). A theory for nursing: Systems, concepts, process (p. 149). New York: John Wiley & Sons, and
King, I. M. (1986a). King’s theory of goal attainment. In P. Winstead-Fry (Ed.), Case studies in nursing theory. New York:
National League for Nursing.
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CHAPTER 12 On Interactions 237
it a method only in 2001. Her transaction process, on the other hand, provides theoretical knowl-
edge as a base for this process that she considers a transaction. Therefore, in making assessments
and diagnoses, nurses must use perceptions, communication, and interaction to be able to make
judgments.
A transaction is made when the nurse and the patient decide mutually on the goals to be
attained, agree on the means to attain the goals that represent the plan of care, and then imple-
ment the plan. Evaluation determines whether or not goals were attained. If not, you ask why
not, and the process begins again. (King, 2001, p. 280)
For King, the process is dynamic; it is differentiated from other disciplines by its knowledge
base. She further extended her use of the transaction process model (perception, communication,
interaction, and transaction) to incorporate moral and ethical reasoning. To her, entering a nurse–
patient relationship should be based on the assumption that every human being is of equal worth
and value, that the relationship is based on justice, and that the nurse maintains a responsibility to
continuously enhance competence and skills. In addition to the concepts of respect for equality
and justice, the nurse should observe beneficence, which occurs when nurses use a knowledge
base to help patients maintain or regain their health (King, 1999). The transaction process depends
on three significant clinical tools: observation, interaction, and documentation. According to King
(2001), the transaction process should be used by every student, staff nurse, and administrator.
King offers the nursing profession a description of the properties of interaction that is essen-
tial to the nursing act; indeed, it is the nursing act, and one of its cornerstones is the attainment of
mutually agreed-on goals. King also offers it as a unique variation of the nursing process. The
goal-oriented nursing record (GONR), developed as a tool analogous to the problem-oriented
medical record developed by Weed (1969), includes both “process and outcomes in nursing situa-
tions” and a record of the goals, the means to achieve those agreed-on goals, and the process used
to achieve them. It consists of five components: a database, a problem list, a goal list, a plan, and
progress notes (King, 1981, pp. 164–165).
The GONR is similar to the nursing process used by other theorists, but it offers a more
dynamic dimension that addresses the process, not only the goals. GONR has the potential of
offering organized nursing care, and it could facilitate nursing audits, enhance abilities in making
nursing diagnoses, increase focus on patients’ participation, and validate the perceptions of
patients during the process (King, 1981, p. 172). Although George (2002) critiqued the theory for
its limitation in applicability to caring for groups, families, and communities, King expanded her
methods to incorporate the family as a client in 1983 (Gonot, 1983, 1986), and the theory has been
used by others as a framework for caring for families and communities.
The numerous examples of use of King’s theory in clinical practice (Smith, 1988) include:
• An elderly patient with a cerebral vascular accident (King, 1983a)
• A patient with renal disease (King, 1984)
• Caring for families (King, 1983b; Doornbos, 1995; Moreira, Araujo, and Pagliuca, 2001)
• Providing care for critically ill infants (Norris and Frey, 2002)
• Providing care for women with hospitalized preterm infants (Viera and Rossi, 2000)
• As a problem-solving tool to facilitate the development of a healthy work environment
and to decrease the incidence of diseases of the computer age, such as carpal tunnel syn-
drome (Norgan, Ettipio, and Lasome, 1995)
• Providing community health nursing care (Asay and Ossler, 1984; Sowell and
Lowenstein, 1994)
• Developing alcohol use/dependency care for adult females (McKinney and Dean, 2000)
• Providing psychiatric care (Gonot, 1983)
• Caring for comatose patients (King, 1986a)
• Caring for adults with diabetes (Husband, 1988)
• As a framework for managed care (Hampton, 1994), and for hospital care (Messmer,
1995)
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238 PART FOUR Reviewing and Evaluating: Pioneering Theories
The theory was extended for testing under King’s guidelines in Japan, Sweden, Portugal, Den-
mark, Germany, and the United States (Bauer, 1998, 1999; Franca and Pagliuca, 2002; Frey, Rooke,
Sieloff, Messmer, and Kameoka, 1995; King, 2000; Zoffmann, Harder, and Kirkevold, 2008), thus
providing a forward-looking approach to decision-making and collaboration in chronic illness care,
which is a hallmark for knowledge development in the future (Meleis, 1985). Woods (1994) used the
theory to demonstrate how mutual identification and achievement of goals were facilitated between
nurses and a group of elderly people with chronic health problems. The theory has been used with
attention to newly evolving concepts, such as quality of care (Sowell and Lowenstein, 1994) and
quality of life (King, 1994). The theory has been used to develop a framework for neonatal care that
is built less on medical models and medicalization and more on a process of interaction between par-
ents and nurses (Norris and Hoyer, 1993). Such examples of the theory–practice link support its util-
ity in and potential for transcending the boundaries of time, geography, and specializations; they also
demonstrate that the theory has been used innovatively and with a trend-setting approach.
With the increasing need for decision making related to “advanced directives,” in which indi-
viduals make known their wishes for their own care during crises, King’s theory may provide the
definitive decision-making transactional framework. The Patient Self-Determination Act (PSDA)
provides individuals with a legal means to accept or reject care even if they may not be able to
make such a decision cognitively or physically. Goodwin, Kiehl, and Peterson (2002) developed a
model for decision making, the Advanced Directive Decision Making Model (ADDM), based on
King’s theory and using seven components: perception and time (personal system), interaction
and role (interpersonal systems), power, status, and decision-making (social systems). This model
guides interactions, addresses complex end-of-life issues, and facilitates the process of achieving
mutual goal attainment for clinicians and clients. It is one of the best examples of developing a sit-
uation-specific theory, derived from an existing theory, to address an important health care phe-
nomenon. It is also an example of why theories need to be and are reflective of certain historical
moments. The situation-specific ADDM was not needed prior to the imperative development of
the PSDA (Omnibus Budget Reconciliation Act of 1990).
To determine the risks of bleeding and complications for clients who cease to use anticoagu-
lants when undergoing endoscopic procedures. Ryle (2008) used King’s theory to integrate evi-
dence related to personal, interpersonal, and social systems, as well as her theory of goal
attainment, with an emphasis on the role of the nurse and the perceptions of nurses and patients.
By utilizing the theory to guide the integration and analyses of ten research studies, the author
concluded that there was no evidence of an increase in complications.
Despite these examples of the clinical utility of the theory, it appears to be more useful for
assessing active, autonomous, collaborative, and individual (fewer examples of group or aggre-
gate utility) relationships with nurses. It is more useful for long-term nurse–patient relationships,
to evaluate “satisfaction, goal attainment, and effective nursing care.” The utility of GONR for
care of infants, children, comatose patients, some psychiatric patients, dementia patients, or some
mentally retarded patients is still in question (Austin and Champion, 1983; Barnum, 1994).
King’s theory is also limited to use only in some health care settings.
The theory would have limited application in settings where clients are unable to interact
competently. In addition, it is not clear how the theory could be utilized with groups. Utilizing
transactions with groups of individuals who had different goals is not addressed by King.
(Austin and Champion, 1983, p. 60)
There are a number of other limitations to clinical utility. The theory does not give explicit
guidelines for assessment, diagnosis, or intervention. The theoretical boundaries to help a practi-
tioner in assessing problems and potential problems and in deciding on clinical therapeutics are
not identified. It analyzes problems, but does not offer guidelines for interventions. Interaction is a
process in all helping relationships; its uniqueness to nursing stems from its relationship to other
phenomena. This is lacking in King’s theory. Carter and Dufour (1994) disagree with these criti-
cisms and offer compelling arguments for the theory’s flexibility and utility, and George (2002)
questions its use for groups, families, and communities.
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CHAPTER 12 On Interactions 239
Although King’s theory focused on the client–nurse relationship, it was also used as a frame-
work to identify barriers to achieving goals for interdisciplinary collaborations of health care pro-
fessionals. Barriers identified are patriarchal relationships, time, lack of role clarification, gender,
and culture. Research findings on the outcomes for lack of collaboration were integrated by
Fewster-Thuente and Velsor-Friedrich (2008), who concluded that lack of collaboration puts
patients at high risk for readmission to intensive care units, death, error, and longer length of stay.
The authors conclude that, by using the theory, they were able to provide a coherent account of
barriers, with negative and positive attainment of goals.
Nursing administration could also use the theory in developing a recording system for nurs-
ing care plans with refinement and modifications related to patient care outcomes. King promised
that, if nurses use goal attainment theory and GONR to enhance accurate documentation and
recording of the goals identified and attained in interactions, effective nursing care could be meas-
ured (King, 1981, p. 155; 1989, pp. 42–45). King discussed the development of a theory of
administration following the same principles used in developing a theory of goal attainment. King
believed that when such theory is communicated in the literature, it will be useful for both nursing
science administration and nursing education administration (King, 1989). Elberson (1989) pre-
sented a description of the utility of King’s theory in nursing administration, and Byrne-Coker and
Schreiber (1990) provided an analysis of the effective use of the theory as a framework for nursing
practice in an agency. It was also used in Canada for developing and implementing a system for
care delivery (Fawcett, Vaillancourt, and Watson, 1995), and for transforming nursing practice in
neonatal intensive care units (Norris and Hoyer, 1993) and in the homes of the elderly (Woods,
1994).
King’s theory is suitable for use in nursing education as a basis for learning, which is one sig-
nificant phase and component of the nursing process. Evidence suggests that the theory provides a
conceptual framework for curricula (Daubenmire and King, 1973; King, 1978, 1996c), and it is
used to guide a curriculum in continuing education (Brown and Lee, 1980). King provided guide-
lines for implementing her theory in an educational setting (1968, p. 30), and in 1986, she pub-
lished a book on curriculum development in which she carefully demonstrated how her theory
could be used as a curricular framework (King, 1986b). She also summarized the potential utility
of theory in curricula (Gulitz and King, 1988; King, 1988a). King’s theory has been used as a con-
ceptual framework for a baccalaureate program at Ohio State University School of Nursing in
Columbus (Daubenmire and King, 1973; King, 1986b) and in models for improved patient care
(Rooke, 1995). The graduate program at Loyola University in Chicago used her theory as a frame-
work (Fawcett, 2001). Other schools also used her theory or components of it as a framework for
curriculum development, as well as for teaching (Fawcett, 1995).
Diagrams depicting relationships between central concepts of the theory, central concepts in
nursing, and major propositions would have enhanced the clarity of the theory and may have con-
tributed even more to the extensive utilization of King’s theory in educational and practice settings.
External Components of Theory
King’s theory is congruent with the values and beliefs about nursing, humanity, autonomy,
patient advocacy, self-reliance, and planning that are espoused by Western societies. Because it
pertains to the conscious, self-directed patient, it is more suited to U.S. values. The focus of the
theory on mutual goal setting and attainment, on interacting with individuals, and on helping indi-
viduals become sufficiently healthy to function in roles is congruent with Western philosophy and
mores of pragmatism and the usefulness of adult members of society. Many other societies that
consider patients helpless, that espouse the sick role as an abandonment of social roles and
responsibilities, and that support the rights of patients to be sheltered from prognosis and health
care goals (as in some Middle Eastern cultures) would consider this theory culturally limited
(Meleis and Jones, 1983). Patients in these societies prefer to relinquish all decisions and goal set-
ting to the expertise of health care professionals.
This claim of the theory’s apparent ethnocentrism is refuted by Husting (1997), Carter and
DuFour (1994), and by King as cited in Fawcett (2005, p. 117). The bases for such refutation are
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240 PART FOUR Reviewing and Evaluating: Pioneering Theories
examples of the successful implementation of King’s theory in Japan and Sweden (Rooke, 1995)
and that her books have been translated into Spanish and Japanese. More support for the theory’s
cross-cultural applicability was provided by Rooda (1992). King (1997b) cites a sigma theta interna-
tional conference in Madrid, at which presenters demonstrated her theory’s relevance, appropriate-
ness, and utility for diverse cultures. Portuguese-speaking scholars used her theory to describe the
perceptions of patients, compliance, and treatment decisions (Franca and Pagliuca, 2002; Moreira
and Araujo, 2002). Many Western theories, in many disciplines, enjoy international utilization by
certain proponents. These select few scholars are, in most cases, Western educated; many others
regard U.S.-generated theories as the answer to all issues. I continue to offer and encourage skepti-
cism about the use of U.S.-generated theories in providing frameworks to uncover, explain, and
understand health care issues in different cultures and societies. Until equal and reciprocal develop-
ment and utilization of theories occurs internationally, my warning remains—international utilizers,
use our U.S.-generated theories carefully, critically, and skeptically. And, at best, be critical about the
fundamental assumptions upon which theories are developed. As to you, the reader, my hope is that
you contribute your critical, supportive, or refuting ideas to keep a healthy dialogue going.
Theory Testing
King outlined hypotheses for testing her theoretical propositions (King, 1987a), and she pro-
posed future studies to test these hypotheses (King, 1986a; Uys, 1987). Fawcett (1995) reports
that, in February 1988, a conference held at the University of South Florida, College of Nursing,
focused on research designed to test King’s theory. As Fawcett indicates, this is a reflection of a
growing body of knowledge related to King. King also developed a criterion-referenced instru-
ment designed to assess physical and behavioral functional abilities, goal setting with clients, and
goal attainment (King, 1986a).
Several studies testing various properties derived from King’s theory are reported in the liter-
ature. Brower (1981) described nurses’ attitudes toward the elderly; Rosendahl and Ross (1982)
described the relationship between attending behaviors on mental status; and Frey (1989)
described the development and initial testing of parent support, child support, family health, and
child health in families coping with insulin-dependent diabetes mellitus. Frey used King’s theory
as the basis for defining concepts, selecting indicators, and developing propositions for testing.
These findings lend support to the relationship between interaction and health as proposed by
King, although Frey questioned the availability of appropriate instruments to use in testing King’s
theory (Frey, 1989, p. 146). There are also indications of the international utility of King’s theory
in research (Rooke and Norberg, 1988). The theory was used to describe awareness and percep-
tions of prostate and testicular cancers and an intervention to enhance such awareness (Martin,
1990). It was tested and supported for its cultural relevance by Frey et al. (1995) and Rooda
(1992). The theory was used as a framework for testing postoperative recovery and satisfaction of
patients (Hanucharurnkui and Vinya-nguag, 1991).
Several studies support the relationship between central concepts in King’s theories. Human-to-
human interaction adds to the perceptual accuracy of nurses of their patients’ expectations, which in
turn contribute to goal attainment (Daniel, 2002). Sieloff’s (2003) study on the assessment of a
departmental power instrument that she developed demonstrated initial support. Walker and Alli-
good (2001) compared and contrasted two theories of empathy and concluded that using King’s the-
ory is more suited for nursing care. Doornbos developed and tested a theory of family caregiving of
young adults with mental illness based on King’s theory. This is an example of situation-specific the-
ory that could prove to be more effective in predicting outcomes as well as dictating nurses’ actions.
King also tested her theory and reported the results in her 1981 book. The study was designed
to answer three questions:
1. What elements in nurse–patient interactions lead to transactions?
2. What are the relationships between the elements in the interactions that lead to transactions?
3. What are the essential variables in nurse–patient interactions that result in transactions?
(King, 1981, p. 151)
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CHAPTER 12 On Interactions 241
The results of this descriptive study supported the components of the interpersonal system and
lent construct validity. The study limitations are numerous, but the study could be considered a pilot
for further research. The study was based on data generated by nonparticipant observations of the
verbal and nonverbal behaviors of nurses and patients. The sample consisted of 17 cases. The results
of this descriptive study support the components of the interpersonal system and provide construct
validity. Specifically, King’s study indicated that interaction was verbal and nonverbal, and that
nurse–patient interactions led to transactions and identification of problems, concerns, or distur-
bances in the patient’s environment. Variables that helped in the achievement of goals were “accu-
rate perceptions of nurse and patient, adequate communication, and mutual goal setting” (King,
1981, p. 155). Despite several limitations of the study (sample size, biases of the researchers, and
limited analysis), this pilot study indicates the potential testability of the theory (King, 1996b).
In an extensive research review of King’s theory-driven projects, the authors provide several
seminal conclusions. Among these conclusions is that, although there has been ongoing discussion
and clarification of the theory, only a few changes have occurred, including adding the concepts of
coping and spirituality (Frey, Sieloff, and Norris, 2002). There have been over 576 publications
related to King’s theory between 1978 and 2000 (Frey et al., 2002), 33 descriptive studies, 14 correla-
tional studies, and nine experimental (Fawcett, 2005). Despite this volume of utilization as a frame-
work for research, the validity of its propositions remains limited, and its contribution to advancing
knowledge remains limited. It is not enough to claim the theory’s use as a framework or to publish the
research. It is imperative to develop a trajectory of related findings, develop a program of sustained
research, develop conceptually based interventions, interpret the data with the theory, and complete
the cycle by refining and extending the theory (Fawcett, 2005). An example of such a study is one
completed by Ehrenberger, Alligood, Thomas, Wallace, and Licavoli (2002) that related uncertainty,
role functioning, and social support to emotional health and to treatment decision making. The find-
ings provide some support for understanding the human emotional state on treatment decisions.
In sum, I share the conclusions by Frey and her colleagues (2002):
King’s contribution to nursing science is longstanding and universally recognized . . . Contin-
ued work in developing and testing middle-range theories derived from the conceptual system
and validating the theory of goal attainment will increase as the number of nurse scholars who
work to advance and extend her perspective of nursing increases. (p. 111)
The support of the King International Nursing Group (KING), founded in 1998, will
undoubtedly sustain the development of more research studies and testing of the theory’s evolving
propositions (Frey et al., 2002). The publication of collected papers on the use of King’s theory in
developing middle-range theory may stimulate research beyond using the theory only as a frame-
work to integrate findings from other research (Sieloff and Frey, 2007). This group is increasing in
number and visibility, and it produces a newsletter with opportunities for meetings and dialogues
to extend King’s theory and to contribute to its development.
King’s vision for the future extension of her theory is contained in the following:
The conceptual system of 3 interacting personal systems, interpersonal systems & social sys-
tems has identified 15 concepts (perception, communication, interaction & transaction, etc.)
that represent basic theoretical knowledge that should be taught with the Nursing Process
method of assess, plan, implement & evaluate. The transaction process in King’s theory of
goal attainment leads to mutual goal setting (the critical variable), and when goals are
achieved this represents outcomes which provide for evidence based practice. (King, 2005,
personal communication)
IDA ORLANDO
Theory Description
In the mid to late 1950s, the Yale School of Nursing shifted from undergraduate to graduate
education and integrated psychiatric concepts into the entire curriculum. Orlando’s theory grew
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242 PART FOUR Reviewing and Evaluating: Pioneering Theories
out of processes inherent in these curricular changes and out of dissatisfaction with the possibility
that nursing care was being prompted by organizational rules rather than by attention to patients’
needs. Orlando’s theory is based on two central questions: What prompts nursing actions? What
are the properties of dynamic nurse–patient relationships that may lead to knowing patients’ needs
and providing effective care?
When Orlando began formulating her conceptualization of nursing, the answer to the first
question was that nurses were prompted in their actions by physician’s prescriptions, organiza-
tional needs, and personal repertoire of experiences rather than by patient needs—in other words,
for reasons other than the patients’ immediate experiences and immediate needs for help (1961, p.
60). This answer did not satisfy Orlando and may have prompted the ideas for the development of
her theory. When Orlando revisited the terms she used in her theory and the goal of the theory, she
redefined it as a “nursing process theory” rather than a theory of “effective nursing care”
(Orlando-Pelletier, 1990a).
The focus of Orlando’s theory is on identifying and clarifying the nurse–patient interpersonal
process during health and illness situations. To her, basically, nurses’ reactions or responses to
patients may be automatic, “disciplined professional,” (1972) or “deliberative” (1961, 1990a). In
each situation, the reaction is based on observation of the patient’s verbal or nonverbal behavior
and is influenced by perceptions, thoughts, and feelings related to the patient’s action that
prompted the nurse’s reaction, or vice versa. The automatic response is guided by “secretiveness,”
during which neither the meaning of the behavior nor the perceptions of the nurse or the patient
are validated. The “disciplined professional response” is guided by “explicitness” of perceptions,
thoughts, and feelings, indicating that the patient’s needs are validated, and ambivalence and dis-
tress are explored. The disciplined professional response also indicates that the nurse has vali-
dated the effectiveness of nursing actions in helping the patient.
The nursing disciplined process requires the following conditions:
• What the nurse says to the individual in the contact must match (be consistent with) any
or all of the items contained in the immediate reaction.
• What the nurse does nonverbally must be verbally expressed, and the expression must
match one or all of the items contained in the immediate reaction.
• The nurse must clearly communicate to the individual that the item being expressed
belongs to herself.
• The nurse must ask the individual about the item expressed to obtain correction or
verification from that same individual (1972, pp. 29–30).
Conversely, not all interactions are based on a nursing process discipline. Nurses may give
automatic nursing care, exemplified in routine care (Orlando, 1961, 1972). Automatic nursing
care does not encompass perception, thoughts, and feelings. These also deal less with finding out
and meeting the patients’ needs for help. There are two types of automatic responses. One is stim-
ulated by the patients’ needs, and, insofar as nurses respond to needs that patients cannot take care
of by themselves, automatic response is expected to be effective. This is deliberative, automatic
response. The other automatic responses are those that result from reasons other than the patients’
immediate needs for help. Automatic responses neither acknowledge nor consider patients’ per-
ceptions and thoughts of the problem.
A nurse’s professional identity is exemplified by her offering disciplined professional actions
that are stimulated by knowledge of patient needs and that are validated by patient responses.
These actions involve a continuous process of reflection as the nurse attempts to explore the
meaning of the patient’s behavior. The nurse perceives the behavior and its meaning, shares these
perceptions, and explores and validates the meanings of these perceptions with the patient. By
sharing, exploring, and validating perceptions, misinterpretations are minimized. Modeling for
interpretation and validation would enhance further use of this process and would enhance under-
standing of our own and others’ reactions and actions (Schmieding, 1987).
When nurses provide these actions, the result is a patient who experiences improvement in
behavior, who has needs met, who feels comfortable, who has a sense of adequacy, and who does
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CHAPTER 12 On Interactions 243
not manifest helplessness or distress. Nurses deal with “immediate needs” in “immediate experi-
ences” of a patient in an illness situation by engaging in “immediate exploration” of the patient’s
perceptions, thoughts, and feelings (Orlando, 1961, p. 65). If nurses provide effective nursing care,
they will see immediate behavioral changes for the better, they will see increased ability and ade-
quacy in better care of self, and, eventually, they will see an increased sense of well-being. Need “is
situationally defined as a requirement of the patient that, if supplied, relieves or diminishes his
immediate distress or improves his immediate sense of adequacy or well-being” (Orlando, 1961,
p. 5). Orlando based her conceptualization of nursing as dynamic interaction on several implicit
assumptions (Box 12-4). It is also based on acknowledgment of feelings and emotions.
There are three problems with the assumptions. First, it is not clear how Orlando derived her
assumptions; no documentation exists. Second, the nature of some of her assumptions limits nurs-
ing to administering only to patients who are under the care of medicine and who cannot meet
their own needs comfortably. Neither of these assumptions is acceptable in nursing today; nurses
may care for patients who are not receiving medical care, and may help to more effectively meet
the needs of patients who are able to meet their own needs. Third, the ratio of assumptions to
propositions is high, necessitating too many conditions for the number of propositions and placing
a severe limitation on the exploratory power of the theory. Fourth, a mechanistic and reductionist
view of human beings appears to be implicit in her theory (Sellers, 1991). However, Orlando was
one of the early thinkers in nursing who proposed that patients have their own meanings and inter-
pretations of situations, and, therefore, nurses must validate their inferences and analyses with
patients before drawing conclusions about patients’ experiences or needs (Forchuk, 1991;
Orlando, 1961).
Orlando’s theory contains more primitive concepts that are unique to her theory (deliberative,
automatic, disciplined professional, dynamic nurse–patient relationship) than derived concepts
BOX 12-4 ASSUMPTIONS—ORLANDO
Implicit Assumptions
• When patients cannot cope with their needs without help, they become distressed with feelings of
helplessness (Orlando, 1961, p. 11).
• Nursing, in its professional character, does not add to the distress of the patient (1961, p. 9).
• Patients are unique and individual in their responses (1961, p. 59).
• Patients’ distress reactions are based on lack of understanding of their experience (1961, p. 17).
• Nursing offers mothering and nurturing analogous to an adult mothering and nurturing of a child
(1961, p. 4).
• Nursing deals with people, environment, and health.
• Patients need help in communicating needs; they are uncomfortable and ambivalent about dependency
needs (1961, p. 24).
• Human beings (nurses and patients) are able to be “secretive” or explicit about their needs, percep-
tions, thoughts, and feelings (1972, p. 26).
• The nurse–patient situation is dynamic; actions and reactions are influenced by both nurse and patient
(1961).
• Human beings attach meanings to situations and actions that are not apparent to others.
• Patient entry into nursing care is through medicine (1961, p. 5).
• The patient cannot state the “nature and meaning of his distress for his need without the nurse’s help
or without her first having established a helpful relationship with him” (1961, p. 23).
• “Any observation shared and explored with the patient is immediately useful in ascertaining and
meeting his need or finding out that he is not in need at that time” (1961, p. 36).
• Nurses are concerned with needs that patients cannot meet on their own (1961, p. 5).
• Nurses concern themselves with patient’s distress (1961, p. 22).
• Nurses should not add to patient’s distress (1961, p. 9).
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244 PART FOUR Reviewing and Evaluating: Pioneering Theories
that have been discussed in other theories (needs, helplessness, environment), which gives the the-
ory its own unique focus and enhances its contribution to nursing theory (Box 12-5). Many of the
central concepts are not defined (environment, health) or, when defined (e.g., interaction), they are
nonvariables (Hage, 1972) (Table 12-2). Because the concepts evolved from her conceptual image
of nursing’s potential reality, they have empirical references, and, therefore, have the potential to
be operationalized (Andrews, 1983).
Properties of action and reaction are well explicated, but outcomes are not defined—such as
improvement, distress, need for help, helplessness—thus making it difficult not only to ascertain
conceptually the need for help but also to ascertain the consequences of either automatic or delib-
erate nursing actions. The most significant variable—effective nursing care—is equated with
either the disciplined professional process or lack of helplessness, distress, and even, at times,
meeting the needs of patients, making the theory both tautological and teleological.
Theory Analysis
The Theorist
Ida Jean Orlando-Pelletier was an associate professor and the director of the graduate pro-
gram in mental health and psychiatric nursing (1958–1961) at Yale University School of Nursing
when her 1961 book was published. The book was the product of a 1954–1959 National Institute
of Mental Health grant, initiated to integrate mental health concepts in nursing programs (Crane,
1980). Her second book, in 1972, was a result of another supported research project (by the
National Institute of Mental Health, Public Health Service) and a general research grant. She was,
BOX 12-5 CONCEPTS—ORLANDO
Need for help Reaction
Distress Perception
Immediate Thought
Need Feeling
Experience Actions
Exploration Secret
Behavioral changes Automatic response
Sense of adequacy Explicit
Helplessness Personal response
Situational conflict Improvement
Nursing process discipline Reactions
Deliberative nursing process Explicit
Disciplined professional response Secret
Visual manifestations
Need for help or improvement
Motor activities
Eating, walking, twitching, and trembling
Physiological activities
Urinating, defecating, temperature, blood
pressure reading, respiratory rate,
skin color
Vocal manifestations
Behavior heard
Crying, moaning, laughing, coughing, sneezing,
sighing, yelling, screaming, singing
Patients may complain, request, question, refuse,
demand, comment, provide statements
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CHAPTER 12 On Interactions 245
TABLE 12-2 DEFINITION OF DOMAIN CONCEPTS—ORLANDO
Nursing “Is responsive to individuals who suffer or anticipate a sense of helplessness.”
“Process of care in an immediate experience . . . for avoiding, relieving, diminishing, or
curing the individual’s sense of helplessness” (Orlando, 1972, p. 13).
“Finding out and meeting the patient’s immediate need for help” (1972, p. 20).
Nurse’s reaction encompasses perception, thought and feeling (1972, p. 59).
Goal of nursing Increased sense of well-being; increase in ability, adequacy in better care of self and
improvement in patient’s behavior (1961).
Health Sense of adequacy or well-being
Fulfilled needs.
Sense of comfort (1961, p. 9, 1969)
Environment Not defined directly but implicitly in the immediate context for a patient (Orlando, 1972).
Human being Developmental beings with needs; individuals have their own subjective perceptions
and feelings that may not be observable directly.
Nursing client Patients who are under medical care and who cannot deal with their needs or who cannot
carry out medical treatment alone. There are two dimensions to their behavior: need
for help and improvement expressed verbally and nonverbally.
Nursing problem Distress due to unmet needs due to “physical limitations,” “adverse reactions to the
setting,” or “experiences which prevent the patient from communicating his needs
(1961, p. 11).
Ineffective nursing activities: acting in a way not helpful to patient or not achieving
professional purpose (1961, p. 72).
Ineffective patient behavior such as uncooperative, unreasonable, demanding, or
commanding behaviors that prevent the nurse from carrying out her care of maintaining
a satisfactory relationship with the patient.
Nursing process The interaction of “1) the behavior of the patient, 2) the reaction of the nurse, and 3) the
nursing actions which are assigned for the patient’s benefit” (1961, p. 36).
Process by which a nurse acts (1972, p. 29).
Nurse–patient relations Central in theory and not differentiated from nursing therapeutics or nursing process.
Nursing therapeutics Direct function: “1) Initiates a process of helping the patient express the specific meaning
of his behavior in order to ascertain his distress and 2) helps the patient explore the dis-
tress in order to ascertain the help he requires so that his distress may be relieved.”
Indirect function: Calling for the help of others (1961, p. 29).
“Whatever help the patient may require for his need to be met” (i.e., for his physical and
mental comfort to be assured as far as possible while he is under going some form of
medical treatment or supervision [1961, p. 5]).
Automatic or deliberative instructing, suggesting, directing, explaining, informing,
requesting, questioning, making decisions for the patient, handling the body of the
patient, administering medications or treatments, or changing the patient’s immediate
environment. Automatic activities: 1) routines of patient care such as serving food,
evening care, 2) routines to protect the interests and safety of patient, such as locking
doors, adjusting side rails, 3) routine practices of organization, such as signatures for
consent forms and releases (1961, p. 84).
Automatic activities redefined in 1972: 1) perception by five senses, 2) automatic
thoughts, 3) automatic feelings, 4) action (p. 25).
Disciplined and professional activities: automatic activities plus matching of verbal and
nonverbal responses, validation of perceptions, matching of thoughts and feelings with
action (1972, pp. 25–32).
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246 PART FOUR Reviewing and Evaluating: Pioneering Theories
at that time, a clinical nurse consultant at McLean Hospital, Belmont, Massachusetts (1962–
1972).
Orlando has held numerous other positions, including consultant to nursing service adminis-
tration and nursing education to schools, to health departments, and to the many students who
called her from across the United States. She was appointed consultant to the New England Board
of Higher Education and the board of the Harvard Community Health Plan. Orlando’s most recent
position was director of nursing at the Tri-City Unit of Metropolitan State Hospital in Waltham,
Massachusetts.
According to Schmieding (1986), Orlando’s 1961 book has been translated into five lan-
guages. Orlando worked closely with and was influenced by Wiedenbach; she, in turn, influenced
Travelbee’s theoretical notions of nursing. Orlando’s book was reissued with new introductions
by the National League for Nursing (1990a, 1990b); this republication of her work acknowledges
the significance of her contributions and the timelessness of her ideas.
Paradigmatic Origins
Although Orlando’s theory evolved from extant practice through the analysis of some 2,000
nurse–patient interactions to discern what is good and bad practice, Orlando’s writing appears to
be influenced by Peplau’s (1952, 1991) focus on interpersonal relationships in nursing. Peplau
defined nursing in terms of relationships between a person in need of help and the nurse who is
able to recognize such a need. Definitions by Orlando and Peplau have some common properties
and, considering that Peplau’s ideas were published in 1952 and Orlando began to formulate hers
in 1954 (Yale received a grant for the purpose of developing an integrated program and, later, a
faculty research development grant that facilitated testing some of Orlando’s theoretical proposi-
tions), one can make an assumption of Peplau’s influence on Orlando. Peplau acknowledged the
influence of Harry Stack Sullivan on the development of her ideas; therefore, one may deduce that
Orlando’s theory has also used some of Sullivan’s concepts and assumptions (dynamic relations,
inadequate communication).
Perceptions, meaning, and evaluation of meaning are central concepts in the theory and are
also central to symbolic interactionism. Considering that Orlando used a method of research that
grew out of the Chicago school of symbolic interactionism in the 1950s, understanding of her the-
ory could be enhanced by studying the assumptions and major concepts of symbolic interaction-
ism. Orlando used field methodology before it became a worldview in research.
Schmieding (1987) suggested that by studying established theories in other disciplines,
nursing theories could be better clarified and developed. She, therefore, proposed to analyze
Orlando’s theory by using John Dewey’s theory of inquiry. She described the similarities and the
differences between Orlando’s and Dewey’s organizing principles around the meaning of experi-
ence, habit, and functions in acting and reacting. She demonstrated that Orlando used experi-
ences, the meaning of experience, and the immediacy of nurse–patient situations as the basis for
her theory and that these same principles are central to Dewey’s theory. Orlando herself did not
acknowledge the paradigmatic origins of her theory, and no references appeared in her original
writings.
Internal Dimensions
Orlando analyzed some 2,000 nurse–patient interactions to identify the properties, dimen-
sions, and goals of interaction. The theory that evolved inductively from these analyses focused on
the nature and dynamics of nurse–patient interactions. All statements in the theory relate to inter-
actions; therefore, it is a concatenated theory. She used a field approach in developing the theory.
Orlando’s background in psychiatric nursing (her academic objectives were to identify psychiatric
content that should be integrated in nursing curricula) has most probably influenced the focus of
the theory on describing the psychosocial aspects of the nurse–patient interactions.
As a single-domain theory that is also a microtheory of nurse–patient interactions, it is limited
to immediate exploration and responses to a given situation. The nurse is an integral part of this the-
ory; nurses’ perceptions, thoughts, and feelings affect their actions and the patients’ reactions. The
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CHAPTER 12 On Interactions 247
entire theory is built on nurse–patient encounters; therefore, using Barnum’s (1994, 1998) classi-
fication method of theory development, Orlando used a mixture of operational and problematic
methods—more of the former than of the latter—and her theory is based on a reciprocal principle.
Forchuk (1991) compared Peplau’s and Orlando’s theories and determined that Orlando has an
interaction paradigmatic perspective, whereas Sellers (1991) proposed that Orlando’s theory is
predicated on a stimulus–response approach. The stimulus is comfort maintenance and the
response is tension reduction. The nurse and patient provide the stimulus and response approach.
Orlando identified a number of problems (helplessness, distress) and what nurses should do
to handle these problems. The concepts in the problems are not operationally defined, and this
limits the development of research hypotheses. Orlando’s theory is focused on the delivery of
nursing care through a disciplined nursing process. However, her focus is on how to deliver care
and not on what care to give. Therefore, her theory provided an early attempt to conceptualize
knowledge of process. It is a nursing process theory of medium- to low-level abstraction, leaning
more toward low-level abstraction. This analysis of the theory was confirmed by Orlando in intro-
ducing her book for republication in (1990a, 1990b). She described her theory as a “nursing
process theory.”
Theory Critique
The early 1960s marked a milestone shift in the way the nursing perspective was viewed. The
interaction theorists, epitomized by Orlando, marked a shift in the perspective of nursing from
phenomena dealing with nurses, functions of nurses, and needs of patients to a focus on the
process of interaction and the potential consequences for the patient. Orlando’s theory—with its
major proposition being a deliberative nursing process (or the nursing process discipline, as it
was relabeled in 1972, and then relabeled nursing process theory in 1990)—is a more effective
process for identifying patient needs and evaluating patient care. Providing effective care was the
focus of many research projects and provided the framework for numerous Yale studies and pub-
lished research (Diers, 1970).
Systematic explorations of relationships between each of the theory’s concepts and patient
outcomes is possible when patient outcomes (improvement, met needs) are articulated, defined,
and operationalized. Explorations could also focus on the effect of the “nursing process disci-
pline” on the assessment process and on implementation of other clinical therapeutics (Orlando,
1972, p. 4). Examples of potential propositions are presented in Box 12-6.
Although Orlando considered the theory to be a theoretical framework for the practice of pro-
fessional nursing (Orlando, 1972, p. 1), it is more congruent in guiding nurse–patient interactions
for the purpose of assessing needs and in providing the nursing therapeutics deemed necessary to
patient care. The process is in fact considered a universal process of interactions between patients
and all health professionals (Marriner-Tomey, Mills, and Sauter, 1989). What may make it more
unique to nursing is the addition of such dimensions as space (hospital) and length of encounters
(number of hours nurses interact with patients).
BOX 12-6 PROPOSITIONS—ORLANDO
• There will be greater improvement in patient behavior and more effective nursing care when nurses use
the disciplined professional response than when they use automatic personal response.
• The nursing reactions include perceptions, thoughts, feelings, and actions.
• When a nurse assesses a patient’s immediate needs, immediate experiences, and immediate resultant
behaviors, nursing care is more effective in decreasing distress and helplessness and increasing comfort.
• When nurse–patient dynamics and an “explicit” relationship are established, the patient is able to
communicate his needs more clearly.
• Effective nursing interactions and processes enhance patients’ comfort and decrease their stress.
• Patient’s and nurse’s reactions are the outcome of a situation.
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248 PART FOUR Reviewing and Evaluating: Pioneering Theories
This theory is used to explicate nurse–nurse relations as well as nurse–patient relations. For
example, it was used in acute psychiatric hospitals and was combined with professional values of
caring for both patients and nurses, and with the use of evidence-based practice, as a foundation of
nursing practice. The result was a relationship-based framework in which reflections and respect-
ful interactions between providers and clients resulted in excellent practice (Allen, Bockenhauer,
Egan, and Kinnaid, 2006).
There is evidence that it has been creatively utilized to identify the elements of effective
nurse–client interactions among postsurgical nursing home residents (England, 2005). The use of
this deliberative communication process provided the framework for identifying patients’ con-
cerns. Similarly, Williamson (2007) found that using Orlando’s theory in home health care helped
nurses’ effective communication styles, led to better observation and identification of patient’s
needs, and empowered nurses in their professional practice.
Orlando’s theory has also been used in nurse–patient interactions with patients who have
been diagnosed with a chronic illness (Zoffmann, Harder, and Kirkevold, 2008). Zoffmann et al.
(2008) used it in a research study to determine how patterns of interaction between providers and
diabetic patients may lead to shared decision making. The assumption is that shared decision mak-
ing will be more accurately based on knowing what patients need, thus leading to more quality
care that results in better compliance.
The theory has several limitations, among them the seeming focus on ill people in acute care
or psychiatric hospitals; on individuals, particularly those who are aware and conscious; on imme-
diate time and situations; on short- rather than long-term care and planning; and on the virtual
absence of a reference group or family members. There are other limitations in the theory, such as
the lack of definition of environment, health, patient outcomes, physiological aspects of needs,
and the nonvariable nature of the central concepts of the theory (e.g., improvement, immediacy,
effectiveness). When we limit the theory goals to only describing the nurse–patient interaction
process for assessment of needs and for evaluation of care, then its limitations diminish, as is man-
ifested by the numerous publications related to this aspect of the theory.
Nurses always have used focused interactions and deliberative processes, whether they have
been aware of it or not. Even when aware of this use, whether they always credit Orlando remains
debatable. Increasingly, however, there are publications on the importance of story-telling as an
educational strategy (Hunter and Hunter, 2006), and on the use of relational conversation, such as
“Self-Care TALK,” as methods for creating partnerships in practice (Leenerts and Teel, 2006). In
this literature, Orlando, as well as other interaction nursing theorists, is credited. Concepts and
linkage from the theory, such as validation of observation and nurse–patient discussion of feel-
ings, thoughts, perceptions, and reactions, are used as the bases for these strategies, which are
designed to enhance quality interaction and the care it provides. Further use would be enhanced
by refinements, extensions, and proposition testing.
Orlando’s theory evolved from the need for curricular changes, and it is therefore logical that
her first test of ideas occurred in an educational setting (Yale University). The first book (1961)
identified teaching and learning strategies and some of the content that could be used in teaching
students how to use the deliberative nursing process.
In her second book (1972), Orlando relayed the results of a training program over a 3-month
period. The training was for 28 staff nurses (as opposed to students in an educational system) in
the use of the nursing process discipline. The purpose was to change their responsiveness from
one that was “personal and automatic” to one that was “disciplined and professional” (Orlando,
1972, p. 4). Outcome variables were observed in nurses, and the study results indicated effective
use of nursing process discipline in nurse–patient encounters by nurses who were in the training
program (Orlando, 1972).
Although there has been relatively limited use of Orlando’s theory as a complete theory in
practice, educational, or administrative settings, the concepts permeate our educational and prac-
tice settings. Since Schmieding (1986) provided the most comprehensive use of Orlando’s theory
in nursing practice and nursing administration, others have used only some components of it
either to illustrate the importance of nurse–patient interactions or for processes to identify the
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CHAPTER 12 On Interactions 249
needs of patients (Williamson, 2007). Sheafor (1991) provides an analysis that supports the
need to incorporate the deliberative Orlando approach in graduate programs. Each situation pre-
sented focuses on problematic situations with patients, nurses, physicians, or other colleagues.
Nurses’ immediate responses and deliberate process responses are then described, illustrating
Orlando’s propositions. In each one of the vignettes offered, the deliberative process clarified
assumptions, cleared misconceptions, checked judgmental thoughts, and enhanced expressions
and interpretations.
External Components of Theory
The theory represents a shift from a view of nursing that was task- and function-oriented—
with goals that stemmed from organizational needs, and with therapeutics that were offered and
based on physicians’ prescriptions—to nursing as an interactive process. Values of nursing shifted
because of, or as a product of, interaction theories. These theories proposed that nursing is a
process, patients are the focus, patients should be consulted in their own care, and patients should
be spared the distress and discomfort associated with misconceptions, misinterpretations, and
noninvolvement in their own care. Patients’ behaviors and participation in interpreting meaning
and validating perceptions should be significant factors in nurses’ reactions. Although the patient
was still viewed as helpless and the deliberative process appeared to be always initiated by the
nurse, many of the assumptions of the theory are congruent with the social and professional values
of the 1980s and 1990s. The uniqueness of individuals assumed by the theory could counteract
automatic responses of nurses because even a nursing process discipline or deliberative nursing
process could turn into an automatic response if the nurse forgets the basic assumptions guiding
the theory.
The theory is useful in assessing patients, but utilizers must be trained for its appropriate use
(Schmieding, 2002). It is used effectively for caring for elderly people (Faust, 2002). Laurent
(2000) developed a leadership theory for the management of patient care, emphasizing that exist-
ing theories borrowed from other disciplines (e.g., Deming Management method, Managers as
Developers model, and Shared Governance and Transaction Leadership) are not as productive for
nursing goals of leadership. Orlando’s theory was used as a road map for nurses providing care in
a mental health setting, to develop a research instrument for testing immediate distress, and for a
study, the results of which demonstrated that the care provided significantly decreased distress
(Potter and Bockenhauer, 2000; Potter and Tinker, 2000). Study of the relationship between nurse-
expressed empathy and patient distress and between patient-perceived empathy and patient dis-
tress was significantly negative. Although a moderately positive relationship was found between
nurse-expressed empathy and patient-perceived empathy, the findings supported some of
Orlando’s propositions (Olson and Hanchett, 1997).
The theory appeared initially to be culturally bound because it was perceived by nurses that
patients in other parts of the world and from other cultures may not want to participate in identify-
ing their needs, and may not feel free to engage in interpretations of meanings. It was also
assumed that patients may prefer to rely on their significant others and health care professionals to
do that for them, and that they may misinterpret the continuous validation proposed in this theory
as lack of knowledge, lack of expertise, or lack of accountability in the care process (Lipson and
Meleis, 1983). It should be noted, however, that her theory has been used in Brazil, where the author
analyzed its use in Brazilian journals (Toniolli and Pagliuca, 2002), and in Denmark to develop a
model of care based on communication and reflection to enhance shared decision-making
(Zoffmann, Harder, and Kirkevold, 2008).
Theory Testing
The theory evolved from Orlando’s observations of nurse–patient interactions. Although the
findings were not reported in a research report, her 1961 book is based on that research. The
research was done in various patient settings to explore the effect of the deliberative process,
which includes the perceptions, thoughts, and feelings of the patient and the nurse regarding
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250 PART FOUR Reviewing and Evaluating: Pioneering Theories
patient needs and the care given. Validation of perceptions, thoughts, and feelings is essential for
enhancing the congruence between patient needs and the care given. Results indicate unique nurs-
ing process is more effective than other approaches in dealing with pain (Barron, 1966; Bochnak,
1963), in reducing stress (Mertz, 1962), in understanding patient needs (Cameron, 1963), in
decreasing postoperative vomiting (Dumas and Leonard, 1963), in relieving distress experienced
by patients during the process of admission to a hospital (Elms and Leonard, 1966), and in
enhancing the use of an ambulatory program for patients with bipolar disorder (Shea, McBride,
Gavin, and Bauer, 1997). In addition, nursing process is also more effective than other approaches
on the outcomes of implicit and explicit verbal acceptance of a nursing procedure, as well as on
the degree of effectiveness of enemas and progress in labor (Tryon, 1963), with the indicators
being higher retention rate, more fecal return, and higher ratio of fluid intake and return (Tryon
and Leonard, 1964).
A number of studies focused on explicating the properties and components of nurse–patient
interactions (Diers, 1966; Gowan and Morris, 1964; Pienschke, 1973; Rhymes, 1964; Wolfer and
Visintainer, 1975) and relational conversations (Leenerts and Teel, 2006). The latter study uncov-
ered several properties for conversations used to create partnerships to promote health. These
include listening with intent, affirming emotions, creating relational images, and planning enact-
ments. Others explored the relationship between the nurses’ social approval of patients and post-
operative recovery behavior as an outcome, finding a significant but weak inverse relationship
between physical status (self-report) and social desirability (Eisler, Wolfer, and Diers, 1972).
These authors question the process and intent of validating experiences with patients (central to
Orlando and Wiedenbach), suspecting that some patients may respond to validation on the basis of
social expectation rather than from “the patient’s inner experience” (Eisler, Wolfer, and Diers,
1972, p. 524).
A significant central concept in Orlando’s theory—perceptions—was used as a framework to
describe the needs of grieving spouses. A study of the grieving spouses’ perceptions of their own
needs before and after the death event revealed high reliability in ability to identify needs and a
consistency in the identified needs (Hampe, 1975). However, when identified needs were com-
pared with met needs, a discrepancy became apparent. Implicitly, if the nurses had asked the
grieving spouses to identify their own needs, perhaps the nurses would have planned to meet each
of those needs in a more systematic and effective manner. A deliberative interaction process can
elicit perceptions of needs even when patients cannot communicate their needs (Gowan and
Morris, 1964). When nurses used the previously identified needs of grieving spouses as specific
targets in their nursing interventions, grieving spouses experienced more met needs (Dracup and
Breu, 1978). In this latter study, the greater satisfaction in nursing care was attributed to the sys-
tematic approach in needs identification.
Gilliss (1976) undertook another study that supports Orlando’s differentiation between pre-
senting problems as perceived by nurses and those as perceived and validated by patients. Gilliss
demonstrated that fewer patients with sleeplessness required sleep medication in an experimental
group in which Orlando’s deliberative process was implemented. In this group, patients’ specific
needs were identified, defined, validated, and met.
Orlando’s theory was used as a framework to research nursing administration. Schmieding
(1988, 1990a, 1990b, 1990c) demonstrated that nursing administrators did not explore the reac-
tion of their staff to problematic situations; the majority of administrators handled by themselves
problematic situations that did not involve their staff, or they told nurses what to do rather than
solicit from them their thoughts or action plans. Using Schmieding’s application of Orlando,
Sheafor (1991) provided recommendations on how to enhance productivity in hospitals.
The processes of interaction, action, and decision making in nursing administration are simi-
lar to these processes involved in nurse–patient interactions. Schmieding (1983) systematically
explored the nature of interaction, decision-making, and action processes in problematic situa-
tions in nursing administration and discovered that Orlando’s theory could provide the needed
nursing focus in nursing service administration. An instrument was developed to describe the
action process of different members of nursing service personnel (Schmieding, 1987). Orlando’s
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CHAPTER 12 On Interactions 251
theory was also used in describing the responses of nursing students to distressed patients
(Haggerty, 1987).
The findings lend support to consideration of the interaction process in achieving effective
patient and nursing care outcomes. However, numerous methodological issues are related to need
identification and increasing patterns of interaction in the nursing process discipline. One such
problem is the paucity of research tools to identify patient needs. Williamson (1978), in attempt-
ing to identify patient needs, questioned the existence of mutually exclusive variables such as
physical and emotional needs and the contextuality of needs and socioeconomic cultural vari-
ables.
Orlando’s books have been translated into Japanese, Portuguese, and Hebrew, among other
languages, thus attesting to its international appeal and utility (Orlando-Pelletier, 1990b). As with
other international uses of a Western theory, the extent of actually using the theory in practice or in
research should be carefully assessed.
JOSEPHINE PATERSON AND LORETTA ZDERAD
Theory Description
Paterson and Zderad (1988) addressed three central questions: What is the meaning of nurs-
ing? How do nurses and patients interact? How can nurses develop the knowledge base for the act
of nursing? The humanistic-practice nursing theory proposes that the nurse and the patient are sig-
nificant components in the nurse–patient situation. The act of caring increases the humanness of
both. They both approach the situation with experiences that influence the encounter. Nurses,
therefore, should consider such encounters as existential experiences and should describe them
from observing “the thing itself,” the phenomena of nursing as they occur in the world. They use a
phenomenological perspective as the basis for a dialogue about lived experiences to uncover
answers to the questions. The sum total of all these experiences will enhance the development of
the science of nursing.
In selecting existentialism and phenomenology as context and method for the development of
nursing knowledge, Paterson and Zderad operate from several premises. The progress of nursing
as a human science is hampered by the mechanistic, deterministic, cause-and-effect methods that
have dominated it; in other words, they rejected the received view, the logical positivist view of
theory development (Paterson, 1971, p. 143). Paterson and Zderad were a decade ahead of the lit-
erature in nursing that later advocated such a move. They have also developed their ideas on the
premise that the experiences of nurses in practice supply the impetus for any useful theory for
nurses. However, they also warned us that preconceived notions influence what is significant and
determinately affect the development of knowledge.
Nursing is a lived dialogue that incorporates an intersubjective transaction in which a nurse
and a patient meet, relate, and are totally present in the experience in an existential way that
includes intimacy and mutuality (Paterson and Zderad, 1970–1971). Nursing brings a person
together with a nurse because of the call of that person for help and the response of the nurse. The
encounter is influenced by all other human beings in the patient’s and nurse’s lives and by other
things, whether ordinary objects (such as utensils, clothes, furniture) or special objects (such as
life-sustaining equipment). The dialogue during these encounters occurs in a time frame as experi-
enced by both partners. When there is synchronization in timing, the intersubjective dialogue is
enhanced. Dialogue occurs in a certain space that is objective, the physical setting, or subjective,
personal space. In their theory, the nurse is expected to know “the nurse’s unique perspective and
responses, the others’ knowable responses, and the reciprocal call and responses, the in-between,
as they occur in a nursing situation” (Paterson and Zderad, 1988, p. 7).
Paterson and Zderad’s theory is based on a number of implicit assumptions (Box 12-7). The
theory has the potential for highly abstract propositions related to nurse–patient interactions (Box
12-8). The level of abstraction does not render propositions ready for testing. Concepts of the the-
ory are well delineated (Box 12-9); however, some conceptual definitions are not complete in the
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252 PART FOUR Reviewing and Evaluating: Pioneering Theories
theory (I/thou, I/it, we, all at once), whereas others provide useful conceptual definitions, such as
empathy (Zderad, 1969) and nursology (Paterson, 1971). The theorists did not offer operational
definitions; however, the theory provides opportunities for others to continue to explicate and fur-
ther develop concepts. Central nursing phenomena, such as environment or well-being, are not
defined nor are they central concepts of the theory. Others, such as nurturance, comfort, and
empathy, are primitive to the theory and are better related to clinical process. Derived concepts,
such as the nursing dialogue, as “meeting, relating, and presence” is more comprehensively
defined than any of the primitive concepts (Table 12-3, p. 254).
Theory Analysis
The Theorists
Josephine G. Paterson, DNS, and Loretta T. Zderad, PhD, are nurse researchers at the Veterans
Administration Hospital in Northport, New York. Paterson (diploma from Lenox Hill Hospital,
BOX 12-7 ASSUMPTIONS—PATERSON AND ZDERAD
Implicit Assumptions
• Nursing involves two human beings who are willing to enter into an existential relationship with each
other.
• Nurses and patients as human beings are unique and total biopsychosocial beings with the potential for
becoming through choice and intersubjectivity.
• The present experiences are more than the sum total of the past, present, and the future, and are influ-
enced by the past, present, and future. In their totality, they are less than the future.
• Every encounter with another human being is an open and profound one, with a great deal of intimacy
that deeply and humanistically influences members in the encounter.
• Human beings are free and are expected to be involved in their own care and in decisions involving
them.
• All nursing acts influence the quality of a person’s living and dying.
• Nurses and patients coexist; they are independent and interdependent.
• A nurse has to “accept and believe in the chaos of existence as lived and experienced by each man
despite the shadows he casts, interpreted as poise, control, order, and joy” (Paterson and Zderad, 1988,
p. 56).
• Human beings have an innate force that moves them to know their angular views and other’s angular
views of the world (Paterson and Zderad, 1976; Zderad, 1969).
From Paterson J.G. and Zderad, L.T. (1976). Humanistic nursing. New York: John Wiley & Sons; Zderad, L.T. (1969).
Empathetic nursing: Realization of a human capacity. Nursing Clinics of North America, 4, 655–662; and Paterson,
J.G. and Zderad, L.T. (1988). Humanistic nursing. NLN Publication, March (41–2218).
BOX 12-8 PROPOSITIONS—PATERSON AND ZDERAD
• Nursing’s existential involvement in patient care is manifested in the active presence of the whole
nurse in time and space as viewed by the patient.
• Nursing’s goal of more well-being is enhanced by both nurse and patient as they experience the
process of making responsible choices.
• Because nursing is involved with human beings, its phenomena are a person needing help and a person
helping in his own situation.
• Intimacy and mutuality in relationships enhance more well-being.
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CHAPTER 12 On Interactions 253
BSNE from St. Johns University, MPH from Johns Hopkins University) received her DNS from
the Boston University School of Nursing. Zderad (diploma from St. Bernard’s Hospital, BSNE
from Loyola University, MSNE from Catholic University) received her PhD from Georgetown
University. Their interest in public health and psychiatric nursing, respectively, is complementary
and well represented in their theory. Their ideas evolved in 1960, while collaboratively teaching
graduate students. After completing their respective doctorates, they developed a course on
humanistic nursing at the Veterans Administration Hospital in 1972. In the process of teaching the
course, their theory evolved. Their 1976 collaborative book is a result of their teaching and
observing clinicians in practice. Their book was republished by the National League for Nursing
in 1988, an indication of the contemporary nature of their ideas and the demand for their theory.
After their retirement, the book was made available as an e-text and may be freely copied for aca-
demic purposes with copyright clearly indicated.
Paradigmatic Origins
It is easy to determine the paradigmatic origins of Paterson and Zderad’s theory. The origins
are explicitly identified as being existential philosophy for theory development and phenomenol-
ogy for research. Existentialism considers a person as a unique being and the sum of all undertak-
ings. It does not purport to find out the “why” of human experience, but just describes the “is” of
it. It views human existence as inexplicable and emphasizes the freedom of human choice and
responsibility for one’s acts. Existential philosophy projects that a person exists but lacks a fixed
nature and is always in a state of becoming.
The theory is based on several sets of ideas: that the person possesses autonomy, free will,
and many opportunities for choosing among available options. However, the options and choices
are considered relative and are perceived subjectively. An absolute reality does not exist for those
who follow the existentialist school of thought. This theory allows nurses to use knowledge
processed through their own lenses and experiences. There is total freedom to create, enhance,
determine, and act. Existential philosophy emphasizes a complete sense of responsibility for all
actions, and Paterson and Zderad based their theory on this stance.
Their theory also has roots in phenomenology. Phenomenology is the study of all aspects of a
phenomenon in all its richness, in all its dimensions, in its entirety—without attempting to separate
BOX 12-9 CONCEPTS—PATERSON AND ZDERAD
Between Becoming
Nurturing I/Thou
Comfort I/it
Being and doing We
Lived dialogue All at once
Nurturing Well-being
Intersubjective transaction More-being
Meeting Choices
Relating Authenticity with one’s self
Presence Intellectual awareness
Intimacy Community
Mutuality Concepts for research
Call and response Authenticity with self
Other human beings Nursology
Things
Time
Synchronicity
Space
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254 PART FOUR Reviewing and Evaluating: Pioneering Theories
the human experiences of any partners in the study (Kant, 1953, pp. 80–90). The focus is on the
here-and-now. Nursing deals with more than that; therefore, any limitations in the theory are limi-
tations of its paradigmatic origins.
Paterson and Zderad relied heavily on such existentialist philosophers as Teilhard de
Chardin, Martin Buber, Gabriel Marcel, and Frederick Nietzsche to develop their theory of nurs-
ing, and they also relied on such phenomenologists as James Agee. Both existentialism and phe-
nomenology are compatible paradigms, allowing the humanistic nursing theory to integrate their
assumptions and concepts and to evolve from both traditions. Barnum identified several advan-
tages in the use of these paradigms to develop the nursing domain. A person could be considered
TABLE 12-3 DEFINITION OF DOMAIN CONCEPTS—PATERSON AND ZDERAD
Nursing A human discipline involving one human being helping another in an interhuman and
intersubjective transaction “containing all the human potentials and limitations of each
unique participant” (Paterson and Zderad, 1988, p. 3). Incorporates all human responses of
a person needing another. “The ability to struggle with other man through peak experi-
ences related to health and suffering in which the participants in the nursing situation are
and become in accordance with their human potential” (1988, p. 7).
Goals of nursing 1. Humanistic nursing itself is a goal.
2. Help patients and self to develop their human potential and to come toward, through
choice and intersubjectivity, well-being or more well-being. To help patients and self to
increase possibility of making responsible choices (1988, pp. 14–17).
Health More than absence of disease: equated with more well-being, as much as humanly possible
(1988, p. 12).
Environment Objective world as manifested in “other human beings” and things. The subjective meaning
of the people and things. Refers to nurses’ and patient’s environment (1988, pp. 31–33, 37).
Human being A unique and “incarnate being always becoming in relation with men and things in a world
of time and space” (1988, p. 18). Has the capacity to reflect, value, experience to become
more. One who asks for help and one who gives help.
Nursing client Both nurse and patient are the nursing clients (incarnate men), who are unique, when they
“meet in a goal-directed (nurturing well-being and more well-being) intersubjective trans-
action (being with and doing with) occurring in time and space (as measured and as lived
by patient and nurse)” (1988, p. 21).
Nursing problem Seeming discomfort that prompts a call for help. “A person with perceived needs related to
the health/illness quality of living” (1988, p. 18).
Nursing process “Deliberate, responsible, conscious, aware, nonjudgmental existence of the nurse in the
nursing situation, followed by disciplined, authentic reflection and description” (1988, pp. 7–
8). Based on awareness on the part of the nurse, continuous assessment (p. 16), and develop-
ing the human potential of the patient for responsible choosing between alternatives.
Nurse–patient The human dialogue is the essence of nursing, interaction is nursing. Nurse–patient
relations experience is an intersubjective transaction with empathy.
Nursing therapeutics A human dialogue involves being and doing, nurturing, well-being or more well-being, and
comforting. Existential involvement that is an active presence besides the doing, to provide
nurturing and comfort and involves experiencing, reflecting, and conceptualizing (1988, pp.
12–23). Nurses offer alternatives and support responsible choosing, share self, knowledge,
and experience.
Focus of nursing On the person’s unique being and becoming (1988, p. 19).
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CHAPTER 12 On Interactions 255
in totality, experience could be viewed as a whole, and knowledge for nursing could be viewed as
more than the sum total of diverse views from a variety of disciplines. Indeed, these paradigmatic
origins give nursing its raison d’être (Barnum, 1994, p. 275). Existential nursing furthers a better
understanding of the environment of one’s self. To use the accepting nature of existentialism is
antithetical to the advocacy needed to make changes in intolerable and oppressive situations that
are mitigated by illness or by other social or political conditions. Existential nursing may provide
the rationale for accepting an unhealthy and noneffective status quo. And it provides no guidelines
for releasing patients from suffering (Barnum, 1998).
Internal Dimensions
The purpose of the theory is to describe the authentic dialogue between nurses and patients and
their lived experiences for the purpose of changing the situation. It is to describe humanistic nursing
practice theory and its components and the human method of nursology—the study of nursing aimed
toward the development of nursing theory. Paterson and Zderad used a method to develop theory,
and the theory is the method. They aimed to develop a theory, using methodology and proposing
research, congruent with the nature of nursing as a human science (Kleiman, 1986). The theory
evolved deductively from a philosophical view—existentialism—but they used a phenomenological
approach to inductively develop a theoretical conception of nursing. Because most of the concepts
are derived from existentialism, one can deduce that the theory is more deductive than inductive.
This is a highly abstract theory developed around an interest in exploring authentic interaction
and the experience of unique people (nurse–patient) as concepts. The theory focuses on properties of
the human encounter—the human situation that exists between nurses and patients; therefore, it is
classified as a microtheory, with more derived than primitive concepts. Its scope is narrow, describ-
ing one aspect of nursing therapeutics or the nursing process—interaction—and one aspect of inter-
action, that is, human encounter. Therefore, it is a single-domain theory. It deals with knowledge of
process: How do people interact, particularly when one needs help and one is willing to give help?
Paterson and Zderad use a dialogue form to describe the “nursing dialogue.” Therefore,
McKeon (as cited in Stevens, 1984, p. 51) would consider their approach to theory development a
dialectical one. They present a whole, explaining the whole (humanistic nursing) through the parts
(the various concepts) and the parts through the whole. The uniqueness of this theory lies in the
lack of boundaries between the experience of the authors as nurses, theoreticians, methodologists,
and writers. Concepts in the theory describe all that, and all experiences describe concepts.
Theory Critique
The theorists, in proposing their humanistic theory of nursing, have also proposed a method-
ology congruent with the assumptions of the theory to develop nursing knowledge (Paterson,
1971). They use the logic of phenomenological methodology and call it phenomenological nur-
sology. The method is aimed at the reality as experienced by the nurse and the patient, subjectively
and objectively. They propose the method for research and nursing practice. Existentialism is the
context of nursing, and concepts are used to develop theory. Phenomenology is the process for
clinical nursing and for research in nursing. Phenomenological nursology evolved from nursing
practice and is usable for nursing research.
The theorists proposed five phases of phenomenological nursology (Paterson, 1971, pp. 144–
146):
1. “Preparation of the nurse knower for coming to know.” This could be accomplished by
total immersion in selected and related literary work. Immersion includes reflecting,
contemplating, and discussing.
2. “Nurse knowing of the other intuitively” by seeing the world through the eyes of the
subject or the patient, becoming an insider rather than an outsider.
3. “Nurse knowing the other scientifically” by replaying the subjective experiences, reflect-
ing on them, and transcribing the amalgamated view. The nurse considers relationships
and analyzes, synthesizes, and then conceptualizes.
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256 PART FOUR Reviewing and Evaluating: Pioneering Theories
4. “Nurse complementarity synthesizing known others” by comparing and contrasting the
differences of like nursing situations to arrive at an expanded view.
5. “Succession within the nurse from the many to the paradoxical one,” evolving from the
multiple realities to an inclusive conception of the whole that incorporates the multiplici-
ties and contradictions.
This is a method to find truths related to everyday practice in nursing or as evolving out of
nursing research.
The theory depicts a way of life, an attitude toward humanity, a goal of actualization worth
striving for on all levels of personal and professional lives. However, it is limited in the form of
guidelines for nursing practice. The only indication of the use of this theory as a framework for prac-
tice has been offered by Paterson and Zderad as occurring in the Veterans Administration Hospital in
Northport, New York. However, the theory is used in discussions of research findings related to a
person’s relationship to time and space, such as hospital rooms or the meaning of waiting for partic-
ular procedures (Hall and Brinchmann, 2009). Another example demonstrating its selection as a
framework for discussion was undertaken by Chan et al. (2008), who used it to describe how nurses’
attitudes toward perinatal bereavement may render bereaving parents powerless when the focus is
not the whole person. Focusing on a disease, a limb, or one aspect of a situation may be an indication
of lack of consideration of the context and the wholeness of the person and experience.
The theory is a philosophy and a methodology that purports to improve not only quality of
care but also the quality of life for the nurse, the teacher, and the administrator. Objective criteria
to measure outcomes are antithetical to the theory and the methodology proposed. Therefore, the
subjective/objective assessment of each individual nurse is expected and accepted; there are no
valid or reliable criteria to measure concepts, nor are they warranted within the philosophical view
that guides the theory.
This is a tautological theory; the process of humanistic nursing is described by the goal of
humanistic nursing, and the complexity of the phenomenon it addresses stems from abstractness
and lack of boundaries between its concepts. It appears to focus on the nurse rather than on the
patient as becoming and actualizing in the course of nursing care. Barnum (1994, pp. 104–109)
asked if what we need is really a holistic nurse, in which case the proper subject matter of existen-
tial nursing theory would appropriately be the nurse rather than the patient. If that is one of the
focuses of nursing, and Donaldson would agree (1983), then Paterson and Zderad have offered a
theory that appropriately describes one of the nursing phenomena.
External Components of Theory
The theory may be incongruent with some prevailing values of practice that address outcome
over process, but it is congruent with values surrounding the research and knowledge development
in nursing that emerged in the mid-1980s in the United States. Humanistic theory proposes under-
standing human beings and their experiences as they exist, rather than how they ought to be or
rather than changing them. The goals of humanistic nursing—of understanding, supporting, and
maintaining—may be in direct conflict with other professional values and goals, such as interven-
tion goals for changes in pain responses or for alleviation of suffering.
As illustrated by Barnum (1998, pp. 209–217), it is a common existential position that suffer-
ing brings about a state of heightened self-awareness, thereby creating an openness to authentic
experience that the patient might not otherwise experience and express. Suffering creates a state in
which the person is brought face to face with his own being. Most nurses, however, seek to
remove (alleviate) suffering. It might be difficult for a nurse who is adhering to this theory to jus-
tify nursing acts that remove a patient from the authentic experience of suffering. Neither Travel-
bee nor Paterson and Zderad would advocate the removal of suffering. Nursing to them is to help
the patients articulate their perceptions of the situation and the meaning of the suffering and to
grow through this suffering.
According to this theory, a nurse–patient encounter involves an open human dialogue that
incorporates a high degree of intimacy to enhance understanding of the subjective world of the
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CHAPTER 12 On Interactions 257
patient (Barnum, 1998, pp. 209–217). In how many such meetings can a nurse be involved in the
course of her working day, and is there potential for emotional drainage leading to burnout? Do all
patients seek and approve of such genuine encounters? Paterson and Zderad would argue that the
higher levels of experience gleaned from each encounter indicate rejuvenation rather than
burnout.
The theory is congruent with that segment of society that espouses subjectivity and being, but
patients may want to experience and evolve their being in genuine encounters within their own
circle rather than with the nursing staff. It is also responsive to those who support the use of poetry
and reflection in providing care (Wagner, 2000).
When, in 1960, Paterson and Zderad were developing the seeds of their theory, they may or
may not have anticipated the supportive literature of the 1980s that advocated phenomenology as
the methodology most compatible with nursing. The 1980s witnessed an emerging worldview in
nursing, denouncing the empirical positivist view (see Chapters 4 and 8) and supporting a phe-
nomenological view (Menke, 1978; Munhall, 1982; Oiler, 1982). Paterson and Zderad advocated
respecting nursing experiences as sources of knowledge and, indeed, of wisdom, providing nurs-
ing with nonmechanistic and nonpositivistic strategies for theory development and research
(Paterson, 1978; Zderad, 1978). Nursing would do well to adopt their views.
Theory Testing
Patients’ perceptions of hospice day care were explored using a phenomenological methodol-
ogy derived from Paterson and Zderad’s humanistic nursing theory. The authors concluded that
patients expressed satisfaction with the service because the nursing care was based on humanistic
care. The staff responded to individuals’ opinions and feelings, and their needs for a sense of
well-being. They gave patients time, and responded to their individual concerns in a flexible way
(Hopkinson and Hallett, 2001).
The theory was also used as a framework to describe nurse practitioners’ interactions with
patients. Their lived experiences of interacting with patients were the focus of the study to uncover
the nature and the meaning of the interaction. Results demonstrated that there are eight essential
meanings that characterize the interactions: openness, connection, concern, respect, reciprocity,
competence, time, and professional identity. These meanings contributed to valuation of the rela-
tionships, which in turn was inferred to contribute to personal and professional growth (Kleiman,
2004).
Numerous other research findings have used grounded theory, modified phenomenological
approaches, and qualitative approaches to nursing research and are congruent with the assump-
tions of this theory. Researchers have used these concepts interchangeably to describe methodolo-
gies depicting parts of each (Stern, 1980; Wilson, 1977). Paterson and Zderad have used the
approach to articulate concepts of empathy (Zderad, 1968, 1969, 1970) and comfort (Paterson and
Zderad, 1976), but these reports appear to be for teaching and clinical insights, as a prelude to sys-
tematic research findings, and require more clarification (Tutton and Seers, 2003; Cutliffe and
Cassedy, 1999). These reports inspired others to explore the same or similar concepts (Kolcaba
and Kolcaba, 1991), and to use them as a means to develop a generation of nurses respectful of
changing demographics and globalization (Dariel, 2009). Kleiman (2009) used the theory, as well
as Heideggerian’s work, to explore the concepts of thinking and learning in the nursing experi-
ence. She offered humanistic learning experiences, an inquiry that is based on generative
processes of reflection and self-discovery (personal communication, May 26, 2010).
However, the theory appears to be incongruent with forensic psychiatry, which requires a
focus on the well-being of patients while simultaneously providing a framework to respond to the
possibility of putting the providers at risk of violent action (Jacob, Holmes, and Buus, 2008).
Humanistic theory does not allow for understanding and coping with these opposite responses.
The theory lends itself to utilization by nurses from different countries. Several international
studies were conducted based on Paterson and Zderad’s theory, with the purpose of describing the
nature of interactions and relationship between nurses and patients (Muniz, Santana, and Serqueira,
2000; Souza and Padilha, 2000) and to describe families’ responses to patients undergoing
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258 PART FOUR Reviewing and Evaluating: Pioneering Theories
chemotherapy (Azevado, Kantorski, and Ornellas, 2000). Others used the theory and tested its
effect as an intervention in critical care (Souza and Padilla, 2000) and in the care of patients who
had undergone surgeries (Medina and Backes, 2002).
Research to explore other theory propositions has potential after the concepts have been oper-
ationalized. For example, the concepts of authenticity, the “between,” more well-being, and all-at-
once are abstract and lack definition to render them researchable. The potential of the theory to
generate research is exemplified in the use of the self (the nurse) and different patterns of presence
in the patient’s “time–space spheres.”
JOYCE TRAVELBEE
Theory Description
Nursing to Travelbee is an interpersonal process between two human beings, one of whom
needs assistance because of an illness and the other who is able to give such assistance. The goal of
the assistance is to help a human being cope with an illness situation, learn from the experience,
find meaning in the experience, and grow from the experience. For a nurse to be able to achieve that
goal, she also has to find meaning in each encounter. Because illness is suffering and pain, the role
of the nurse is to deal with suffering and pain. If the nurse experienced personal suffering, she
would be far better able to understand the patient’s suffering. Nurses should not shy away from
becoming emotionally, interpersonally, and existentially involved with their patients because it is
through such involvement that empathy, sympathy, trust, and eventually, rapport, are established.
The central questions that Travelbee’s theory answers are: How do nurse–patient, human-to-
human relationships get established? For what purpose? Travelbee (personal communication,
1970) further asked: What is it that enables some individuals to cope with stress over a prolonged
period of time? In attempting to answer these questions, Travelbee theorized that suffering is a
common life experience that every person encounters at some point, that particularly occurs
around illness, and that is divided into phases.
Human relationships help people cope with suffering, and Travelbee conceptualized relation-
ships as progressing in stages, beginning with the phase of original encounter and evolving to the
phase of rapport. A person’s attitude toward suffering ultimately determines how effectively he
copes with illness. The nurse’s role is focused on helping patients find different meanings for suf-
fering, meanings that are of particular importance to them.
Travelbee provides us with an exhaustive conceptualization of sympathy, rapport, and suffer-
ing as fine examples of a factor-isolating theory. Suffering is defined as:
. . . a feeling of displeasure that ranges from simple transitory mental, physical, or spiritual
discomfort to extreme anguish and to those phases beyond anguish; namely, the malignant
phase of despair, the feeling of “not caring,” and the terminal phase of apathetic, indifference.
(Travelbee, 1966, p. 70)
It is an experience that is variable in its intensity, duration, and depth. Beyond the beginning
feelings of suffering, and when suffering becomes extremely intense physically, mentally, and
spiritually, suffering progresses to the malignant phase, in which a person experiences anger, help-
lessness, and bitterness. If suffering persists, a person ceases to complain or express feelings
related to anger and helplessness and instead displays apathetic indifference.
Although reactions to suffering are individualistic, there are some common responses. These
are “nonacceptance, blaming self or others, bafflement, anger, self-pity, depression, anguish” dur-
ing a “why me?” stage (Travelbee, 1966, p. 88). Or, human beings may respond to suffering
through no protest or even with an affirmative reaction, thereby accepting the suffering. Accept-
ance may occur because of personal philosophy, perception of the nature of humanity, or religious
convictions. Pain and suffering are related. “To suffer is to be immersed in a black ocean of pain”
(Travelbee, 1966, p. 89).
To deal with pain and suffering, a nurse has to establish nurse–patient interactions by getting
to know the patient, by becoming involved, by ascertaining needs, and by fulfilling the purpose of
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CHAPTER 12 On Interactions 259
nursing, which is to alleviate suffering and to help people find meaning in a situation. Communi-
cation is the key tool for the nurse. Nurses use various clinical therapeutics to keep channels of
communication open, such as validating perceptions, reflecting by self or with patient, and using
open-ended comments to solicit more information. Nurses can deliberately prevent communica-
tion breakdown by perceiving patients as human beings, recognizing levels of meaning when
communicating, listening with reflection, and avoiding clichés, automatic responses, and undue
interruptions (Travelbee, 1966, pp. 91–117).
Communication is the vehicle through which nurse–patient relationships are established.
Such a relationship is defined as “an experience or series of experiences between a nurse and a
patient . . . [or] a family member . . . in need of the service of the nurse.” The relationship has two
characteristics: it is a “mutually significant meaningful experience” and, through it, the nursing
needs of the individual (or family member) are met (Travelbee, 1966, p. 125). Nurses and patients
go through several stages to achieve the goal of established nurse–patient relationships. Each
stage has certain tasks, and a healthy development of the relationship is accomplished by master-
ing each task. The stages are:
1. Phase of the original encounter: Emotional knowledge colors impressions and percep-
tions of both nurse and patient during initial encounters. The task is “to break the bond
of categorization in order to perceive the human being in the patient” and vice versa
(Travelbee, 1966, p. 133).
2. Phase of emerging identities: Both nurse and patient begin to transcend their respective
roles and perceive uniqueness in each other. Tasks include separating oneself and one’s
experiences from others and avoiding “using oneself as a yardstick” by which to evaluate
others. Barriers to such tasks may be due to role envy, lack of interest in others, inability
to transcend the self, or refusal to initiate emotional investment.
3. Phase of empathy: This phase involves sharing another’s psychological state but stand-
ing apart and not sharing feelings. It is characterized “by the ability to predict the behav-
ior of another” (Travelbee, 1966, p. 143).
4. Phase of sympathy: Sharing, feeling, and experiencing what others are feeling and expe-
riencing is accomplished. This phase demonstrates emotional involvement and discredits
objectivity as dehumanizing. The task of the nurse is to translate sympathy into helpful
nursing actions (Travelbee, 1964).
5. Phase of rapport: All previous phases culminate into rapport, defined as all those experi-
ences, thoughts, feelings, and attitudes that both nurse and patient undergo and are able to
perceive, share, and communicate (Travelbee, 1963, 1966, pp. 133–162).
When relationships are established, the nurse can help patients to accept and find meaning in
their experiences or to accept their humanness through either circuitous or indirect methods
(avoiding direct confrontation by using parables or by the nurse opening herself and sharing simi-
lar personal experiences) or direct methods (asking pertinent questions or logically explaining the
situation). Establishment of rapport in nurse–patient relationships and finding meaning in suffer-
ing eventually lead to the development of hope in patients (Travelbee, 1971).
Travelbee based her theory on numerous assumptions that are interspersed throughout her book.
These assumptions are presented in Box 12-10. Travelbee’s assumptions are explicit and congruent
with selected concepts and theory propositions. The concepts are abstract and have face validity, but
the boundaries are not clear or operationally defined (What is hope and how can it be measured?)
(Box 12-11).Travelbee is consistent in her views of humanity, uniqueness, existential encounters, and
nursing. The theorist’s definitions of health, nursing, relationships, nursing problems, and nursing
therapeutics are conceptually clear, with the integrity of the assumptions preserved throughout the
definitions (Table 12-4). Rapport is a phase toward the nurse–patient relationship; the phases overlap.
Further operationalization will help determine which behaviors belong in which phase of the process
of establishing nurse–patient relationships. Travelbee often relied on dictionary definitions. Research
relating to different concepts was not cited. The theory lends itself to numerous propositions central to
the practice of nursing. Examples are offered in Box 12-12 on page 262.
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260 PART FOUR Reviewing and Evaluating: Pioneering Theories
BOX 12-10 ASSUMPTIONS—TRAVELBEE
• The nurse–patient relationship is the essence of the purpose of nursing (Travelbee, 1966, p. 13).
• Human beings are rational, social, and unique beings and are more different than alike (1966,
p. 29).
• All human beings undergo certain experiences and will search for meaning in them during the process
of living. These experiences could be considered as coherent wholes and could be understood (e.g., ill-
ness, anxiety, joy, harm). Therefore, likeness and similarities between human beings are in the nature of
their experiences (1966, p. 30).
• Labels tend to evoke stereotypical categories. Nurses should remember that patients are human beings
who differ from other human beings only in “requesting the assistance of other human beings believed
capable of helping them solve health problems” (1966, p. 34).
• Relationships are established when both partners perceive each other’s uniqueness. Then, such human
relationships transcend roles and are true, meaningful, and effective relationships based on perceptions
of uniqueness (1966, p. 36).
• Nurse–patient relationships are based on perceiving the patient as an illness or nursing as a task. Ill-
ness is only understood in the context of perceptions of the patient and the nurse.
• Illness, suffering, and pain experiences could be self-actualizing if individuals find meaning in them.
• Human beings are motivated to search for and understand the meaning of all life experiences.
• Illness and suffering are not only physical encounters for human beings, they are emotional and spiri-
tual encounters as well (1966, p. 69).
• Nurse–patient interaction, when purposeful, fulfills the goals of nursing (1966, p. 93).
• “Communication is a process that can enable the nurse to establish a nurse–patient relationship and
thereby fulfill the purpose of nursing—namely to assist individuals and families, to prevent and cope
with the experience of illness and suffering and, if necessary, to assist them to find meaning in these
experiences” (1966, p. 94).
• Nurses are expected to ascertain the meaning of exchanged messages.
BOX 12-11 CONCEPTS—TRAVELBEE
Perception
Pain
Suffering
Communication
Therapeutic self
Hope
Self-actualization
Transcend self
Therapeutic self
Nurse–patient relationship/human to
human relationship
Phase of original encounter
Phase of emerging identities
Phase of empathy
Phase of sympathy
Phase of rapport
Finding meaning in illness and suffering
Circuitous
Parable approach
Veiled
Personal experience
Direct
Questioning
Explanation
Transitory discomfort
Anguish
Malignant despair
Not caring
Apathetic indifference
Love
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CHAPTER 12 On Interactions 261
TABLE 12-4 DEFINITION OF DOMAIN CONCEPTS—TRAVELBEE
Nursing An interpersonal process and service vitally concerned with change and influence of others.
An interpersonal process whereby the professional nurse practitioner assists an individual
or family to prevent or cope with the experience of illness and suffering and, if necessary, to
assist the individual or family to find meaning in these experiences (Travelbee, 1966, pp. 5–6).
Goal of nursing To assist an individual or family to prevent or cope with the experience or illness and
suffering and, if necessary, to assist the individual or family to find meaning in these expe-
riences (1966, pp. 10–12, 20), with the ultimate goal being the presence of hope (1971).
Health World Health Organization (WHO) definition: “Health is a state of complete physical,
mental, and social well-being and not merely the absence of disease or infirmity. The
enjoyment of the highest attainable standard of health is one of the fundamental rights
of every human being without distinction of race, religion, political, economic, or social
condition” (1966, p. 7).
Environment Not defined.
Human being A unique thinking, biologic, and social organism, an irreplaceable individual who is unlike
any other person, who is influenced by heredity, environment, culture, and experiences.
Always in the process of becoming and capable of choosing (1966, pp. 26–34).
Understanding of a human being is through his perception of himself.
Nursing client A patient is a human being who requests assistance from another human being who he
believes is capable of helping and will help in solving his health problems.
Nursing problem Communication breakdown and distortion:
“1. Failure to perceive patient as a human being
2. Failure to recognize levels of meaning in communication
3. Failure to listen, using value statements without reflection
4. Clichés and automatic responses
5. Failure to interrupt” (1966, pp. 106–117)
Nursing process Process to ascertain needs, validate inferences, decide who should meet needs, plan a
course of action, and validate.
“Disciplined intellectual approach,” a logical method of approaching nursing problems,
using knowledge and understanding of concepts from all other sciences and nursing in
caring for patients (1966, p. 15).
Nurse–patient An experience between an individual in need of the services of a nurse, and a nurse for the
relations purpose of meeting the needs of the individual.
Nursing therapeutics Therapeutic use of self (nurse). Disciplined intellectual approach to patient problems.
Everything the nurse does for and with the patient is designed to help the individual or
family in coping with or bearing the stress of illness and suffering in the event the
individual or family encounters these experiences (1966, p. 8).
Help patients find meaning in their experiences (1966, p. 10).
Methods to find meaning are: 1) Circuitous (indirect) method, which includes (a) parable
method (tell analogous story), (b) veiled problem approach (use indefinite pronouns), or (c)
personal experience approach (shared experience); 2) Direct method, which includes ques-
tioning in jest and explaining (1966, pp. 16–19, 173–179).
“Communication techniques:
Use of open-ended comments or questions
Use of reflecting technique
Use of sharing perceptions
Deliberate use of clichés” (1966, pp. 106–110).
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262 PART FOUR Reviewing and Evaluating: Pioneering Theories
Theory Analysis
The Theorist
The late Joyce Travelbee was a faculty member at several schools of nursing. She worked as
an assistant professor in the Department of Nursing, Louisiana State University, New Orleans,
then as an instructor in psychiatric and mental health nursing in the Department of Nursing Edu-
cation at New York University, then as a professor at the University of Mississippi School of Nurs-
ing in Jackson, and finally at Hotel Dieu School of Nursing in New Orleans. She received a
diploma in nursing from Charity Hospital, New Orleans, a bachelor of science from Louisiana
State University, and graduated Yale with a master of science in nursing. She acknowledged Ida
Orlando’s influence on her work.
Paradigmatic Origins
Travelbee based her theoretical formulations on existentialist philosophy, from which she
drew many of the theory’s assumptions. A developmental approach is somewhat demonstrated in
her writing, as she used the concepts of stages of development of the nurse–patient relationship,
stages of suffering, tasks to be mastered, constant change and development, and the becoming
nature (Chin, 1974), after going through each of the stages. The continuous sense of becoming is
both a developmental and an existential concept.
The incongruence perhaps lies in the assumptions of developmental theory of an orderly pro-
gression, and the lack of orderliness inherent in the existentialist philosophy. Despite this short-
coming, Travelbee has effectively and usefully synthesized assumptions and concepts of both
developmental theory and existential philosophy by depicting the complexity of humanity through
BOX 12-12 PROPOSITIONS—TRAVELBEE
• To know and understand perceptions of time and life experiences increases the nurse’s abilities to meet
the needs of patients.
• “The nurse’s perception of patients is a major factor in determining the quality and quantity of nursing
care she will render each patient” (Travelbee, 1966, p. 34).
• If nurses perceive patients as illnesses, tasks, or sets of stereotype characteristics, their focus in care in
(institutional) rather than person-centered (1966, pp. 36–41).
• As patients become a “chore and a task, the nurse withdraws and directs her energy toward meeting
institutional needs” and patients experience anger, irritability, tension, restlessness, sadness, depres-
sion, hopelessness, apathy, and transient somatic symptoms (1966, pp. 38–40).
• An individual’s socioeconomic status affects the level of dehumanization a person is subjected to.
• “The quality of nursing care given any patient is determined by the nurses’ beliefs about illness, suffer-
ing, and death” (1966, p. 55).
• “The spiritual values of the nurse or her philosophical beliefs about illness and suffering will determine
the extent to which she will be able to help patients find meaning (or no meaning) in these situations”
(1966, p. 55).
• Nurses are able to empathize with patients who are similar to themselves (1966, p. 142).
• Experience of illness affects, to a varying degree, all those associated with the patient, and subse-
quently affects the patient’s perception of the experience (1966, p. 66).
• There is a direct relationship between caring and suffering; the more a person cares and is attached to
an object or a person, the more the person suffers when that object or person is lost (1966, p. 72).
• Responses to pain are influenced by cultural background of the person, philosophical premises, spiritu-
ality, level of anxiety, and responses of others to the person in pain (1966, p. 81).
• Identify the properties of hope, determinants of hope and hopelessness (1971).
• There is a direct relationship between the extent to which the individual’s need for cognitive clarity and
security are met and the individual’s anxiety level (1971, p. 190).
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CHAPTER 12 On Interactions 263
significant milestones (Sarlore, 1966). Her conception of empathy could be clearer if cast within
the framework of role theory, particularly role taking.
Travelbee herself credited Victor Frankel (1963) (with whom she corresponded and met) and
Rollo May (1953) with influencing her theories.
Internal Dimensions
Travelbee’s theory is a hierarchical one, developed around the concepts of nurse–patient
relationship, suffering, and pain to explore the relationships among them. It is both a concate-
nated theory, isolating and conceptualizing the central theory concepts, and a hierarchical one, as
it interprets the relationship among these variables. Travelbee used the field approach in develop-
ing her theory, as is demonstrated in conceptualizing rapport in terms of other phases leading to
and incorporating rapport. It is a descriptive and prescriptive microtheory that is also considered
a single-domain theory.
The theory addresses one of the major concepts in nursing—interaction—but is limited to
interaction surrounding illness. The theory focuses on those components of illness that are consid-
ered of concern to nursing; these are suffering and pain. It adds mainly to knowledge of the
process of providing nursing care and provides significant existence propositions (nurse–patient
interactions proceed through phases) and relational propositions (rapport increases patient’s
acceptance of illness).
Travelbee uses an operational method to develop highly abstract relationships. She incorpo-
rates the nurses’ perceptions and acceptance with components of the nursing problem areas and
nursing therapeutics. The nurse perceives, understands, and assigns meaning to behavior and is
therefore part of the theory. The nurse’s communication is one of the nursing problems, and the
self could be used as the intervention through empathy and sympathy.
An operational method of theory development allows choices between alternate theories and
actions. An example can be seen in the alternatives that Travelbee provides to dealing with suffer-
ing. She proposes using the direct method of confronting the patient with his suffering or the indi-
rect method of having the nurse sharing her own experiences to prompt mutuality in sharing.
Operational methods tend to be more acceptable to nurses because of their preferences for well-
identified choices.
The theory’s explanatory power is low (higher ratio of assumptions to explicitly stated proposi-
tions) and is limited to knowledge of disorder (suffering) and knowledge of process (relationships).
Travelbee used a deductive approach to develop her theory (Duffey and Muhlenkamp, 1974).
Although she explicitly stated the sources that influenced the theory deductively (existentialist
philosophy), the inductive approach is more assumed than explicit. It is assumed that she observed
nurse–patient relationships in acute and suffering incidents. Such observations are not an integral
part of her theory, and it is not clear whether she developed her theory based on extant or ought-
to-be practice. One can deduce that it was the former rather than the latter.
Theory Critique
The theory is teleological. The process of establishing relationships is achieved after several
stages in nurse–patient encounters, including rapport; however, rapport is considered the nurse–
patient interaction. It is both goal and process; it is both process and product. The theory is tauto-
logical and parsimonious; assumptions and relationships could be presented without the
numerous repetitions, and more attention needs to be given to the propositions. Finding meaning
is analogous to coping but leads to coping, and vice versa.
The complexity of the theory is demonstrated in the abstractness of the concepts, limited
operational definitions, and potential multiplicity of relationships. Therefore, its use in research,
practice, education, and administration appears to be limited.
Although many of the central concepts in Travelbee’s theory are derived from other theories
(empathy, sympathy), she does not appear to have developed her propositions using the findings
of other researchers. Some of Travelbee’s ideas are common practice in nursing. The nursing
process as we have come to teach it and use it involves several of the steps outlined by Travelbee.
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264 PART FOUR Reviewing and Evaluating: Pioneering Theories
Observations are carried out to validate the needs of patients, to validate inferences made, to make
decisions about personally taking action or not, and to then plan a course of action; then, the
action is evaluated. The patient is the final authority.
Doona (1979), in preparing a second edition of an earlier Travelbee book (1969), used Trav-
elbee’s intervention theory as a guideline for the field of psychiatric nursing. Beyond this publica-
tion, no published evidence was found that directly develops, implements, or refines Travelbee’s
ideas. The theory has the potential for use in practice within the limitations of its scope and its
microtheory nature, both of which refer only to individual patients who are ill and suffering, who
are conscious, who are willing to invest in the development of rapport, and who participate in
finding meaning in and making decisions about their care.
Cook (1989) demonstrated the utility of the theory in assessing suffering of nurses due to job
distress at the height of the nursing shortage that forced their hospital to adopt a new system of
patient care. The theory was used to define the nature and degree of suffering, the nature of each
phase in the development of meaningful interactions between members of a group of nurses who
met regularly to deal with their job stress. The rapport described by Travelbee was achieved prior
to planning interventions. The intervention plan based on Travelbee (1971) included alleviating
suffering, redefining the situation, and finding meaning in their experiences through disciplined
and intellectual approaches and the use of the self (Cook, 1989, p. 205). The process of rapport
development and the interventions helped the group members to feel less victimized and to gain
control over their professional lives. The result was improved self-esteem, better problem solving,
a more supportive environment, and rediscovery that a new system is providing them with greater
autonomy and more challenging roles.
While her theory is not used in its totality as a framework for research, curriculum, or prac-
tice, it is often cited in support of the nurse’s role in interpersonal relationships with patients to
understand their suffering (Tranvag and Kristoffersen, 2008), in exploring the definitions and
meanings in the concept of “hope” (O’Baugh, Wilkes, Luke, and George, 2008; Tutton, Seers, and
Langstaff, 2009), and in the therapeutic use of self (Wadensten, Engholm, Fahlström, and Häg-
glund, 2009). While interpersonal processes in nurse–patient relations and patient-centered care
continue to gain momentum, some authors continue to attribute these concepts to Travelbee’s
writings (Weaver, Morse, and Mitcham, 2008; Wiklund, 2008). Similarly, as more questions arise
about the role of spirituality in health and illness, Travelbee’s concepts of meaning and purpose in
life lend credibility and support to the primacy of establishing a strong rapport with patients
(Timmins and Kelly, 2008).
Her existentially based ideas about the interpersonal relationship have also been used as pro-
viding a humane perspective in developing models for electronic patient records (von Krogh and
Naden, 2008) or in strategies for treating adults with depression (Parrish, Peden, and Staten,
2008). It is notable that her ideas about hope, suffering, relationship, and interpersonal rapport
continue to inform the writings of nurse researchers in different parts of the world; for example,
Norway (von Krogh and Naden, 2008), Australia (O’Baugh, Wilkes, Luke, and George, 2008),
Ireland (Timmins and Kelly, 2008), Sweden (Wiklund, 2008; Wadensten, Engholm, Fahlström,
and Hägglund, 2009; Tutton, Seers, and Langstaff, 2009), and other countries.
No other published material uses Travelbee’s theory in education or administration, despite
favorable review of her 1966 book (Sloane, 1966; Wolff, 1966). Travelbee indicated that the Uni-
versity of Mississippi School of Nursing in Jackson was beginning to modify its curriculum to use
her theory (personal communication, 1970). However, the limited scope of the theory restricts its
utility for all aspects of nursing.
External Components of Theory
The focus of the theory on the uniqueness and dignity of the human being, on humanity, on
autonomy, and on acceptance of others’ values makes its assumptions congruent with Western
values. The more recent emphasis on the role of hope—the ultimate goal of finding meaning in
suffering—in healing and recovery tends to give more theoretical credence to Travelbee’s propo-
sitions pertaining to the meaning of an illness and attitudes toward suffering. However, illness is
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CHAPTER 12 On Interactions 265
viewed by society as an aberration, an abnormality, or a condition to be avoided and eliminated.
This value is antithetical to Travelbee’s basic assumption that illness is a part of life, and finding
meaning in illness and suffering is a growing experience. Therefore, professional values could
clash with the theory’s values (used here as an assumption). Many patients could consider the
assumption of shared nurse–patient relationships to find meaning problematic and may even go so
far as questioning the cost-effectiveness of such emphasis on relationships. The lack of a biologic
view of the patient and the limited positivistic orientation of the theory undoubtedly limit the util-
ity and the acceptance of the theory by nurses.
Relationships are significant in the helping fields; they are an integral part of assessment for
care, and they are focal in delivering care. Travelbee articulated for nursing how such relationships
are formed and for what purpose. Hers is a theory to describe one of the central domain concepts in
nursing.
Theory Testing
Central relationships in Travelbee’s theory—effects of nurse–patient relationship on suffer-
ing and coping—have not been researched. However, the concept of empathy has been the center
of numerous research studies. Various tools have been developed to measure degrees of empathy
(Barrett-Leonard, 1962; Cartwright and Lerner, 1963; Truax and Carkhuff, 1967). Most of the
studies of the 1960s and 1970s concluded that existing tools lacked construct and predictive valid-
ity and that their reliability was low (Chinsky and Rappaport, 1970; Kurtz and Grummon, 1972).
Other studies using Travelbee’s theory explore differences between perceptions of high and low
empathizers in effective communication (Stetler, 1977) and properties of interaction surrounding
pain (McBride, 1967). Results have been inconclusive. Freihofer and Felton (1976) explored the
nature of nursing actions perceived to offer support, comfort, and ease the suffering of a terminally
ill patient and of significant others of terminally ill patients. More descriptive studies of this type will
lend data to explore the construct validity of nurses’ actions and options for suffering patients.
The theory was cited widely by authors and researchers in the United States and Japan in the
late 1990s and at the turn of the century (Moses, 1994; Hisama, 2001) as a framework to describe
suffering (Morse, 2001, 2005), and spirituality and spiritual care (Hawley, 1998; Narayanasamy,
1999; Tuck, Wallace, and Pullen, 2001). It has been used in some research studies (Begat and Sev-
erinsson, 2001; Landmark, Strandmark, and Wahl, 2001; McCann and Baker, 2001) as a frame-
work for intervention to increase hope (Rustoen and Hanestad, 1998a, 1998b), as a framework for
sharing of the self for the elderly (Nowak and Wandel, 1998), and for supporting the process of
aging (Wadenstenand and Carlsson, 2003). Studies are mostly single episodes and do not provide
systematically for theory refinement, extension, or further development. Travelbee’s theory
remains significant in providing a framework to describe the human encounter between nurses
and patients who are suffering from life-threatening illness or a long, debilitating disease course.
It requires extended encounters to establish relationships as envisioned by Travelbee.
ERNESTINE WIEDENBACH
Theory Description
Ernestine Wiedenbach developed a concept of nursing that was congruent with the prevailing
ideas at Yale in the late 1950s and early 1960s, and that shifted nursing focus from the medical
model to a patient model. She introduced the notion of caring into nursing. In her early work
(1963), she attempted to develop a concept that encompassed all nursing; this evolved into a pre-
scriptive theory. The theory addresses the central question: How do nurses help patients meet their
needs? Help, to Wiedenbach, is an integral part of nursing, and it is comprised of all actions that
enable individuals to overcome whatever hampers their ability to function. Help came in different
ways, one of which is in the form of intentional caring, as differentiated from help without caring.
Needs and functions that dominated nursing thought at the time continued to be a dominant
theme. However, Wiedenbach added to it concern for patients, in focusing on ways to allow them
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266 PART FOUR Reviewing and Evaluating: Pioneering Theories
to express their fears. Needs can be ascertained only if the nurse validates her perceptions, feel-
ings, and thoughts with those of the patient. Therefore, nurses’ actions should abide by the follow-
ing parameters: actions should be mutually understood and agreed on with full knowledge of
implications, and they should be either patient-directed or nurse-directed or both. When they are
nurse-directed, they must be deliberate and based on patient needs. To Wiedenbach, nurses
develop a helping prescription with the reality of the situation (physical, physiological, psycho-
logical, emotional, and spiritual) by exploring nurses’ philosophies of nursing (central purpose
and assessment of the situation). Throughout a continuous process of observation and validation,
nurses’ observations are focused on determining inconsistencies (deviations from normal) and
perseverance in ensuring that the patients realize their needs. Nurses make plans for action to
“minister help needed.” The plan has to be validated by patients before implementation. Nurses
use themselves, patients, or appropriate others as therapeutic agents.
Wiedenbach (1970a) identified several assumptions that guided her theory, and there are
other implicit assumptions (Box 12-13). There are some inconsistencies in the assumptions, such
as uniqueness and orderliness, self-directed and dependent, but on the whole, Wiedenbach made a
deliberate effort to identify the philosophical premises on which she developed her theory. A stu-
dent of her theory may be confused by the numerous premises appearing at different points
throughout her work. Inconsistencies also exist in using principles, philosophy, and assumptions
interchangeably, when, at times, any one of these also were used to mean propositions.
Assumptions and concepts are congruent (Box 12-14). Concepts in the theory are mostly
derived (needs, interaction, perception), and because Orlando, Wiedenbach, Dickoff, and James all
worked together closely in developing their ideas, despite some of their perceptions of differences
BOX 12-13 ASSUMPTIONS—WIEDENBACH
Explicit Assumptions
• “Each human being is endowed with a unique potential to develop within himself the resources that
enable him to maintain and sustain himself” (Wiedenbach, 1970b, p. 1058).
• “The human being basically strives toward self-direction and relative independence and desires not
only to make best use of his capabilities and potentialities, but desires to fulfill his responsibilities as
well” (1970b, p. 1058).
• “The human being needs stimulation in order to make best use of his capabilities and realize his self-
worth” (1970b, p. 1058).
• “Whatever the individual does represents his best judgment at the moment of doing it” (1970b, p. 1058).
• “The helping art of clinical nursing is a deliberate blending of thoughts, feelings, and overt actions”
(1964, p. 11).
• “There are three more basic premises in nursing: ‘reverence for the gift of life,’ ‘respect for dignity,
worth, autonomy, and individuality of each human being,’ and ‘resolution to act dynamically in relation
to one’s beliefs’ (1964, p. 16).
• Characteristics of professionalism: clarity of purpose, mastery of skills and knowledge, sustaining pur-
poseful working relationships with others, interest in advancing knowledge and dedication to furthering
the goal of mankind (Dickoff, James, and Wiedenbach, 1968).
Implicit Assumptions
• Patients are dependent beings normally willing to utilize help (Wiedenbach, 1970b, p. 1060).
• Patients can use their sensitivities to frustrate health caregivers and “thwart their efforts to obtain the
results they desire” (1970b, p. 1060).
• Individuals like to live an orderly life, and life is an orderly process.
• Factors such as physical, physiological, psychological, and spiritual influence the nursing situation.
• Individuals want and have the resources to be healthy, comfortable, and capable (1964).
• Professional nursing respects dignity, worth, autonomy, and individuality of each human being.
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CHAPTER 12 On Interactions 267
(Wiedenbach, 1970b), it is not easy to discern which concepts are primitive and which are derived.
All these theories are extensions of each other; although Wiedenbach developed the concept of
validation, validation is an integral part of Orlando’s nursing process discipline. For Wiedenbach,
one of nursing’s goals is to promote comfort; for Orlando, a goal is to alleviate distress. Wieden-
bach focused on perceptions of people in need of help, and Orlando focused on perceptions as a
significant concept in interaction. Wiedenbach provided interpretation of the invisible act of
“caring” and proposed its significance in successful nursing care. The helping art of nursing
depends, in theory, on the importance the nurse attaches to her thoughts and feelings and how
deliberately she uses them (Wiedenbach, 1963). Barnum (1998) equated the concept of concern
described by Wiedenbach with what later was called caring.
The major concepts in this theory tend to be concrete and nonvariable (comfort, valida-
tion, need for help), and they are not operationally defined, perhaps by design, because
whether a patient is comfortable or not depends on the patient’s perception and the meaning he
or she attributes to the event and situation (Table 12-5). The definitions tend to be contextual,
and this has the advantage of allowing variable definitions (comfort is in the eye of the
beholder), but it also decreases utility in practice and research. Health and environment are not
defined; a nursing client is defined in terms of hospital care and is contingent on awareness of
needs. Relationships between concepts in Wiedenbach’s early and later writing are not always
clear (i.e., prescription, validation). The explanatory power of the theory is hampered by a lack
of clarity.
The theory lacks propositions and linkages between concepts, but one can derive propositions
related to the process of assessment and intervention. The principles of help are amenable to the
development of existence propositions and, subsequently, relational propositions (Box 12-15, p. 269).
Theory Analysis
The Theorist
The late Ernestine Wiedenbach held a bachelor of arts degree from Wellesley College,
Wellesley, Massachusetts, and a diploma in nursing from Johns Hopkins School of Nursing, Balti-
more. She received her master’s degree in public health nursing from Teachers College, Columbia
University. She practiced as a nurse midwife (VandeVusse, 1997). At the time of her theory’s
development, she was an associate professor of maternity nursing at the School of Nursing, Yale
University (she began working there around 1952) (Bennet and Foster, 1980). She worked closely
with two philosophers, Patricia James and James Dickoff, who were teaching a course in philoso-
phy for nurses. She also worked closely with Ida Orlando and was an associate professor emeritus
at Yale. Wiedenbach died in 1998 (Burst, 1998), but her legacy in midwifery endures (Nickel,
Gesse, and MacLaren, 1992).
BOX 12-14 CONCEPTS—WIEDENBACH
Need for help
Help
Inconsistency/consistency
Purposeful perseverance
Self-extension
Preconception
Interpretation
Actions
Rational
Reactionary
Deliberate
Ministration
Realities
Central purpose
Prescription
Skills
Procedural
Communication
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268 PART FOUR Reviewing and Evaluating: Pioneering Theories
TABLE 12-5 DEFINITION OF DOMAIN CONCEPTS—WIEDENBACH
Nursing A helping art with knowledge and theories. A goal-directed and deliberate blending
of thoughts, feelings, perceptions, and actions to understand the patient and his
condition, situation, and needs, to enhance his capability, improve his care, prevent
recurrence of problem, and deal with anxiety, disability, or distress (Wiedenbach,
1964).
Goal of nursing “To facilitate the efforts of the individual to overcome the obstacles which currently
interfere (or maybe later interfere [1970b, p. 1058]) with his ability to respond capably to
demands made of him by his condition, environment, situation, and time” (1963, p. 55).
“To meet the need the individual is experiencing as a need for help” (1963, p. 55).
Health Not defined.
Environment Conglomerate of objects, policies, setting, atmosphere, time, human beings, happenings
past, current, or anticipated that are dynamic, unpredictable, exhilarating, baffling, and
disruptive (1970, p. 1061).
Human being Possesses self-direction and relative independence, makes best use of capabilities, fulfills
responsibilities, has resources to maintain self; in other words, is a functioning being
(1964).
Nursing client A person who is under the care of some member of health care personnel, who is in a
vulnerable position, with a perceived need for help.
Nursing problem Inability or impaired ability of an individual to cope with situational demands due to
interferences (1963, p. 56). Discomfort.
Nursing process Deliberative, to identify need for help and interferences with ability to cope. Through
observation, understanding, and clarification of the meaning of cues, determination of
causes of discomfort (through inspection, palpation, temperature, etc.) and determination
of whether or not patient is able to meet his own needs. Ministration of help needed and,
the last step in the process, validation that help given was indeed help needed (1963,
pp. 56–57).
Nurse–patient The deliberate use of nurses’ perceptions, thoughts, feelings, and actions.
relations
Nursing Deliberate action that is either nurse directed, patient directed, or mutually understood
therapeutics and agreed on (1970b, p. 1059). (These are the nurse’s options, and the choice is hers.)
It is designed to deal with a person who is in need of help by “any measure or action
required and desired by the individual that has the potential for restoring or extending his
ability to cope with the demands implicit in his situation” (1963, p. 56).
Help, which is any measure or action that enables the individual to overcome whatever
interferes with his ability to function capably in relation to his situation (1963, p. 56).
Giving advice, information, referral, ministering or applying a comfort measure. Deliberate
actions are mutually understood and agreed on, patient directed, and nurse directed.
Communication is an important tool.
Helping is based on three principles: inconsistency or consistency, purposeful perseverance
and self-extension (1970b).
Focus of nursing Goal-directed activities focused on identifying “the patient’s perception of his condition”
and his need for help (1963, p. 55).
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CHAPTER 12 On Interactions 269
Paradigmatic Origins
Basically, Wiedenbach’s view of a human being and her view of a nurse are functional. She
views patients in terms of their capabilities to function and carry out their responsibilities.
Wiedenbach was influenced by Ida Orlando, James Dickoff, and Patricia James (and perhaps the
reverse is also true). Such influence is seen in her explication of nurses’ actions and reactions and
the focus on interpretation and validation of perceptions, feelings, thoughts, and actions. There-
fore, it would be useful for the reader to also review the discussion of paradigmatic origins found
under Orlando.
Some of Wiedenbach’s assumptions and concepts regarding the motivation of human beings
and nurses’ impulsive responses appear at times to reflect conditions or stimulus–response types
of actions and reactions (Wiedenbach, 1968). Careful analysis of the theory may identify develop-
mental themes or parallel themes with a psychoanalytical orientation, such as internal needs, frus-
trations, and motivations. However, the meaning of the situation or the event as perceived and
expressed by an individual demonstrates a departure from psychoanalytical concepts to a phe-
nomenological approach. These are speculations on paradigmatic origins. One origin is clear and
documented; this theory evolved out of 40 years of clinical and teaching experiences (Wieden-
bach, 1964, p. vii, 1968, 1969), and later developments supported the process nature of the theory
(Wiedenbach and Falls, 1978).
Internal Dimensions
Wiedenbach’s theory was developed around the need for help and validation of such need
through patient perceptions and is therefore a concatenated theory that lends itself first and fore-
most to existence propositions. It is an inductive theory evolving from observations of clinical
practice and patients’ needs for help after many years of practice in the maternal and child nursing
subspecialty. It is a microtheory, explicating a component of the interaction process focused on
validating perceptions, thoughts, and feelings before a deliberate action is planned. It is a theory
with narrow scope—the deliberative nurse–patient interactive process used in a clinical situation
to identify needs and verify actions. It addresses one component of one of the central concepts in
nursing: nurse–patient interaction. It deals with knowledge of process and with describing a com-
ponent of the process inherent in assessing and providing care.
Wiedenbach used a field approach in identifying dimensions of interaction and validation,
and used a combination of operational and problem approaches to theory development. She
BOX 12-15 PROPOSITIONS—WIEDENBACH*
• When nurses observe inconsistencies in patients’ actions, they use their perseverance in identifying the
need for help and in offering help.
• Exploration and validation of nurses’ and patients’ perceptions, thoughts, and feelings increase the
effectiveness of help offered to patients in need of help.
• Deliberate nursing action is an overt act consisting of several components: the need for help, validation,
and ministration of help.
• Congruent nurse and patient perceptions of the need for help and evaluation of help enhance effective
care and decrease discomfort.
• Mutually understood and agreed-on nursing actions will have a positive effect on the patient.
• Help given to individuals in need of help is categorized as: identification of variance from normal (princi-
ple of inconsistency/consistency); identification of an individual’s need for help (principle of purposeful
perseverance); utilizing self or others for help, advice, information, referral, or comfort (principle of self-
extension).
*Propositions delineated under Orlando could also be propositions derived from this theory.
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270 PART FOUR Reviewing and Evaluating: Pioneering Theories
focused her conceptualization around problems of discomfort and the need for help, and around
the function of the nurse in observing, assessing, and exploring and validating feelings, thoughts,
and fears. She used persuasion and personal beliefs to drive these concepts home to nurses.
Perhaps because of the concreteness of the theory, the circle of contagiousness of ideas was
wide and reached diverse geographical locations and settings. Although nurses may not articulate
the concepts and linkages emanating from Wiedenbach, the central ideas of her theory are used
widely. Hers is a good example of theory with tautology, lack of parsimoniousness in presenting
ideas (presented in philosophical dialogue), and teleology (identifying the need for help is both a
process and an outcome). The ratio of assumptions to existing propositions decreases its current
power of explanation.
Theory Critique
The patient’s perspective has become an integral part of the lexicon of nursing since the
1980s. Whether these concepts infiltrated nursing thought as a result of Orlando and Wiedenbach
can only be determined through extensive analysis of nursing literature and through comparison
of writings in the decades prior to 1960 and the decades following the publications of Orlando,
Wiedenbach, Travelbee, Paterson, Zderad, and other interactionist theorists. An analysis of net-
working of ideas and people and the development of conceptual genealogical trees may enable us
to ascertain the influence of the different theorists on the development of nursing knowledge.
It is apparent that the circle of contagiousness for research was limited to research in or sur-
rounding Yale, but the circle of contagiousness for practice was much wider and engulfed the United
States and foreign countries. Concepts such as patient-centered care, perceptions, validation, and
exploration of thoughts, feelings, and actions are used in many practice settings, and concepts such
as comfort are credited to Wiedenbach and Orlando (Griffiths and Andrews, 2007; Williams, 2008).
Some considered Wiedenbach instrumental in focusing on comfort and give her credit for the subse-
quent development of Kolcaba’s theory of comfort (Kolcaba, 2003). The theory provides guidelines
for implementing the nursing process and has stimulated many attempts at conceptualizing the inter-
action process, but it is limited in its power for prescription (Rickleman, 1971). The scope of the the-
ory remains limited to individuals who are conscious in a hospital setting, who are basically
motivated to participate in their own care, who are inconsistent (in a state of disharmony with their
surroundings, situation, or expectations) (Wiedenbach, 1965), and who are able to perceive their
need for help. Patients who are consistent (do not deviate from normalcy), who are noncompliant,
and who do not perceive a need for help are not nursing clients. It has inspired nurse midwives by
providing a framework that explicates a midwifery perspective (Burst, 2000; Sharp, 1998; Vande-
Vusse, 1997). It was also used as a framework for studying nursing care of cancer patients (Andersen
and Adamsen, 2001). However, its use in practice continues to be limited.
Administration literature in nursing may be considered an extension of Wiedenbach’s theory;
however, deliberate action, perceptual clarification, and validation could be claimed by any effec-
tive and efficient organizational theory.
External Components of Theory
The external components of Wiedenbach’s theory are the same as those for Orlando’s theory.
Theory Testing
As with Orlando’s theory and perhaps in combination with it, numerous research studies
were launched to test the what and how of a deliberative process and validation of interaction in
assessing and intervening with patients in need of help. A review of the research and publications
based on Wiedenbach’s theory revealed two findings: first, both Orlando and Wiedenbach are
cited in most research related to concepts of either theory; and second, Wiedenbach’s ideas still
appear in the literature as researchers continue to test propositions emanating from her theory.
One type of research using Wiedenbach’s theory focused more on the prescriptive proposi-
tions of effect of deliberate nursing process (validation) on several patient outcomes. Such
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CHAPTER 12 On Interactions 271
research was hospital-oriented (preoperative preparation, admission procedures, obstetric prepa-
ration, and patients in need of pain relief). (See discussion under Orlando.) Experimental groups
usually received care that included an identification of patient’s needs focused on verbal and non-
verbal behavior (Shields, 1978), nurses’ perceptions compared and contrasted with patients’ per-
ceptions, and actions to provide help to restore the patient’s functional ability based on a
continuous process of validation.
Conversely, nonexperimental care given to the control group was personal, automatic, tech-
nique oriented, organizationally focused, and more authoritarian or friendly, but not deliberate and
goal-oriented. Patient outcomes generally were significantly better in the first than in the second
group. Outcomes considered included physiological measures, such as emesis during postopera-
tive or postdelivery recovery, and degree of change in heart and respiration rates. Other outcomes
were psychological, and included subjective patient reports of alleviation of distress (Elms and
Leonard, 1966; Leonard, Skipper, and Woolridge, 1967; Wolfer and Visintainer, 1975).
Other research was related to the exploration of an implicit assumption that the client is truth-
ful in validating the nurse’s perception of his condition. Eisler, Wolfer, and Diers (1972) found
that a slight correlation existed between social approval needs of patients (but not the patients’
inner experience) and their reports of physical well-being, thereby casting doubt on previously
unchallenged assumptions that validation indeed gets at patients’ true perceptions of the situation.
Numerous other research reports could be related to the theory, providing further validation
or invalidation of its concepts. For example, Larson (1977) found that a client’s socioeconomic
status and social desirability of the diagnosis affected the nurse’s perceptions of the patient’s char-
acteristics. The “should” advice in Wiedenbach’s theory is therefore expanded to include the
“realities” of the nurse–patient situation. There is no indication that Wiedenbach made any sub-
stantial changes in her conceptualization based on the results of these research studies. A set of
propositions for using change as an outcome variable is presented in Box 12-15 on page 269.
CONCLUSION
The theorists presented in this chapter transformed how nurses thought about their practice and
changed the nature of research questions investigated in the discipline of nursing. They provided
the rationale to study processes of care and relationships between nurses and patients, as well as
the organization and structure of interpersonal relationships. They provided the language, con-
cepts, and outcomes that characterize care, as well as define the nature of the discipline. It is
through the theories articulated by the interaction theorists that such concepts as process, valida-
tion, interpretation, lived experiences, interaction, interpersonal relations, trust building, forming
bonds, and advocacy, among many others, became an integral part of our lexicon. These ideas
were pioneering when these theorists took the risk to introduce them, and now we have them as an
integral part of our discipline.
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272 PART FOUR Reviewing and Evaluating: Pioneering Theories
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4. Compare and contrast how communica-
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relations are conceptualized and defined
in the theories discussed in this chapter.
5. The paradigmatic roots for Paterson and
Zderad’s theory appear to be substan-
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7. Select one proposition in each theory
that you consider critical for testing to
advance and build theory.
REFLECTIVE QUESTIONS
1. Interactions between patients and
nurses are considered central to the
nursing encounter and act. Discuss the
place of “interactions” in contemporary
nursing.
2. Which of the theories presented in this
chapter reflects current values and goals
in the practice of nursing?
3. In what ways could utilizing the theories
of interaction contribute to quality care?
Select one of the theories discussed in
this chapter and identify three research
questions derived from the theoretical
propositions in the theory. Briefly
describe how you may go about devel-
oping a research study to answer the
questions.
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CHAPTER 12 On Interactions 273
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C H A P T E R 13
On Outcomes
In this chapter, five theorists’ ideas are presented. All five theorists are focused primarily on
the outcomes of nursing care, facilitating and promoting harmony with the environment, bal-
ancing and stabilizing internal and external systems, conserving energy, and mobilizing
resources to meet the challenges of stressors and/or adaptation. Although grouped together
because of the ultimate goals for nursing for each of the theorists, they differ in their paradig-
matic origins and the central questions they ask. Among them, Martha Rogers provides a
unique focus on the conceptualization of the irreducible nature of the connection of person and
environment.
When Martha Rogers asked the central question of her theory, What is the focus of nurs-
ing? the answer was readily human being–environmental fields, “people and their world”
(Rogers, 1992). Human beings and the environment are both unitary, irreducible, pandimen-
sional, negentropic energy fields that are identifiable by pattern. Neither unitary human being
nor unitary environment can be discussed, considered, or understood in isolation from the other.
They are interrelated in an irreducible way. This innovative and visionary approach on human
being–environment, unique to nursing and different from other theorists’ views of human
being–environment, made it easy to consider Rogers as a significant force in our conceptual
understanding not only of the centrality of environment in nursing thought and actions, but also
of the inseparability of human being–environment relationships and the significance of har-
mony between them as a consequence of nursing care. Rogers’ theory is described, analyzed,
and critiqued in this chapter. Rogers’ science of unitary human beings also provides many
insights about “environment” from a nursing perspective. I also encourage you to look at Flo-
rence Nightingale’s work for a conceptualization of environment, as well as at other theorists’
conceptualizations of environment. As of this writing, I believe that Rogers’ theory is the only
one that integrated human being–environment interactions into a coherent whole and proposed
it as a unit of analysis. Hers is a prototype theory.
The works of the four other theorists—Levine, Johnson, Neuman, and Roy—emerge as sig-
nificant developments in the conceptualization of the nursing client and the goals and outcomes of
nursing care. Central questions for these theorists are: Who is the nursing client? In what ways
does a nursing client benefit from nursing care? What is the outcome of care? Three theorists,
Dorothy Johnson, Sister Callista Roy (a mentee and student of Johnson’s), and Betty Neuman
focused on defining client systems. Johnson asserted in all her metatheory, as well as in theory
publications, that what differentiates nursing from medicine and other health sciences is its per-
spective of a nursing client as a behavioral system. To Roy, a client is an adaptive being with two
subsystems for adapting—the regulator and cognator mechanisms—and four adaptive modes.
According to Neuman, the human being—as represented by central structure, lines of defense,
and resistance—becomes a client when threatened or attacked by environmental stressors. The
nursing activities and actions that are deliberately destined for caring for patients, potential
patients, or people at risk (or families and communities) are the rationale for grouping these theo-
rists under nursing outcomes. The theorists have described and discussed nursing therapeutics
with various degrees of emphasis that lead to different outcomes. Many images emerge when the
concept “nursing therapeutics” is considered. One is Levine’s proposed actions for conservation
of energy (outcome theorist); a second is Orem’s proposed strategies to enhance self-care (need
theorist), and others may be delineated from the writings of different theorists (see Chapter 9,
Tables 9-6, 9-12, and 9-18).
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280 PART FOUR Reviewing and Evaluating: Pioneering Theories
DOROTHY JOHNSON
Theory Description
The early questions Dorothy Johnson addressed pertained to the knowledge base nurses needed
for nursing care (Johnson, 1959a). To Johnson, nursing care did not depend on medical care, nor was
its goal recovery from illness or adoption of more desirable health practices. She labeled nursing’s
responsibilities that are related to medical care and better health “delegated medical care” and “health
care,” respectively (Johnson, 1961). Although nurses also performed functions related to “delegated
medical care,” the essence of nursing, its central mission, should lie in “nursing care,” which Johnson
considered ill-defined, with no delineated theoretical framework. When the latter is defined, when the
specific goals are articulated, then we will be able to speak of a science of nursing (Johnson, 1959b).
Johnson’s conceptualization of nursing, then, is based on the premise that nursing makes a
unique, independent contribution to health care that is distinct from its delegated dependent contri-
butions (Johnson, 1964). All contributions delegated to nurses, and unique to patient care and cure,
are significant, but, as professionals, nurses are obligated to articulate and communicate to the public
their primary mission and their nursing goals, as well as their secondary mission, which is delegated
from medicine. The public is aware of the latter but less aware of the former. A client, to Johnson,
behaves in an integrated, systematic, patterned, ordered, and predictable way. Behavior is goal ori-
ented, and goals are an organizing framework for all behavior. Behavior is the sum total of biologic,
social, cultural, and psychological behaviors. Nurses deal with the integrated responses of clients.
Johnson (1980) conceptualized a nursing client as a behavioral system, with behaviors of
interest to nursing organized into seven subsystems of behavior (Box 13-1). Each one of the sub-
systems is analogous to the anatomy of a biologic subsystem. It has similar components, a struc-
ture, and a function. Each of these has subcomponents that distinguish the subsystem of behavior
and make it identifiable (Johnson, 1990). The structural components are a drive or a goal, a set, a
choice, and an action or behavior.
• First is the drive or the goal of the subsystem, which is also the reason or motivation for
behaviors in the subsystem. Goals or drives are universal; however, the strength of the goal
may differ and, in fact, may fluctuate in the same person from strong to weak. Goals have
different meanings in different people or at different times in the same person, and goals are
not observable. Another parameter on which goals may differ is their objects. For example,
when observing the eating behavior of a Middle Eastern immigrant, an inference may be
made that the goal of eating is to achieve appetite pleasure or to internalize an external envi-
ronment (universal drive). The variety of the food and the total absorption into the act of eat-
ing (to the exclusion of external environment) may demonstrate the strength and the meaning
of the eating behaviors. The object is the type of food preferred by Middle Eastern immi-
grants (who are Muslim), usually highly salty, high in protein, and free of pork and alcohol.
• A second structural component is the set, which is the ordinary, regular, normal behavior a
client prefers to use to meet the goal of the subsystem. For example, pureed vegetable
soup is a type of food (preferred for healing properties) normally eaten by Middle Eastern
immigrants during an illness. Another example of set is a Middle Eastern immigrant’s
preference to have a room full of visitors during a hospitalization to meet his affiliative
needs and to handle the stress of hospitalization. Therefore, expecting and maintaining a
large group of family members at the bedside is a structural imperative acquired through
previous experiences of this particular person.
• Choices represent another component in the structure of a subsystem. Choices represent the
available repertoire of options that a person has to meet particular goals. Choices are regu-
lated by gender, age, cultural background, and socioeconomic status, among other vari-
ables. To meet the needs of procreation without a commitment to a partner—for example,
through artificial insemination—is an option within the repertoire of some women and not
of others, based on their perceptions of their own choices. Choices are not readily observed,
but they could be inferred.
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CHAPTER 13 On Outcomes 281
• Finally, the goal, set, and choice are complemented by directly observing the behavior
of the client or his or her actions. The behaviors that bring about desired goals, and
whether or not the normal patterns of behavior are appropriate under the circumstances
of the health or illness situation, are examples of observations and analyses that may
be useful. Behaviors are also compared and contrasted with available options for the
individual.
In addition to having structural components, each of the subsystems also has a function that is
analogous to the physiology of biologic systems. The goals of the subsystem, which are part of the
structure, are not entirely distinct from its function. The functional requirements of the subsystems,
and indeed the client system, continue to grow, develop, and remain viable. Therefore, Johnson
questioned what assistance subsystems may need to be able to do so, and her answer was “certain
functional requirements” (1980, p. 212) that can be met by the individual or by others when the
individual cannot meet such requirements. These functional requirements are:
1. Protection from unwanted, disturbing stimuli
2. Nurturance through giving input from environment (food, friendship, caring)
3. Stimulation by experiences, events, and behavior that would “enhance growth and
prevent stagnation” (Johnson, 1980, p. 212)
BOX 13-1 THE SUBSYSTEMS OF BEHAVIOR—JOHNSON*
Achievement Subsystem
The function is mastery or control either of some parts of environment or of self in such areas as physical,
creative, mechanical, social, and intellectual skills. These are measured against some acceptable yardstick.
Affiliative Subsystem
Inclusion into relations, intimacy, relating, bonding with the ultimate function of survival.
Aggressive Subsystem
Modes used to protect and preserve oneself from dangers, whether real or imaginary.
Dependence Subsystem
Used interchangeably with attachment; the ultimate function being approval, attention, or recognition and
physical assistance through assistance from a repertoire of others.
Eliminative Subsystem
Difficult to differentiate from the biologic elimination system. It incorporates modes of behavior in the
excretion of wastes, addresses when, how, why, and under what conditions a person externalizes what
is internal and what needs to be expelled.
Ingestive Subsystem
Similar to digestive biologic system but incorporates when, why, how, and under what normative
conditions the internalizing of external environment takes place. Its function is “appetitive satisfaction.”
Sexual Subsystem
Recognizes strong similarity to biologic system but considers all other behaviors that are related to
subsystem (e.g., gender–role identity, courting, mating). The function is procreation and gratification.
*Based on Grubbs, J. (1980). An interpretation of the Johnson behavioral system model. In J. P. Riehl and C. Roy (Eds.),
Conceptual models for nursing practice (2nd ed., pp. 217–254). New York: Appleton-Century-Crofts; and based
on Johnson, D. E. (1980). The behavioral system model for nursing. In J. P. Riehl and C. Roy (Eds.), Conceptual models for
nursing practice (2nd ed., pp. 207–216). New York: Appleton-Century-Crofts.
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Johnson also spoke of the relationship between the human being and the environment. This
relationship was not as well explicated in her theory, although its importance is strongly inferred;
she referred to environments as internal or external. Subsystems continue to maintain themselves
as long as both the internal and external environments are orderly, organized, and predictable, and
as long as each of the goals is met. When a disturbance occurs in structure, in function, or even in
the functional requirements (even though the structure and function may not have been affected),
nursing care is indicated. Nursing has the goal of maintaining, restoring, or attaining a balance or
stability in the behavioral subsystem or the system as a whole. Nursing acts as an “external regula-
tory force” to modify or change the structure or to provide ways in which subsystems fulfill the
structure’s functional requirement (Johnson, 1980, p. 214; Johnson, 1990).
Johnson based her theory on a number of explicit and implicit assumptions (Box 13-2). The
theory specifies that the behavior of the person who is ill is the object of nursing care and not the
disease. Therefore, nursing’s specific contribution to patient welfare is fostering efficient and
effective behavioral functioning in the patient during and following illness (Johnson, 1980,
p. 207). Later, Johnson added prevention as a nursing situation requiring nursing actions, although
this goal was not included in her early writings (1990, 1992).
Nursing makes its major contributions through the identification of a behavioral subsystem or
subsystems that are threatened or could potentially be threatened by illness or hospitalization. In
Johnson’s theory, the source of difficulty is clearly within the subsystem or within the functional
requirements, whether or not manifested in structure, function, or functional requirements. John-
son’s assumptions are explicit and clear (Johnson, 1990). The theory provides useful definitions for
person, health, nursing problem, and nursing therapeutics, and no definitions for nursing process,
interactions, or environment. Definitions are highly abstract; however, extensions offered by Auger
(1976) and Holaday (1980) provide clear operationalization of definitions of person and of nursing
therapeutics. One of the potential problem areas in clarity is the use of some concepts with different
meanings, one set is more acceptable (as defined by medical science) and less esoteric than another
BOX 13-2 ASSUMPTIONS—JOHNSON
Explicit Assumptions*
• Behavior is the sum total of physical, biologic, and social factors/behaviors.
• “The behavior of an individual evident at any given point in time is the product of the net aggregate of
consequences of these factors over time and at that point in time.”
• “When these regularities and constancies are disturbed, the integrity of the person is threatened and
the functions served by such order are less than adequately fulfilled.”
• A person is a system of behavior characterized by repetitive, regular, predictable, and goal-directed
behaviors that always strive toward balance.
• There are different levels of balance and stabilization. Levels are different at different time periods.
• Balance is essential for effective and efficient functions of the individual (a minimum of energy
expenditure, maximum satisfaction, and survival).
• Balance is developed and maintained within the subsystem or the system as a whole to maintain
adaptation and environment.
• Changes in structure or function of a behavioral subsystem are related to dissatisfied drive, lack of
functional requirements, or changes in environmental conditions.
Implicit Assumptions
• A person could be reduced to small components to be studied.
• A person as a system is the sum total of its parts (i.e., subsystems).
• All behaviors can be observed through sensory data.
*This section is based on D. Johnson’s class notes from the University of California, Los Angeles, 1970 and Johnson,
1968a.
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CHAPTER 13 On Outcomes 283
(as defined from subsystems of behavior perspective). Ingestion and elimination definitions are
more mainstream. Both, when considered from a biologic standpoint as compared to behavioral
subsystems, denote different meanings (Box 13-3 and Table 13-1).
The goals of nursing are to maintain or restore a behavioral system’s balance and stability. These
goals are observed in those behaviors of human beings that are orderly, purposeful, systematic, and
BOX 13-3 CONCEPTS—JOHNSON
Behavior Structural Components Functional Requirements
Subsystems of Behavior Goal Protection
Affiliative Set Stimulation
Ingestive Choice Nurturance
Eliminative Action Internal Regulation
Aggressive Function External Regulation
Sexual Restore
Dependence Maintain
Achievement Attain
Stability
Instability
TABLE 13-1 DEFINITION OF DOMAIN CONCEPTS—JOHNSON
Nursing An external regulatory force that acts to preserve the organization and integration
of the patient’s behavior at an optimal level under those conditions in which the
behavior constitutes a threat to physical or social health or in which illness is found
(Johnson, 1980, p. 214).
Goal of nursing Restore, maintain or attain behavioral integrity, system stability, adjustment and
adaptation, efficient and effective functioning of system (Johnson, 1980, p. 214).
Health Efficient and effective functioning of system; behavioral system balance and stability.
Environment Identified internal and external environments, but provided no specific definition.
Human being A biopsychosocial being who is a behavioral system with seven subsystems of behavior.
Nursing client A biopsychosocial being as a behavioral system threatened by loss of order, pre-
dictability, or stability due to illness or potential illness. “All patterned, repetitive,
purposeful ways of behaving that characterize each man’s life are considered to
comprise his behavioral system” (Johnson, 1980, p. 209).
Nursing problem Instability in the system or one of the subsystems due to functional or structural
stress: (a) inadequate drive satisfaction; (b) inadequate fulfillment of the functional
requirements; (c) changes in environmental conditions (Grubbs, 1980, p. 224).
Nursing process Not addressed.
Nurse–patient relations Not addressed.
Nursing therapeutics Regulate and control: (a) providing protection, nurturance, or stimulation to subsys-
tems; (b) by external mechanisms restricting, defending, inhibiting, or facilitating
(Johnson, 1961, 1980).
Focus Responses of person to stress, the reduction of stress, and the support of natural
defenses and adaptive processes (Johnson, 1961, p. 66).
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284 PART FOUR Reviewing and Evaluating: Pioneering Theories
are effective in meeting the structural and functional needs of each subsystem. These behaviors, if
effective, will allow human beings to benefit from their nurses’ caring. Hence, the subsystems
could be self-maintaining. Illness causes behavioral system imbalance and instability. The conse-
quences of nursing care are adjustment, balance, and stability. An unintended consequence that was
not discussed by Johnson is unwarranted dependence on others for meeting the needs of the subsys-
tems. The theory does not address the potential consequences of such dependence.
Johnson did not clearly identify theoretical propositions in her published work, but she dis-
cussed the implications of her theory for nursing research in a number of theory and research con-
ferences. Her position has been that appropriate, cumulative research in nursing is only possible
when we agree on the mission and goals of nursing (Johnson, 1974). Propositions in Johnson’s
theory are existence propositions. Existence propositions (Zetterberg, 1963) in this case led to fac-
tor-isolating theories (Dickoff, James, and Wiedenbach, 1968) (Box 13-4).
BOX 13-4 POTENTIAL PROPOSITIONS—JOHNSON
Person
1. Behavior is orderly, systematic, and organized around seven subsystems of behavior. Each subsystem
of behavior is identifiable by structure, goal, set, choice, behavior by function, and by a number of
functional requirements.
2. Internal regulatory mechanisms affect the structure, function, and functional requirements in the
subsystem of behavior of the entire system.
3. Behavioral subsystem disorders are manifested in disturbances in structure, function, or functional
requirements in each subsystem. Behavioral subsystem disorders are differentiated into insufficiency
in one of the subsystems, dominance in one or more of the subsystems, or incompatibility between
two or more of the subsystems.
Environment
1. External regulatory mechanisms affect each subsystem of behavior, and the entire system is
demonstrated by structure function and the subsystem functional requirements.
Health
1. Health, a behavioral system balance or stability, is manifested in the effective and efficient attainment
of the goals and functions of each subsystem of behavior as judged by the nurse and mediated by the
right of the patient.
2. Balance could be determined through manifestations of general harmony with and between the
behavioral systems.
Nursing Process
1. Johnson’s theory does not yield any theoretical propositions related to the nursing process. Assessing
and diagnosing, using Johnson’s theory, brings about efficient and effective nursing care.
Interactions
1. Johnson’s theory does not yield any theoretical propositions related to the nursing process except
when we consider subsystem interactions.
Nursing Therapeutics
1. Nursing is an external force that functions through control or modification of external regulatory
mechanisms for the purpose of achieving balance and stability as demonstrated by efficient and
effective functioning.
2. Nursing therapeutics are differentiated into nurturance, stimulation, and maintenance.
3. Nursing therapeutics deal with insufficiency, dominance, and incompatibility.
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CHAPTER 13 On Outcomes 285
Theory Analysis
The Theorist
The late Dorothy Johnson (she died in Florida in 1999), a pediatric nurse by training, received
her bachelor of science degree from Vanderbilt University School of Nursing in Nashville, Tennessee,
and a master of public health degree from Harvard University. She started her career at the Vanderbilt
University School of Nursing in Nashville, and spent the balance of her nursing career as a professor
of pediatrics at the University of California, Los Angeles (UCLA), where she influenced the lives and
theoretical identities of many faculty members, administrators, and students (and where I was privi-
leged to work with her). Her interest in sociology and psychology influenced the development of her
theory. She also had a strong influence on the theoretical and clinical work of many of her mentees.
Johnson worked with students in the master’s program. Although some wrote master’s theses
and many went on for further education, the focus of the program, for which she was primarily
responsible, was on preparing clinical specialists in pediatrics. Perhaps that may explain the
paucity of research related to her theory, as well as her strong influence on the theoretical and clin-
ical work of many of her mentees.
Paradigmatic Origins
Johnson stated that her theory is a product of philosophical ideas; sound theory and research;
her clinical experiences; and many years of thinking, discussing, and writing (Johnson, 1978). Her
theory had several sources. First and foremost, her conception of a person as a system of behavior is
analogous to the concept of a person as a biologic system, differentiated into a set of biologic sys-
tems, such as cardiovascular, skeletal, endocrine, digestive, and so on. Just as each biologic subsys-
tem is differentiated by a structure, as demonstrated in anatomic dissection, a behavioral system has
a structure when abstractly dissected. A structure has several components: a goal, a set, a choice, and
behavior. Biologic subsystems have functions and so do behavioral subsystems. Physiology speaks
to biologic subsystem functions. Both sets of subsystems have functional requirements.
Johnson’s assumptions are congruent with general systems theory assumptions, and concepts
consistently evolve from Johnson’s systems assumptions. For example, functioning of systems;
interdependency of subsystems; balance in subsystems; and regularity and constancy of behav-
iors, energy, boundaries, and disequilibrium are concepts defined by Bertalanffy (1968). Some
concepts were used by Johnson with consistent meaning. Johnson considered integration, whole-
ness, organization, interaction, and integration of a human being as subsystems, all of which are
derived from systems theory. The impact of her writings on nursing science in general and on the-
ory in particular underwent a revival in the 1980s. More writing in theory in the 1980s and 1990s
demonstrated the profound impact of her 1950s renaissance theory ideas.
Johnson’s theory is also based on a systems paradigm, as perceived from a sociological per-
spective. One sees the influence of Talcott Parsons (1951) on her writing in more than one way,
but especially in her attempt to conceptualize all nursing as dealing with a person as a system of
behavior. Parsons attempted to conceptualize one theory to encompass all sociology. He perceived
the science for Social System Analysis, with the social system representing society, as the focus of
sociological explorations. Components of the structure of a social system—goal, set, choice, and
behavior—are the same in Johnson’s as in Parsons’ theory.
Johnson relied on practice to provide the impetus for her theory, on sociology to provide a
paradigm for her writing (Johnson, 1992; Parsons, 1951; Buckley, 1968; Chin, 1961), and on psy-
chology (Rapaport, 1968; Sears, Maccoby, and Levin, 1957) to support the validity of the derived
concepts, such as Ainsworth’s (1972) on affiliation and Feshback’s (1970) on aggression. She
acknowledges the profound influence of Nightingale on her thinking about nursing and on the
development of her theory (Johnson, 1992).
Internal Dimensions
Johnson’s theory embodies an analytical model of what a nursing client is and the problems
a client manifests when she or he experiences an illness. It is a theory developed to answer the
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questions: What is nursing? How different is nursing from medicine? When does a person become a
nursing client? The answers are presented by explicating the person as a behavioral system model, and
the problems are situated in the structural or functional components of each behavioral system and
between systems. This model is based on a field system of relations focusing on the ill or potentially ill
person, the relationships within and between the subsystems of behavior, and between the person and
the environment system. The theory revolves around the human being as a behavioral system.
Johnson’s theory has a constructive beginning that is a hypothetical conceptualization of a
human being from a nursing perspective. It is based on a parallel conceptualization of a human
being as a set of biologic subsystems. It is also analogous to the conceptualization of Parson’s
(1951) social system in terms of a structure, function, goals, set, choices, action, functional imper-
atives, and the goal of stability for the subsystems. Therefore, Johnson’s is a deductive, hypotheti-
cal theory. However, Johnson grounds her theory in the care of children, and one can see her
pediatric nursing expertise in the development of this theory.
Although Johnson’s goal was that her ideas would describe and explain all behaviors and
actions that are within the domain of nursing (therefore making it a macrotheory of nursing), her
theory is useful microtheory in describing and assessing the effect of the illness experience and its
consequences on human beings. It is a middle-range theory addressing normal and abnormal pat-
terns of behavior in the nursing client. It provides guidelines for understanding an individual
patient’s experience but not that patient’s relationship with the environment, as well as the preven-
tion of the patient’s illness or the nursing therapeutic needed. Johnson’s theory has a broad scope
as it describes and explains a wide range of problems related to the assessment of clients (all
drives, needs, and regulators affecting behavior).
It is interesting to note that, whereas Johnson advocates that nursing should develop knowl-
edge of control (1968a), the phenomena that she addresses and develops are related to knowledge
of order in human beings and are related somewhat to the beginnings of knowledge of disorder,
hence the classification of middle-range and broad scope.
Three extension theories are credited to Johnson’s subsystems of behaviors. The first, according
to Alligood (2002), is the theory of person as a behavioral system. The second theory is the theory of a
restorative subsystem with the goal of achieving a state of equilibrium by redistributing energy
between and among all subsystems of behavior (Grubbs, 1980; Alligood, 2002). The third is the the-
ory of sustainable imperatives. Holaday (Holaday and Turner-Henson, 1987; Holaday, 2002) expli-
cated this part of Johnson’s theory through her own work with children who are chronically ill.
Johnson considers restoration as a goal rather than a separate subsystem of behavior (Johnson, 1990).
Theory Critique
Johnson’s theory provides nursing with a sufficiently broad scope to include a number of
diverse areas of nursing. However, the theory is limited to nursing’s concern for the ill, hospital-
ized person, and is less congruent with nursing’s orientation toward health (e.g., Johnson, 1987).
Johnson offers the nursing practice a concept, broad in scope, of a person as a system of
behavior. This concept helps in organizing the assessment of normal patterns of behavior and
deviations from the normal workings of internal and external environmental mechanisms. These
deviations may influence any one of the subsystems of behavior, which subsequently will affect
other subsystems in meeting their goals. Although the theory includes concepts of nursing prob-
lems and nursing therapeutics, these concepts are highly abstract in Johnson’s work. The exten-
sions offered by Auger (1976), with the addition of the restorative subsystem, and somewhat by
Grubbs (1980), of further extending this new subsystem, help to provide a point of entry for nurs-
ing therapeutics. Despite Dorothy Johnson’s close working relationship with Jeanine Auger, Judy
Grubbs, and Bonnie Holaday, Johnson did not support the changes and extensions they proposed
and developed. She reiterated in the 1990s that her conceptualization of human beings includes
the original seven subsystems of behavior (Johnson, 1990). Johnson’s theory clearly articulates a
mission of nursing and differentiates it from medicine. Knowledge of order (normal patterns of
behavior) and knowledge of disorder (abnormal patterns of behavior) are synthesized from social,
behavioral, and natural sciences, making the patient the focus of care, rather than focusing on the
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CHAPTER 13 On Outcomes 287
disease, surgery, or malfunctioning of biologic systems. The theory provides, in abstraction, broad
guidelines to knowledge of control—that is, to nursing therapeutics; the theory’s complexity,
however, stems from its high abstraction level.
The nursing process used by many educational and nursing service institutions was not
addressed in Johnson’s theory because Johnson focused on a theory of human behavior responses
to the stress of illness. Grubbs (1980) demonstrated how Johnson’s client assessment theory could
be used in conjunction with the nursing process. Holaday (1987, 2002) provided a way to use the
theory to assess a person and environment, and to plan and evaluate interventions. She built on
Randell (1991), who helped in expanding the definition of environment.
Hence, their extensions added to the assessment component, which focused only on the
human being. Auger and Dee (1983) used the theory as a guideline to develop a patient classifica-
tion system. The system provided nursing and hospital administration with the capability to estab-
lish levels of staffing based on patients’ needs. Clinicians used Johnson’s theory as a basis for the
development of a classification system that was helpful in providing purposeful care to patients in
psychiatric units (Dee and Auger, 1983). The classification system they developed could be used
effectively in other settings as well (Dee, 1986, 1990).
Several other analyses documented the theory’s utility in practice (Derdiarian, 1993a, 1993b).
Small (1980) used the theory to interpret her research and as a framework for caring for visually
impaired children. The authors found it helpful in providing a framework for diagnosis, selecting
interventions, and evaluating outcomes. Rawls (1980) described and evaluated the theory’s utility
in caring for patients with amputations. The theory’s utility for nursing therapeutics, however, is yet
to be realized, fully developed, and adequately used (Reynolds and Cormack, 1991).
Because the assessment of individual patterns of behaviors requires contiguous time in which
to get to know the patient, Johnson’s theory is better suited for long-term care, and the complexity
of the model requires a professional nurse with sound grounding in a number of sciences. It pro-
vides an effective guide for assessment and a frame for the diagnosis and intervention of individu-
als, but lacks a framework for the assessment of families or communities (Lobo, 2002). However,
patterns of behavior that reflect disorder and that require a nurse’s care are yet to be systematically
identified, defined, and developed.
Johnson has profoundly influenced theoretical thinking since 1959, but sparse publication of
her theory has limited the radius of her ideas. Johnson always maintained that nursing curricula
should be guided by a well-evaluated conceptualization framework of nursing (Johnson, 1989).
Within that belief system, several curricula emanated from her theory. Most of the application
work was done at the institution where Johnson taught—UCLA (implementation began in about
1964). However, the mobility of her colleagues and students has helped in implementing her the-
ory in educational programs at the University of Colorado (Hadley, 1970), the University of
Hawaii (Marjorie Dunlop), and Vanderbilt University. The theory was used as a framework for
nursing practice at the UCLA Neuropsychiatric Institute (Dee, 1990; Dee and Poster, 1995; Dee
and Van Servellen, 1998) and for testing care provided to adolescents in inpatient psychiatric
hospitals (Poster and Beliz, 1988, 1992).
The use of Johnson’s theory in the United States was based on an operationalization of the
theory into the UCLA curriculum and on the fact that Wu (1973) and Auger (1976) developed and
published their books, in which they extended Johnson’s ideas. The combination of these two
books provided the beginning student with knowledge of order that replaced the old fundamentals
of nursing. Those fundamentals were based on the medical model and were taught to beginning
students. No published material is available to describe the painstaking efforts of the UCLA
School of Nursing faculty in translating Johnson’s ideas into a curriculum—a curriculum that was
later emulated with refinements in Hawaii and Colorado. In the 1980s, Harris (1986) chronicled
the utilization of Johnson’s theory as a framework for the curriculum at UCLA.
External Components of Theory
Johnson diligently identified the assumptions, defined some of nursing’s central domain con-
cepts (person and health), and provided guidelines for their utilization in conjunction with the
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nursing process. The assumptions and conceptualizations are congruent with current professional
values regarding the uniqueness of nursing, its separateness, and its interdependence. In addition,
the view of stability is becoming accepted as a worldview for nursing. However, the theory’s
focus on the individual and disorder is incongruent with nursing’s claim to health maintenance
and promotion and to nursing’s interest in aggregates, as seen in community health.
Johnson was one of the first nursing scholars to identify the significance of congruence
between nursing goals and societal expectations (Johnson, 1974, p. 376). She continued over the
years to emphasize that the client and the public are the ultimate judges of the nursing mission,
which is to preserve the integrity of a patient’s behavior particularly as the patient’s physical or
social health is threatened (Johnson, 1990). The theory grew from her conviction that improve-
ment in care is the ultimate goal. The studies done by Grubbs (1980), Holaday (1981), and Small
(1980) assume such congruence and speak to patients’ satisfaction with care. However, as with all
other theories, such congruence between public expectations and nurses’ stated goals needs to be
explored. Perhaps the public’s interest in health and in health care commensurate to its cost is in
the best interest of nurses and will augment nurses’ views of their mission with the public’s view
of nursing’s goals. Until then, it is safe to assume that a theorist who spoke vehemently for
improved patient care and for the significance of the public view in shaping the nursing mission
has translated those views into her theory.
Theory Testing
Johnson, in presenting her theory, invariably spoke of the significance of theory in guiding
research (1968b, 1990, 1996). She admonished that research using her theory should focus on
identifying and explaining “the behavioral system disorders which arise in connection with ill-
ness, and . . . develop the rationale for and means of management” (Johnson, 1968b, p. 6). Other
components of her theory that have or are yet to be the focus of research are the determinants of
those behaviors or actions that are part of the structure, and the function of behavioral subsystems.
Damus (1980) explored the validity of theory in practice and collected observations related to
behavioral system disorder in patients with post-transfusion hepatitis. Her study demonstrated a
positive relationship between behavioral and physiological disequilibrium, and a relationship
between nursing diagnosis and nursing intervention. More important, this study lent support to the
idea that, indeed, the “source of subsystem disorders can be identified and predicted” and also lent
unequivocal support to the theory’s usefulness in nursing practice (Damus, 1980, p. 287).
Holaday’s study of achievement utilizing a study population of well and chronically ill chil-
dren (1974, 1981), as well as Holaday and Turner-Henson’s (1987) and Holaday, Turner-Henson,
and Swan’s (1996) studies of chronically ill children and family use of physical and nonphysical
activities out of the school system, were designed to explicate the achievement subsystem and
lend validity to the notion of integral patterns of behaviors. In addition, Porter’s (1972) work on
stimulation of premature infants lends similar validity to notions of the subsystem, its utility, and
isolation in patient care. Holaday completed two research studies related to the affiliative subsys-
tem of behavior (1981, 1982) and the achievement subsystem (1974). In the first, the cry of the
chronically ill infant received a different pattern of maternal response than the cry of the well
infant. The set–goal components of the subsystems provided the interpretation for the mother’s
responses to the cry. Derdiarian (1990a) provided further support to the theory’s utility as a frame-
work for enhancing nurses’ satisfaction. She also supported Johnson’s assumptions about the
interrelationships between subsystems of behavior (Derdiarian, 1990b). The theory was also used
as a framework to explain the attitudes of nurse administrators toward nurses who are impaired by
alcohol and drug use (Lachicotte and Alexander, 1990). In addition, the theory was used as a
framework for a study about pain management in adult patients with cancer and bone metastasis
(Wilkie, 1990; Coward and Wilkie, 2000). The focus of this study was the aggressive system of
behavior and the role of pain in protecting patients from overdoing and enticing them to seek
treatment. Johnson’s theory was the first to point out the importance of organizing the observa-
tions of patients’ actions and behaviors into patterns of behavioral systems. Colling, Owen,
McCreedy, and Newman (2003) studied the impact of the Pattern Urge–Response Toileting
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(PURT) of frail elderly living in a community dwelling. The results demonstrated that PURT is
useful in providing better intervention to the incontinent elderly. More importantly, their interpre-
tations of the results indicate that, by restoring the goals of the eliminative subsystem, the goals of
other subsystems could also be restored, hence achieving an outcome of balance in the total sys-
tem of the human being. The consistent use of Johnson’s theory in a psychiatric hospital allowed
researchers to identify and evaluate the outcomes of patient care driven by a nursing perspective
(Poster, Dee, and Randell, 1997).
Five research tools were developed to measure perceived quality of nursing care and per-
ceived behavioral changes of cancer patients, based on Johnson’s theory. The first patient indica-
tors of nursing care were developed to record “incidences of readily observable physiological
complications acquired by institutionalized patients” and to measure quality of care (Majesky,
Brester, and Nishio, 1978, p. 365). They were based on Johnson’s assumption that the occurrence
of a complication is a manifestation of a person’s “ability to cope with stresses on the behavioral
systems” (p. 365). Therefore, to monitor behavioral changes, a nurse can derive the status of a per-
son on a health–illness continuum. The 105 items of potential complications representing infec-
tion, immobility, and fluid imbalance were subjected to validity screening and reliability testing.
The second research tool, the Derdiarian behavioral system model, resulted in 193 items cate-
gorized to represent each subsystem of the behavior, which are useful for identifying perceived
changes due to cancer (Derdiarian, 1983, 1984; Derdiarian and Forsythe, 1983). Derdiarian (1990a,
1991) demonstrated that the use of theory-driven assessment tools enhances the satisfaction of
nurses and patients and the quality of care. These attempts are useful beginnings for factor isolat-
ing, categorizing, and providing empirical descriptions of some central concepts in the theory.
The third research tool was a projective test developed by Lovejoy (1983, 1985) to assess
family functioning as perceived by children with leukemia. The fourth instrument was developed
and validated by Dee (1986) as a classification instrument for psychiatric patients. The fifth was
developed by Bruce, Hinds, Hudak, Mucha, Taylor, and Thompson (1980) to measure the quality
of outcomes for patients with renal disease. Each of these tools has the potential for further sup-
port of the theory and its utility.
These tools demonstrate the theory’s usefulness in the assessment of nursing problems. One
of the requirements for subsystem survival is the provision of stimulation. To identify the needs of
premature infants, Porter (1972) explored the relationship of sensory stimulation and growth and
development of premature infants. Subsequently, others have provided evidence that marked
growth and development occurred when premature infants were stroked frequently and when
infants were handled frequently.
Attributions of success to internal and external variables differentiated between chronically
ill and healthy children. The chronically ill children tended to attribute success and failure to out-
side variables, and normal children tended to attribute the same to internal variables. Holaday
(1974) interpreted the results to indicate disequilibrium in the achievement subsystem. Both stud-
ies lend more empirical clarity to two of Johnson’s subsystems. She built further on her previous
studies by considering chronically ill children’s use of out-of-school time (Holaday and Turner-
Henson, 1987; Holaday et al., 1996). The dependency subsystem also received some investigative
attention (Stamler and Palmer, 1971). These studies support the presence of subsystems conceptu-
ally and their relationship to other subsystems.
Other studies are based on psychiatric patients (Dee, 1986), in which those indicators in
patient care central to nursing were described (Majesky et al., 1978). The potential in these studies
is tremendous because the researchers are attempting to delineate patient care outcomes based on
nursing interventions.
Outcomes of behavioral system stability are still complex and highly abstract. Factor-isolating
studies and exemplars are needed to delineate different states of stability. The theory’s clarity is
demonstrated in its view of the person, and its lack of clarity is viewed in outcomes. Nursing serv-
ice administrations have used the theory to develop nursing assessment forms for history, nursing
admission, and discharge. The questions in the forms evolve from a behavior system framework
that characterizes this theory (Dee, 1986; Dee and Auger, 1983).
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Theories can be used as a framework for interpretation. A good example of this use is pro-
vided in the research of Holaday (1981, 1982, 1987), described previously. Holaday found that
maternal responses to ill infants were characterized by quick response time and immediacy, moth-
ers were in the close vicinity of infants at all times, and the mother’s interventions were multiple
rather than singular. In other words, mothers tended to pick up the ill infant, and rock, pat, and
give a pacifier, as compared with just picking up the well infant. Mothers of the ill infants did not
discriminate between different types of cries as well as did mothers of the well infants (e.g., cries
due to pain or restlessness). Holaday interpreted her results using Johnson’s components of the
behavioral subsystems theory, that is, set–goal, which was narrow in the case of ill children. In
other words, mothers of chronically ill children responded to every cry with no discrimination.
With this theory-based interpretation, nursing implications according to Holaday (1981, 1987)
were for helping mothers with their set-goal of the affiliative subsystem, that is, the subsystem that
focuses on relationships.
Johnson’s theory was used internationally as a framework to describe perceived rights for dis-
closure of information related to each subsystem of behavior. Two factors emerged to be signifi-
cantly related to perceptions of rights for disclosure. These factors correspond to the achievement,
ingestion, and elimination subsystems. The findings support these subsystems’ functions of the need
for mastering the environment through information and the need for incorporating information
regarding patients’ concerns (Naguib, 1988).
MYRA LEVINE
To the late Myra Levine, nursing action was a conservation activity, and the outcome she concep-
tualized is the conservation of energies, which for her equals health. Myra Levine is distinguished
from other theorists by her focus on conservation principles as a framework for nurses’ actions.
When Levine spoke of conservation, she included the need for conservation of environments as
well as endangered species (Levine, 1996).
With constant changes in the world, stability through conservation is essential. The outcome
of conservation is adaptation, which includes historicity (the information transmitted through
genes) and specificity (parameters specific to well-being) to enhance the individual’s fit and har-
mony with internal and external environments. Adaptation also includes redundancy—wave-like
adaptive responses that include activities that spread the energy cost. Redundancy is the “frugal
use of energy guaranteed by fail-safe systems” (Levine, 1996, p. 39). When I think of Myra
Levine, the first images that are conjured are of an integrator who was able to assimilate nursing
as a “humanitarian enterprise” (Levine, 1999) with physics, from which she utilized great conser-
vation laws (Feynman, 1965), with physiology (living organisms) (Bernard, 1957), and adaptation
(homeorrhesis) (Bertalanffy, 1968; Cannon, 1939). I also think of her as a critical thinker whose
skepticism prompted her to write a scathing critique of nursing theory entitled “The Rhetoric of
Nursing Theory” (Levine, 1995). Levine, like other pioneering theorists, provided an innovative,
coherent view of nursing to differentiate it from medicine (a differentiation that occupied nurs-
ing’s thinkers in the 1960s) but went even further to suggest an alternative to the concept of med-
ical diagnosis, proposing trophicognosis to better reflect nursing’s focus on the art and science of
nursing (Levine, 1966a, p. 57). Finally, Levine was the consummate supporter of liberal arts and
humanities education in nursing (Levine, 1999).
Theory Description
The central questions that Levine addressed are:
• What are the ways in which nursing care is delivered?
• What are the goals of nursing actions?
• Why are nursing actions provided?
To answer these questions, Levine conceptualized the methods of nursing as conservation of
patient resources, as alteration of environment to fit those resources, and as an extension of the
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CHAPTER 13 On Outcomes 291
patient’s perceptual system until his own system is healed. These questions address nursing thera-
peutics and, to a lesser degree, a perspective on health. The central idea in her theory is well man-
ifested and exemplified in the label she chose: Energy Conservation: A Universal Concept
(Levine, 1990).
The impetus for Levine’s conceptualization of nursing appears to be her attempt to separate
the domains of medicine and nursing. Her first published work focused on proposing trophicogno-
sis as a new label for nursing assessment and a “plan of action to substitute the concept of nursing
diagnosis” (Levine, 1966a, p. 57). Her rationale for the proposal was her desire to differentiate
between diagnoses that have the connotation of medical diagnosis and disease orientation. How-
ever, using the concept of diagnosis tends to highlight the overlap between medicine and nursing
rather than highlight the differences.
Trophicognosis is defined as “a nursing care judgment arrived at by the scientific method”
(Levine, 1966a, p. 57). It denotes the knowledge of the art of nursing and is analogous to diagno-
sis and prognosis for the art of medicine. Labeling nursing assessment as a nursing diagnosis is
only giving diagnosis a new label, but when trophicognosis is used, it emphasizes nursing care
judgment based on the process of scientific method. Levine offered, then, a useful beginning for
the use of the nursing process. Although the new label was not used in nursing, Levine’s attempts
in 1965 (published in 1966a) supported what other theorists had begun doing: delineating nurs-
ing’s focus and differentiating between nursing and medicine. However, Levine later admonished
nurses to simplify their language and not invent language that confuses other health care providers
(Levine, 1989a), an admonition that contradicts her original proposal (to describe diagnosis as
trophicognosis).
Levine then put her “intellectual energy” into conceptualizing a human being as an adaptive
being, in constant interaction with the environment, whose behaviors are integrated in responses
to internal and external environmental stimuli. Nurses are interested in integrated responses of
whole patients to noxious stimuli, particularly when the individual is not able to adapt behavior to
environmental demands. Nursing is expected to create an atmosphere (therefore, environment was
beginning to reemerge as a central phenomenon in nursing) to encourage healing and to promote
adaptation (1966b). Although this theory is classified as an outcome theory, it demonstrates a focus
on nursing therapeutics, and some have used it as a framework for diagnosis and intervention
(Taylor, 1989). Levine also provided a detailed description of environment. She described environ-
mental dimensions as internal and external. Responses of human beings emanate from the internal
environment. Both the internal and external environments influence each other, and the internal
environment is constantly challenged to meet the external environment’s demands. The two envi-
ronments are joined through adaptive patterns, and when the interaction between them is harmo-
nious, the wholeness of an individual manifests itself. Throughout the challenges and changes in
the environments, the body maintains its integrity through some control mechanisms that lead to
autoregulation of the internal environment (Levine, 1973).
Building on Bates’ (1967) description of environment, Levine described the external environ-
ment as perceptual, operational, and conceptual. The perceptual environment is that component
“which an individual responds to with sense organs” (Levine, 1973, p. 12). The operational envi-
ronment includes all that affects an individual physically, such as microorganisms and pollutants.
The conceptual environment includes symbols, values, culture, language, thinking, and personal
styles, among others (Levine, 1973, 1989b). The interaction between the internal and the external
environments is where a person’s adaptation resides; it is where the fit between person and envi-
ronment occurs (Levine, 1989b).
Levine (1973) identified nine models to guide assessment (the relationship between each
major theory concept and every model is not entirely explicit):
1. Vital signs
2. Body movement and positioning
3. Ministration of personal hygiene needs
4. Pressure gradient systems in nursing intervention (fluids)
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292 PART FOUR Reviewing and Evaluating: Pioneering Theories
5. Nursing determinants in provision for nutritional needs
6. Pressure gradient system in nursing (gases)
7. Local application of heat and cold
8. Administration of medication
9. Establishing an aseptic environment
Assessment would include the organismic and environmental systems. The first allows for
description of all physiological and biologic adaptive integrative systems, such as response to fear
(fight or flight), response to inflammation, and response to stress. The other systems of response
are to the environment, which is more than one’s immediate surroundings (Levine, 1969). It is the
perceptual environment “depending on the ability of a person to receive sensory stimuli via his
sense organs,” the operational environment, including all those physical entities that do not need
to be recorded by senses (radiation, microorganisms), and the conceptual environment “deter-
mined by the dependence of human beings on the symbolic exchange of language and ideas.” It
also includes cultural determinants (Levine, 1971a, p. 262).
The environment is not always “user-friendly.” Successful engagement with the environment
depends upon the individual’s repertoire––that store of adaptations which is either built into
the genes or achieved through life experience. While there are redundant or back-up systems
that offer options when the initial response is insufficient, health and safety are products of a
competent conservation process. The goal of conservation is health. (Levine, 1990, p. 193)
The “holistic nursing challenge” is to nurse whole patients at the interface of organism and
environment to promote adaptation. Levine decided against “holistic” in 1969 in favor of “organ-
ismic” in describing human beings because holism was more a myth rather than based on science.
She returned to holism in 1973 “because I realized it was too important to be abandoned to the
mystics” (Levine, 1996, p. 39). She accepted Erik Erickson’s (1968) definition of holism—which
acknowledges mutuality between the parts, open and fluid boundaries––because it stood the test
of time. Her utilization of adaptation as an outcome through energy conservation was also a con-
stant in her writings. Conservation of energy is important to the disease process, and begins with
regulation of metabolism in response to noxious forces that have instigated the disease process. It
does not only mean limitation of activity, it also means “proper disbursement of energy expense,
allowing for activity within the range of the individual’s capability, safety, and comfort” (Levine,
1971a, p. 259). Conservation of structural integrity is accomplished through tasks that support the
physiologic and anatomic positioning. Conservation of integrity is related to environmental
processes. It includes conservation of personal integrity through preservation of sense of worth
and integrity and conservation of social integrity through the recognition of cultural, ethnic, reli-
gious, and family relationships (Levine, 1967).
Levine defines health through the definitions of integrity and wholeness. She defines
integrity as:
. . . having the freedom to choose; to move without constraint, as slowly or as swiftly as
desired, and to exercise decisions in all matters––trivial and otherwise––without apology,
indebtedness, or guilt. Integrity is the experience of life, the sensations of the body and its
limbs, the sensory recording of every place and time on the mind and in the spirit. (Levine,
1990, p. 93)
Maintenance of system integrity depends on perceptual systems (basic orienting, visual, audi-
tory, hepatic, and taste and smell). When perceptual systems are deficient, the organismic responses
are altered, and the nurse uses her perceptual system in an attempt to maintain wholeness in the
individual. This is how healing can proceed (Levine, 1969). Health is also a pattern of adaptive
changes (Levine, 1973), with many degrees of adaptation. Health is personally defined, thereby
reflecting one’s life experiences (Levine, 1991). Even disease, to Levine, is a pattern of adaptive
change because there is neither good nor bad adaptation nor maladaptation (Levine, 1996). Organ-
ismic responses, which are the physiological and behavioral responses to environment, influence
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CHAPTER 13 On Outcomes 293
each other and coexist in individuals. They have four dimensions. The first is the fight-or-flight
response, which is the most primitive organismic response (Levine, 1973). The second is the
inflammatory immune response, which is essential for maintaining structural continuity and for
promoting healing (Levine, 1989b). The third response level is that of stress, which is cumulative
over time (Levine, 1989b). And the fourth level of organismic response she calls “perceptual
awareness,” which is the mechanism of collecting and integrating environmental information and
then converting it into meaningful experiences (Levine, 1969). Perceptual awareness encom-
passes five subdivisions: the basic orienting system (inner ear, which responds to balance, change
in gravity, acceleration, and movement), the visual systems (for looking), the auditory systems
(for listening to sounds), the hepatic system (for touch), and the taste/smell system (for informa-
tion and facilitation of chemical and nutritional stimuli and needs) (Levine, 1969).
Levine’s conceptualization is based on numerous implicit and explicit assumptions that were
dispersed throughout her writings between 1966 and 1989. They are presented in Box 13-5. Basic
to her theory are her beliefs in the wholeness of patients (Levine, 1989c, p. 126). Patients are part-
ners in the care process, and nurses should work to develop a trusting dialogue. It is interesting to
note that Levine used the term “patients” instead of “clients” because “clients” comes from a
Latin root that means a follower; however, “client” does not exactly mean a follower. The deriva-
tion of client is from Latin clinare, to bend or incline and cliens, one who has someone to lean on,
BOX 13-5 ASSUMPTIONS—LEVINE
Implicit Assumptions
• The nurse creates an environment in which healing could occur (Levine, 1966a).
• A human being is more than the sum of parts.
• Human beings respond in a predictable way (1966a).
• Human beings are unique in their responses (1966a).
• Human beings know and appraise objects, conditions, and situations (1973).
• Human beings sense, reflect, reason, and understand (1973).
• Human beings’ actions are self-determined even when emotional (1973).
• Human beings are capable of prolonging reflection through such strategies as raising questions or
redirecting attention.
• Human beings make decisions through prioritizing courses of actions.
• Human beings must be aware and able to contemplate objects, conditions, and situations in order to act
purposively.
• Human beings are agents who act deliberately to attain goals (1973, pp. 12–13).
• Adaptive changes involve the whole individual (1967).
• Human beings are adaptive (1996).
• A human being has unity in his response to the environment. He responds in an integrated way (1966a).
• Every person possesses a unique adaptive ability based on one’s life experience, which creates a
unique message (1967).
• There is an order and continuity to life (1966a).
• Change is not random.
• A human being (as a whole) responds organismically in an ever-changing manner (1967).
• A theory of nursing must recognize the importance of detail of care for a single patient within an
empiric framework that successfully describes the requirements of all patients (1966a).
• A human being is a social animal.
• A human being is in constant interaction with an ever-changing society.
• Change is inevitable in life (1973, p. 10).
• Nursing meets existing and emerging demands of self-care and dependent care (1985).
• Nursing is associated with conditions of regulation of exercise or development of capabilities of
providing care (1973).
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294 PART FOUR Reviewing and Evaluating: Pioneering Theories
which comes from Greek klinein, to lean, which has its roots in Sanskrit srayate, he leans on
(Webster’s Third New International Dictionary, 1986).
All major concepts are derived from other paradigms, except for the concepts of trophicogno-
sis and conservation, which are primitive to this theory (Box 13-6). Both are theoretically defined;
the first was also operationally defined, but because of its esoteric nature, nurses preferred “nurs-
ing diagnosis” over trophicognosis. The derived concepts are not operationally defined and have
unclear boundaries. Concepts such as wholeness, social well-being, integrity, and adaptation are
used interchangeably and are not well differentiated (Table 13-2, pp. 295–296).
Levine’s theory offers existence propositions that are based on conceptualizing the assess-
ment of levels of responses, internal and external environments, and focus of nursing as conserva-
tion of energy and integrity through therapy or support. It offers concepts that appear on the
surface to be linked together; however, relationships between each set of these concepts are not
clear (e.g., well-being and adaptation, conservation and responses). Therefore, as it stands now,
this is a theory with existence propositions and no relational ones. Levine’s propositions are sum-
marized in Box 13-7.
BOX 13-6 CONCEPTS—LEVINE
Wholeness
Holism
Noxious stimuli
Organismic responses
Fight or flight
Inflammatory responses
Stress
Perceptual awareness
Homeostasis
Homeorrhesis
Adaptation
Historicity
Specificity
Redundancy
Equilibrium
Environmental exchange
Orderly synchronization � Health
Desynchronization � Disease
Conservation
Energy
Integrity
Structural
Personal
Social
Intervention
Supportive
Therapeutic
Perceptual systems
Basic orienting
Visual
Auditory
Hepatic
Taste, smell
Environment
Perceptual
Operational
Conceptual
Perceptual systems
Basic orienting
Anatomical
Visual
Dynamic exchange
Trophicognosis
BOX 13-7 PROPOSITIONS—LEVINE
• Awareness of an environment influenced behavior at all times.
• Conservation of patients’ energy is a consequence of nursing intervention.
• Components of nursing interventions are conservation of individual patient’s structural integrity,
personal integrity, and social integrity.
• Nurses are participants in every patient’s environment and influence patient’s adaptation.
• “Conservation insures stability and familiarity, consistency and reliability” (Levine, 1996, p. 38).
• “The internal environment and the external environment are joined through adaptive patterns, and the
individual’s wholeness is a function of their harmonious interaction” (Levine, 1996, pg. 38).
• “Negative feedbacks provide the mechanisms for successful adaptation by supporting the living
systems with the most economic, most energy-sparing systems” (Levine, 1996, p. 39).
• “The loss of redundant systems in adapting accounts for the process of aging. A critical loss of redun-
dancy is not compatible with health and is often life-threatening” (Levine, 1996, p. 39).
• “The humanities promise a tempering and a gentling of the relationships between patient and nurse”
(Levine, 1999, p. 217).
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CHAPTER 13 On Outcomes 295
TABLE 13-2 DEFINITION OF DOMAIN CONCEPTS—LEVINE
Nursing Has a unique body of knowledge and is a human interaction. Its goal is to conserve
energies and integrities through changes in the environment.
Goal of nursing Restoration of individual’s wholeness, integrity, well-being, and independent activity.
Conservation of energy, social, personal, and structural (Levine, 1967).
When necessary, maintenance of appropriate balance between patient abilities,
involvement in the care, and nurses’ actions.
Maintenance and individuality.
Health “Health and illness are patterns of adaptive change” (1966b, p. 2452).
Is equated with successful adaptation; in fact, one criterion of successful adaptation
is the attainment of social well-being (1966b, p. 2452).
Health as integrity means being in control of one’s life and having the freedom to
choose (Levine, 1990).
Environment Is both internal and external. It is a setting, a background, and the dynamic exchange
that involves both the individual organism and the setting and background. Environ-
ment is perceptual, operational, and conceptual. Perceptual environment is based
on a person’s sense organs’ interpretation. Operational environment includes the
things that affect an individual physically, such as virus, and the conceptual environ-
ment evolves out of an individual’s cultural patterns, values, and spirituality and is
mediated by symbols of language and thought (1969, p. 94; 1973, p. 12).
Person An ever-changing organism who is in constant interaction with his environment and
who is constantly striving to maintain his integrity. Responses of a human being are
a unified whole.
Nursing client A total, whole person, a system of systems, in a state of dyssynchronization and in
need of assistance to conserve energy, structural, personal, and social integrity
(1969; 1973). An ill client maintains his integrity through four levels of physiologi-
cally predetermined protective responses. These are fear, inflammatory process,
stress, and perceptual awareness as mediated through sense organs.
Nursing problem The internal or external environment as it threatens the total integrity of a whole per-
son. Organism responses to threat coexist in a single individual: (1) Response to
fear by fight or flight, an instantaneous reaction, a most primitive reaction; (2)
Inflammatory response, a second-level response, a response of entire resources of
an individual, a systematized energy directed as exclusion and removal of intruding
irritant or pathogen; (3) Response to stress produces defensive response in the form
of changes that are nonspecific in a human being. Structural changes and gradual
loss of adaptation energy occurs, until exhaustion is reached; (4) Sensory response
producing perceptual awareness, the information and experience in life are only
meaningful when perceived in an integrated whole by the individual. All are energy
exchange transmissions from individual to environment and back. The result is a
physiological or behavioral activity.
Nursing process Assessment, diagnosis, and intervention, using steps of the scientific method, with
great emphasis on observation as a central tool (1973, pp. 23–29).
Nurse–patient relations “Depend on perceptual system of both persons” (1969, p. 97).
The nursing process and action are for conservation.
(continued )
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296 PART FOUR Reviewing and Evaluating: Pioneering Theories
Although Levine described the conservation principles in what may be construed as assump-
tions, her principles could formulate the major propositions. She proposed that the goal and the
process of nursing action is the conservation of energy, the goal of conservation is health, and
health is to be whole with integrity (Levine, 1990). Such propositions are supported by assump-
tions emanating from other paradigms about the significance of energy and integrity for a human
being.
Levine, in a personal communication (cited in Fawcett, 1989, p. 157), provided further sup-
port for the classification of her theory as a theory for nursing therapeutics. She proposed a theory
that she called “therapeutic interventions,” in which she described seven areas for which interven-
tions should be developed. These are therapeutic regimens to support the healing process of the
body, to substitute for failure of autoregulation, to focus on restoring the integrity and well-being
of individuals, to promote comfort and human concern, to decrease the threat of disease, to create
functional changes, and to correct metabolic imbalances.
Theory Analysis
The Theorist
Myra Levine is a graduate of the Cook County diploma program, and she has a nonnursing
bachelor’s degree from the University of Chicago, and a master of science in nursing from Wayne
State University, Detroit. She took postgraduate courses at the University of Chicago (Artigue
et al., 1994). She then retired and became a professor emeritus in the medical–surgical nursing
graduate program at the University of Illinois, Chicago, where she taught and collaborated in
teaching the theory seminars. Her writings evolved while she was a predoctoral and postgraduate
student at the University of Chicago. She has an extensive clinical (private duty nurse, staff nurse),
administrative (director of nursing), and teaching background (preclinical instructor in Cook
County; a faculty member at Loyola University, at Rush University, and at the University of Illi-
nois) (Esposito and Leonard, 1980). Myra Levine died on March 20, 1996, in Illinois.
TABLE 13-2 DEFINITION OF DOMAIN CONCEPTS—LEVINE (Continued )
Nursing therapeutics The nurse acts in a therapeutic way when the intervention changes the course of
adaptation toward a renewed social well-being. The nurse acts in a supportive way
when the intervention maintains or fails to maintain the status quo and when there
is no alteration in the course of adaptation (1966a; 1967).
Focus is on creating an atmosphere where healing could occur; therefore, the target
is the environment. Based on appreciation of the patient’s responses.
To conserve patient’s resources, alter the environment to fit the resources, and act as
the patient’s perceptual system when his own is impaired.
Adaptation The process of change whereby the individual retains his integrity, his wholeness
within the realities of his environment (1969, p. 95).
Focus of nursing Organism responses that are singular but integrated, maintenance of wholeness.
Nurse–patient interaction.
Consequences Adaptation process of change within which an individual maintains his integrity and
his wholeness.
Illness Dyssynchronization with outer events
Loss of a portion of well-being
Loss of wholeness; “Health and illness are patterns of adaptive response” (Levine,
1966b, p. 2452).
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CHAPTER 13 On Outcomes 297
Paradigmatic Origins
In introducing holism in the mid-1960s, Levine was critical of the scientific approach that
advocated experimentation, deductive thinking, and analysis of experiences that only led to more
mechanistic and dualistic approaches to patient care. The ultimate result was the compartmental-
ization of human beings. She recommended an inductive approach that evolved from experience
and clinical practice and incorporated the wisdom of the person. To her, a paradox existed
between holism and humanism on the one hand and dualism and scientific thought on the other.
Despite these admonitions, Levine used a deductive approach to develop her theory and recom-
mended the scientific method for collecting data about nursing care.
Levine’s clinical background in medical–surgical nursing and the close association of this
background with medical, biologic, and pathophysiological sciences influenced the development
of her theory. The theory draws on concepts and assumptions from systems theory (Bertalanffy,
1968), adaptation theories (Cannon, 1939; Dubos, 1966; Selye, 1956), developmental theory (sur-
prisingly, Erik Erikson [1968] was cited for the definition of wholeness, totality, and system
[Levine, 1969, p. 94]), existentialism (Buber, 1967; Tillich, 1961), and nursing theorists (Abdellah
and Levine, 1986; Nightingale, 1969; Rogers, 1961).
Levine also drew her ideas from several concepts that, in her view, had a major impact on
nursing. These are the natural healing concept, the germ theory, theory of multiple factors, and the
unified theory of health and disease. Although she promoted the scientific method for nursing in
both the development of nursing science (Levine, 1966b) and in the development of nursing
process (Levine, 1966a), she encouraged us to consider life processes holistically by transcending
the duality of mind and body. She also warned against the apparent dissociation between environ-
ment and individual as evidenced in the nature–nurture arguments. Cause-and-effect mechanistic
views are dehumanizing and antiholistic. Organism responses, purposeful life, integrative approach,
and adaptation are concepts that guided her view of nursing. She advocated a return to nursing as
it used to be:
Nursing has always been characterized by an intensely humanistic purpose, an expression at
once of the selfless giving as opposed to selfish rewards that accompany human interaction.
(Levine, 1971a, p. 263)
It is, after all, in the role of patient advocate that the nurse has historically fulfilled her
responsibility to bring compassion, protection, and commitment to the bedside. (Levine,
1971b, p. 43)
Internal Dimensions
Levine’s is a concatenated theory developed around concepts of adaptation, conservation,
responses, and environment and therefore has an appropriate set of existence propositions. It is a
microtheory with limited scope, addressing conservation of energy and integrity. It evolved
deductively out of hypothetical beginnings, a view of what nursing ought to be. It is a descriptive
theory that attempts to describe strategies of nursing care and of the nursing client. It addresses
mainly phenomena of disorder, fight-or-flight, stress responses, inflammation responses, and per-
ceptual awareness responses.
Levine used a problematic method approach in her theory (Barnum, 1994, pp. 29). Responses
of people are holistic, but are differentiated into four different problems; conservation is offered
separately in four different types. Whereas a person is not reduced to components, responses are
limited to four problematic responses. Nurses’ actions are limited to conservation. It could be
argued, therefore, that there is a certain element of reductionism in Levine’s theory.
Theory Critique
Levine developed her notions in the mid-1960s, when nurses were struggling with increas-
ing mechanization, when they were beset with fragmentation caused by specialization, and when
they were trying to differentiate between different types of nursing and also between nursing and
medicine. She began by differentiating between medical and nursing judgment, by offering
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trophicognosis to replace nursing diagnosis. She saw the process of clinical judgment—the nursing
process—as a means of focusing on nursing issues in patient care. Holism and humanism, and
person–environment interactions, are abstract concepts attached to the nursing act and not clearly
defined, but Levine was among the first to redirect our attention to them. The essence of the nurs-
ing act is conservation. It is what all human beings strive for and, when not able to adapt to nox-
ious stimuli, the nurse becomes their conservator.
Fortunately, or unfortunately, the theory drew heavily from pathophysiology and was there-
fore perceived as a theory oriented to acute care of ill individuals. However, Hirschfeld (1976) dis-
cussed the cognitively impaired older adult and demonstrated how Levine’s four principles of
conservation could be applied to give direction to nursing interventions when impairments are
present. This appears to be the only published indication of the utility of Levine’s theory in the
practice arena, and it does provide support for the notion that the theory can be used clinically.
Levine’s use of holism, humanism, and integrative approaches to understanding response
reflects the philosophical bases of nursing; however, these approaches tend to be abstract concepts
and in need of operational referents. There is inconsistency in how they are used in her writing,
arising from the view of human beings through a pathophysiological approach and a reduction of
responses to those that are biologically bound. The inclusion of perceptual awareness amid the
focus on biologic responses to fear, stress, and inflammation almost seems an additive thought
and not an integrative one. The theory’s major concepts—adaptation and energy—are not well
defined. Yet, in a clinical sense, nurses constantly deal with and consider the energy of the patient
in their plans for any therapeutic interventions.
The theory’s complexity is perhaps due to its lack of clarity and the disconnectedness of its
concepts—the principles of conservation, organismic responses, and adaptation—as well as to the
lack of clarity about the boundaries between the concepts (Levine, 1971a, p. 258). Conservation is
a goal and an intervention process in different parts of the theory, but organismic and environmen-
tal responses overlap when Levine discusses perceptual awareness. In later work, she defined the
goal of conservation as health and health as integrity (Levine, 1990). The goals of conserving
energy are also adaptation (Levine, 1996). It could be argued that three responses––fear, stress,
and inflammation––are simply syndromes in response to stress, as defined by Selye. Complete
definitions and the development of propositions connecting responses, environment, and conser-
vation would render this theory testable.
Other functional limitations in the theory may have deterred others from using it, and this
may be the reason that citation reviews after 2000 do not reveal writings that utilized the theory.
Holistic nursing appears to be limited to integrating the social and personal aspects of care in
acute-care individuals who are dependent on the health care professional. The theory does not
lend itself readily without extensive interpretation to long-term care and care of families or com-
munities. However, in 1991, Cox provided a compelling example of how the theory was translated
for use in long-term care. While the theory offers guidelines for assessment of responses and envi-
ronment, and guidelines for goals of nursing therapeutics, it is limited in conceptualizing the
means by which the nurse can achieve these goals. Similarly, the theory does not lend itself read-
ily to preventive and health promotion care, but the potential for extension exists. However, the
theory has been used effectively as a framework to guide community nursing services for the
homeless in Philadelphia, in emergency rooms. and for patients with congestive heart failure
(Pond, 1990, 1991; Pond and Taney, 1991).
Some have used the theory in curricula development for educational settings (Grindley and
Paradowski, 1991; Hall, 1979; Riehl, 1980). Others have used it in administration settings as a
framework for identifying outcome criteria for nursing care of patients on a neurology unit (Taylor,
1974). Taylor’s account of her use also substantiates the theory’s utility for the use of the nursing
process in assessment and diagnosis.
The theory’s circle of contagiousness is limited. Its use in research, education, and administra-
tion has suffered from the problematic approach in articulating the theory, the lack of interpretation
of holistic and total human being, the limited operationalization of integrative responses, the over-
lap between concepts (e.g., personal and social integrity), and, most of all, the lack of propositions.
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That is not to say that the potential is not there; it only means that the existing literature by Levine
focuses on assumptions, concepts, and definitions. Each of the conservation principles lends itself
to existence propositions and each of the nine descriptive models can generate research questions.
External Components of Theory
The theory is congruent with general professional and societal views of health and patient
care. Levine espoused holistic care before holism became an accepted lexicon in both nursing and
societal language. The definition of patients as total individuals has a parallel in Rogers’ unitary
human being (Rogers, 1970). Two other of Levine’s ideas are widely accepted now in nursing
thought: the focus of nursing on life processes and the significance of the environment (Donald-
son and Crowley, 1978; Flaskerud and Halloran, 1980), although not directly credited to her.
To use an individual’s natural resources, to conserve energy, and to preserve the integrity of
the individual were, at the time of its writing, values of the future that have now become more
intrinsic in our discipline. Their social significance make the theory appealing to the general pub-
lic, but the challenge remains. How do we achieve these goals of nursing care? What are the out-
come criteria by which we nurses know when we have and when we have not achieved these
goals? Are they or are they not cost-effective in prevention and intervention?
While nursing was attempting to devise ways to measure energy and study unitary human
beings and the meaning of healing, Levine demonstrated inconsistencies in ideas and displayed
impatience with the lack of scientific data used to study therapeutic touch. In response to an article
by Krieger, she wrote a scathing letter to the editor, admonishing nurses to stick to science in
developing nursing (Levine, 1979). In this letter she warned:
The professional implications of nurses engaging in “healing” based on the spurious notion
that “excesses of energy” in the human body can be transmitted to the “ill person who can be
thought of as being in less than an optimal energy state” are frightening. The science is spuri-
ous, as is the explanation that this “appears to be done physiologically by a kind of electron
transfer resonance.” (p. 1379)
Levine charges that this type of thinking will take nursing on to a “hocus pocus” “faith healing”
path and that nursing cannot afford to indulge in this kind of “charlatanism” (p. 1380).
Levine is an advocate of theoretical formulations that are based on coherence, but calls for
corroboration of truth in nursing. She offered nursing in the mid-1960s a forward view of environ-
ment, holistic nursing, the total person, potential significance of perceptual apparatus in nursing,
and nursing action as conservation.
Theory Testing
One research study tested a proposition that could be viewed as an extension of Levine’s the-
ory. The proposition states that mediation of stimuli through the perceptual system of the nurse
could be enhanced if the nurse and patient share the same subjective time. To explore this proposi-
tion, which is closely related to Levine’s notion of hepatic perceptual system (which mediates
touch, thought, muscles, joints, and skeletal system), Tompkins (1980) explored the effect of
restricted mobility on the perceived duration of adverse events. She found that “decreased per-
ceived duration . . . may be a mechanism for preserving system integrity in those whose mobility
is restricted” (p. 333). This is the only published study that has tested the relationship between
system integrity and perceptual systems.
Hirschfeld (1976) applied Levine’s theory to the care of cognitively impaired elderly patients
and found the theory useful in determining priorities. Newport (1984) used Levine’s theory as a
framework for a study designed to contrast temperatures of newborns who were put in warmers
with those who were placed in skin-to-skin contact with mothers. Other research could evolve
from the propositions described earlier in Box 13-7.
Levine’s theory has had limited research utilization and, as such, it has not been refined or
extended. The principles of conservation were used with elderly study populations, with popula-
tions suffering from decubitus ulcers, and in exploring Finnish nurses’ perceptions of the extent to
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300 PART FOUR Reviewing and Evaluating: Pioneering Theories
which elderly patients’ integrity is maintained in long-term institutions (Teeri, Välimäki, Kata-
jisto, and Leino-Kilpi, 2007). Fawcett (2005) indicated that, even when research was conducted
utilizing Levine’s theory, it was limited almost exclusively to single studies, thereby precluding its
further development. There are a few exceptions, one of which is a multisite study of the effects of
exercise on fatigue in patients undergoing a series of cancer treatments (Mock, Pickett et al., 2001;
Mock, Ropka et al., 1998).
Levine’s theory has also been used to describe pressure ulcers, as well as in developing dif-
ferent nursing therapeutics to heal the wounds that result from these ulcers (Burd, Langemo et al.,
1992; Burd, Olson et al., 1994). Her theory has been used to guide both investigations as well as
the discussion sections of research studies that focused on understanding the relationship between
fatigue as an alteration in physiologic function and expenditure of energy (Mock, St. Ours, Bositis,
Tillery, et al., 2007; Delmore, 2006; Allvin, Berg, Idvall, and Nilsson, 2007). It has proved to be a
useful framework to use in describing how illness undermines the physical, structural, and social
integrity of individuals, whether due to hearing changes or intrusive procedures (Irvin, 2007), and
in designing theory-based interventions such as an exercise program for patients with cancer
(Mock, St. Ours, Hall, Bositis, Tillery, et al., 2007).
In Levine’s tradition of integrating liberal arts with nursing, the use of music therapy in the
acute care setting was investigated. The recommendation of the authors is to emphasize how signif-
icant the support of educators and administrators is in facilitating the use of music therapy as a
helpful tool to conserve physical and emotional energy from anxiety (Gagner-Tjellesen, Yurkovich,
and Gragert, 2001). (Levine would be pleased!) The theory was used to identify a nursing diagnosis
of infection risk at preoperative time (Piccoli and Galvao, 2001). The theory also lends itself well to
being utilized as a framework for complementary therapies (Mantle, 2001).
It is refreshing to see attempts to identify different schools of thought that inform nursing
phenomena and to simultaneously uncover similarities that could lead to more refinement of theo-
ries. Energy, a major concept in Levine’s theory, is also addressed by Martha Rogers (1964,
1970), as well as by Florence Nightingale (1969). Todaro-Franceschi (2001) identified two ideas
of energy in nursing: energy as part of a process and energy as a phenomenon. She concluded that
Levine’s energy is more mechanistic, as part of casual processes, whereas Rogers’ idea of energy
is as a phenomenon not necessarily observable, measurable, or quantifiable. However, for both,
the common thread is that change is purposeful and depicted by transformation. Nurses can assist
human beings with energy transformation/interchange, and this transformation/interchange of
person and environment is purposeful.
Theories are judged by the extent to which they guide subsequent work, although Levine’s
theory has had limited impact on the research enterprise in nursing. The stimulation of dialogues
about significant phenomena in nursing, such as the one offered by Todaro-Franceschi based on
Levine’s theory, is encouraging and indicative of the robustness of Levine’s ideas.
BETTY NEUMAN
Theory Description
The client open system is the focus of Neuman’s systems theory (she calls it Neuman systems
model). This system is open to environments but maintains stability and integrity through elabo-
rate circles of protection and defenses; the goal of nursing is to prevent instability or to bring a
state of stability to individuals who need or are receiving nursing care. Questions that led Neuman
to develop her conceptualization in the early 1970s arose when teaching a graduate course in com-
munity mental health consultation (Neuman, 2002a). The central questions for this theory are:
How can nurses organize the vast knowledge needed to deal with complex human situations that
require nursing care? How do nursing clients interact, adjust to, and react to stress? Neuman con-
siders her theory to be wellness-oriented, and she provides a holistically focused conceptualiza-
tion of clients, as well as a holistic view of nurses (Neuman, 1989a, 1995). Neuman articulated a
number of basic assumptions about client systems, environmental stressors, responses to stress,
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CHAPTER 13 On Outcomes 301
lines of resistance and defense health, energy, and wellness (Neuman, 1989a, pp. 17–22; Neuman,
2002b). These explicit assumptions are described in Box 13-8. Central concepts of her theory are
presented in Box 13-9.
To Neuman, nurses deal with each client as a whole. Nursing clients are people who are
anticipating stress or who are dealing with stress (Neuman and Young, 1972). A client, also
referred to as a client system, encompasses four dimensions: an individual or a person, a family, a
community, and a social issue. Whether well or ill, a client is composed of dynamic interrelated
components of five variables. These are the physiological variables, which are related to body
structure and function; psychological variables, which are related to mental processes and interac-
tive environmental responses; sociocultural variables, which are related to the integrated influences
of sociocultural conditions; the developmental variables, which are related to age and development;
and the spiritual variables, which are related to beliefs and influences that are spiritual (Neuman,
2002b). The spiritual aspects of Neuman’s theory were absent in her earlier conceptualization
(Neuman, 1982). They were added to other variables and developed in her conceptualizations of
the composite client system (Neuman, 1989a, 1989b), and they were further developed in her sub-
sequent writings.
BOX 13-8 ASSUMPTIONS—NEUMAN*
1. Nursing clients are dynamic; they have both unique and universal characteristics and are in constant
energy exchange with environments.
2. The relationship between client variables—physiological, psychological, sociocultural, developmental,
and spiritual—influence a client’s protective mechanisms and determine a client’s response.
3. Clients present normal range of responses to the environment that represent wellness and stability.
4. Stressors attack flexible lines of defense, then normal lines of defense.
5. Nurses’ actions are focused on primary, secondary, and tertiary prevention.
*These assumptions are based on Neuman (1995).
BOX 13-9 CONCEPTS—NEUMAN
Person/client system (individual, family, community,
social issue)
Physiological
Psychological
Sociocultural
Developmental
Spiritual
Basic structure/central core
Flexible line of defense
Normal line of defense
Lines of resistance
Stressors
Intrapersonal
Interpersonal
Extrapersonal
Environment
Internal
External
Created
Health
Optimal client system stability
Wellness
Stability
System integrity
Prevention and interaction
Primary
Secondary
Tertiary
Reconstitution
Theory of optimum client system
stability
Theory of prevention
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302 PART FOUR Reviewing and Evaluating: Pioneering Theories
The client or client system is defined in terms of a core structure and a series of concentric
circles, in addition to the five variables. The core structure includes basic survival factors that are
universal and that characterize all species, as well as all unique features of a particular client sys-
tem. The basic universal survival factors are the innate and genetic factors and natural strengths
and weaknesses of the system. Therefore, according to Neuman, this component of the universal
core structure is where the innate factors that regulate temperatures, the genetic response patterns,
and any innate strengths or weaknesses in all body organs are found. However, this core structure
also contains those unique aspects of a client system that characterize a person, such as cognitive
abilities. A client’s response patterns are determined and regulated by this core structure. Both
universal and unique features of a client system are described by Neuman as normal temperature
range, genetic structure, response pattern, organ strength and weakness, ego structure, and
“knowns” or commonalities (1989a, pp. 27–29; 2002b).
A client system is also described through two lines of defenses: a flexible one and a normal
one (Neuman, 1982). All environmental stressors first attempt to attack the flexible line of
defense. It is visually represented in Neuman’s diagrams as the outermost circle surrounding the
basic core structure of energy sources; the line is depicted as broken to signify its flexible nature.
It is a buffer to a client’s normal line of defense, also known as the “client’s normal or stable
state.” The function of this line of defense is to fight the invasions of stressors or to fight the
responses to stressors. Neuman (1989a, 2002b) describes this line of defense as:
. . . accordionlike [sic] in function. As it expands away from the normal defense line, greater
protection is provided; as it draws closer, less protection is available. It is dynamic rather than
stable and can be rapidly altered over a relatively short time period or in a situation like a state
of emergency or a condition like undernutrition, sleeplessness, or dehydration. (1989a: pp. 28
and 29; 2002b, p. 17)
The function of the flexible line of defense as buffer to the normal line of defense is rendered inef-
fective by some stressors, singularly or in groups. The stressors will then attack the normal line of
defense, and when that in turn becomes ineffective in warding off the effect of the stressor—
allowing it to penetrate the core structure or allowing reactions to stress to occur—then a response
to stress will be manifested. Responses are described as instability or illness.
The normal line of defense is another component of the client system. It is vital in protecting
the basic core structure and integrity of the system. “This line represents what the client has
become, the state to which the client has evolved over time or the usual wellness level” (Neuman,
1989a, p. 30; 2002b, p. 17). Although not quite as flexible as the flexible line of defense, the nor-
mal line of defense still has the capability of expanding or contracting over time. It is depicted by
a solid circle surrounding the next layer of the client system, which denotes the lines of resistance.
This is where system stability and integrity are manifested, and this is where the normal patterns
of wellness levels for the client system are found. Its dynamic nature is apparent in its ability to
remain stabilized in dealing with stressors. Levels of stability could be determined through the
analyses of lines of defense, lines of resistance, basic structure, energy resources, or survival fac-
tors interacting with the five sets of variables, physiological, psychological, sociocultural, devel-
opmental, and spiritual (Neuman, 2002b).
Stressors singularly or in groups could continue to penetrate the client system, heading for its
basic structure and energy resources. Before the stressor is allowed to influence the basic core of a
client system, however, it has to penetrate what Neuman calls lines of resistance. These lines,
which are involuntarily activated, are represented by three broken concentric circles surrounding
the core of a client system. As a stressor succeeds in penetrating the normal lines of defense, the
lines of resistance are activated. “These resistance lines contain certain known and unknown inter-
nal factors that support the clients’ basic structure and normal defense line, thus protecting system
integrity” (Neuman, 1989a, p. 30).
A question that could be posed is: Are there common stressors for all client systems? Neuman
Systems Model Research Institute selected “stressors attacking client systems” as a potential focus
for collaboration. An integrative study was initiated to discover the results of studies conducted by
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CHAPTER 13 On Outcomes 303
researchers who used Neuman’s theory as a framework between 1983 and 2005 (Skalski, DiGero-
lamo, and Gigliotti, 2006). The findings delineated five client populations as subjects of the
reviewed studies: caregivers, cancer survivors, ICU patients, care receivers, and parents of chil-
dren undergoing surgeries. The authors concluded that the stressors identified were dependent on
context, and that middle-range theories could be developed specifically related to any one client
group, such as caregiver role strain or cancer survivors. These situation-specific stressors activate
and attack different lines of resistance and defense.
Neuman provides the “mobilization of white blood cells” as an example of activation of a
line of resistance. If lines of resistance succeed in warding off stressors, that is, “reversing the
reaction to stressors,” then the client system reconstitutes its energy resources and basic structure
(Neuman, 1989a, p. 31). If lines of resistance fail, then energy is depleted. The degree of energy
depletion goes from minimal to death.
Each one of these concentric circles has a major function. The flexible line of defense shields
the normal line of defense; the normal line of defense is a buffer to each of the lines of resistance;
and all these lines combine function to prohibit the stressor from invading the core structure of a
human being. All the lines combined also protect the core structure from reacting to stress. Each
defense and resistance line varies according to such variables as age and development (Neuman,
1995).
Nurse theorists were asked to reflect on how their theory related to the stressor “adversity.”
Gehrling and Memmott (2008) responded on behalf of Neuman’s theory. In the face of adversity
(i.e., extremely unfavorable conditions, situations, and experiences), the lines of defense are acti-
vated. However, in the process, the client (person, family, or a community) experiences a state of
imbalance, which is, in Neuman’s terms, a result of the adverse event. The client system faces the
task of attempting to become more stable (Neuman, 2002b). Reconstitution is the process of
bringing back a balanced outcome, with or without a nurse’s event. Nursing action is designed to
return the system to a balanced state. During reconstitution, nurses strengthen the client system
through such interventions as correcting misperceptions, strengthening coping strategies, and pro-
viding support (Gehrling and Memmott, 2008).
According to Neuman, environments are internal, external, and created, and all may influ-
ence a client system in a circular fashion (Table 13-3, p. 304). Client systems and environments
relate reciprocally, and the outcome of this relationship is corrective or regulative for the client
system. The internal environment is intrapersonal; the external environment includes the interper-
sonal and extrapersonal components; and the created environment is a composite of the intraper-
sonal, interpersonal, and extrapersonal components. Neuman described the internal and external
environments in the following way:
The internal environment consists of all forces or interactive influences internal to or contained
solely within the boundaries of the defined client/client system. It correlates with the model
intrapersonal factors or stressors. The external environment consists of all forces or interactive
influences external to or existing outside the defined client/client system. It correlates with both
the model’s inter- and extrapersonal factors or stressors. (Neuman, 1989a, p. 31)
The created environment is dynamic and is an interface that exists and connects the internal
and external environments (Neuman, 2002b). Although the created environment may be created
unconsciously by a client, it acts as a reservoir for the existence or maintenance of the integrity of
the client system. The expressions related to this environment are conscious, unconscious, or both.
The environment infiltrates all systems and all structures; it is purposeful, and it protects the func-
tions of client/client systems.
The insulating effect of the created-environment changes the response or possible response of
the client to environmental stressors, for example, the use of denial or envy (psychological),
physical rigidity or muscular constraint (physiological), life cycle continuation of survival
patterns (developmental), required social space range (sociocultural), and sustaining hope
(spiritual). (Neuman, 1989a, p. 32; 2002b, p. 20)
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304 PART FOUR Reviewing and Evaluating: Pioneering Theories
The goal of the created environment is the unconscious stimulation of the client’s health. It
includes self-esteem, values, beliefs, and energy exchanges. Therefore, caregivers should explore
ideas, beliefs, and fears as much as they explore symptoms and other causal factors. Finally, we
should remember that energy is continuously flowing between client and environment. The purpose
of the caregiver’s assessment and intervention is to bring optimal stability, which is the best possible
state of wellness. Determining levels of wellness is accomplished through a consideration of client
energy levels (Neuman, 1989a, p. 33). When more energy is expended than generated, the client sys-
tem moves to entropy or illness. As more and more energy is expended, and less and less energy is
being generated, death may result. Neuman defined entropy as “a process of energy depletion and
disorganization, moving the system toward illness or possible death” (Neuman, 1989a, p. 48).
To Neuman, stressors occur within the internal and external environmental boundaries of
clients and have the potential for disrupting the stability of the client system (1989a, p. 50). Stressors
attempt to penetrate the flexible and normal lines of defense, and the results are positive or negative
responses. How a client system responds to stress is determined by the resistance demonstrated
through lines of defense and resistance, and by the dynamic relationship of the five variable areas
TABLE 13-3 DEFINITION OF DOMAIN CONCEPTS—NEUMAN
Nursing Is concerned with all and potential stressors. Deals with assessment of effect and
potential effects of environmental stressors (Neuman, 1989a, p. 34).
Goal of nursing To keep client’s system stable. To assist clients to adjust, which is a requirement for
optimum wellness level (1989a, p. 34). “Facilitate optimum wellness for the client
through retention, attainment or maintenance of client system’s stability” (1989a,
p. 25; 2004, p. 3–33).
Health Health is wellness. It is a point on a continuum running from greatest negentropy to
maximum entropy (1989a, p. 25). When all parts of a client are in harmony or in bal-
ance, and when all needs are met, optimal health is achieved. Health is also energy.
Optimal is the best possible health state achievable.
Human being A physiological, psychological, sociocultural, developmental, and spiritual being. Rep-
resented by central structure, lines of defense, and lines of resistance.
Nursing client A human being, family, group, community that is threatened with, or that is attacked
by, environmental stressors.
Environment “All internal and external factors or influences surrounding the identified client or
client system.” Three types of environments were identified: internal, external,
and created. The stressors are part of the environment. The internal environment
is contained within the boundaries of the client system. The external environment
contains forces outside a client system. The created environment denotes a
client’s unconscious mobilization of such structural components as energy factors,
stability, and integrity (1989a, pp. 31–33, 1995).
Nursing problem A whole client system threatened with or actually manifesting responses to
stressors.
Nursing process Neuman describes three central steps: nursing diagnoses, nursing goals, and out
comes (1989a, pp. 39–41).
Nurse–patient relations Not discussed.
Nursing intervention Prevention is the intervention identified by Neuman. There are three components
in her prevention as intervention typology: primary, secondary, and tertiary.
Reconstitution is part of tertiary prevention.
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CHAPTER 13 On Outcomes 305
(Neuman, 2002a) described earlier. Stressors, to Neuman, can be intrapersonal, which occur
within the boundary of the client system. Or, stressors can be interpersonal, which are external
environmental forces outside the boundary of the person, but within what she calls the proximal
range, which is between one or more roles or systems of communication. The third set of stres-
sors, the extrapersonal stressors, are external to the individual boundaries; she calls this a distal
range, such as policies, economics, or other social concerns (Neuman, 2002b).
Nurses focus their attention on responses that are labeled stressful, and these responses are
within the domain of nursing. The nurse diagnoses the level of stability, internal and external envi-
ronmental stressors, and the effect of stressors on a client’s system stability (Neuman, 2002c).
The goal of the caregiver is to maintain or to bring about the system’s stability, a process Neuman
calls reconstitution. Reconstitution brings the system to a state of stability or wellness that is higher or
lower than the previous state. Nursing actions are described in terms of prevention. Prevention is pri-
mary, secondary, or tertiary. Those preventive aspects of care that occur before the stressors invade the
client system are primary. Primary prevention identifies potential stressors and augments positive cop-
ing and function. When stressors attack the client system, nurses mobilize and support internal and
external responses, protect the core structure, facilitate treatment, and continue with any needed primary
prevention. These actions are described by Neuman as secondary prevention (Neuman, 1989a, p. 21;
1989b, p. 56; 2002c). Tertiary prevention takes place after the system has been treated through second-
ary prevention strategies. Tertiary prevention provides support to the client and attempts to add energy to
the system or reduce energy needed in order to facilitate reconstitution (Current Nursing, 2010).
Neuman (2002b, p. 30) acknowledges the development of two theories as extensions from
her model. With Audrey Koertvelyessy, she identified the major theory of the model as the theory
of optimal client system stability, as well as a proposed theory of prevention as intervention (cited
in Neuman, 2002b, p. 31).
Fawcett (2005, p. 184) identified three middle-range theories derived from Neuman’s model.
Based on client system stability, a theory of optimum student system stability was developed by
Lamb (1999), a theory of well-being by Casalenuovo (2002), and a theory of infant exposure to
tobacco smoke by Stepans and Knight (2002). In Lamb’s theory, student and faculty levels of inter-
action are related to their level of stress. In the Casalenuovo theory, the research proposes that
stress, fatigue, and well-being are related in patients with diabetes. And, in the third theory, Stepans
and Knight focused on the relationship between stress generated by environmental tobacco smoke
and the normal lines of defenses, and sudden infant death syndrome. However, Gigliotti (2003)
concluded that no explicit middle-range theories have been generated from Neuman’s model.
Theory Analysis
The Theorist
Betty Neuman, a community mental health nurse, received her bachelor’s degree in nursing
in 1957, and master’s degree in nursing in 1966 from UCLA. She started her teaching job in 1966
(when we became office mates at UCLA), and was charged with coordinating the community
mental health consultation clinical specialist program.
Although the UCLA faculty was busily operationalizing and implementing Johnson’s theory at
that time, Neuman was uninvolved in this process. She was concerned about the development of a
framework to describe the consultation role of nurses, one that could help students describe and
explain their actions and the rationale for their actions. The result of that concern was the develop-
ment of her theory of a client who is in need of health care. Because the role of community mental
health consultant is not necessarily exclusively a nursing role, this may explain why Neuman main-
tains in her writings that her theory is designed for use by any health professional (Neuman, 2002a).
Neuman has worked as a teacher, consultant, and writer, and she has maintained a small pri-
vate practice as a licensed marriage and family counselor. She taught programs in stress reduction
and in self-help for retarded children. Neuman received a doctorate from Ohio University in 1985.
Currently, she is retired; however, she continues to lecture, write, and consult, and she is a consult-
ant for the Neuman Systems Model implementation trustee group (Neuman, 1989c, p. 453; 2002a).
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306 PART FOUR Reviewing and Evaluating: Pioneering Theories
Paradigmatic Origins
Neuman’s theory has several paradigmatic origins (Neuman, 2002a). One origin explicitly
identified by Neuman is systems theory, as conceptualized by Bertalanffy (1968). Neuman used
Caplan’s (1964) preventive functions, which she used in teaching the master’s program in com-
munity mental health to define the levels of actions of nurses (Neuman, 1989c). Other origins
identified by Neuman are Chardin’s (1955) conceptualization of wholeness; Putts’ (1972)
application of systems theory in nursing; ideas about adaptation and environment (Neuman,
1989a, p. 12); Marxist ideas of synthesis of man and environment (Cornu, 1957); Gestalt psy-
chology (Edelson, 1970), in which the interactions of people and their environments are
described; and Selye’s (1950) ideas about stress and bodily responses. Neuman relied heavily
on these sources, which are all equally appropriate for use by mental health workers. It is the
multiplicity of Neuman’s sources that provides the breadth in her theory and its potential inter-
disciplinary nature.
Internal Dimensions
This is a highly abstract and deductive theory, constructed from hypothetical beginnings,
and it was derived from a number of paradigms. The theory is hierarchical, evolving from a set
of principles describing relationships between lines of defense, lines of resistance, basic struc-
ture, and energy resources. Neuman’s is a field theory that explains the relationship of a client
system to the environment, and it is a macrotheory that attempts to describe client system rela-
tionships with the environment and nurse actions in any situation that requires nursing care. The
theory has a broad scope; it provides a framework that describes components of the domain of
nursing as a whole. It is also a grand theory of the nursing client, and it explains the primary,
secondary, and tertiary prevention needs of nursing clients and the nursing actions for each level
of prevention.
Neuman’s theory was constructed through the synthesis of different theories that she believed
are essential for use by community mental health consultants in their practice. Examples of such
theories are systems theory, crisis theory, Gestalt theory, and stress and adaptation theory. Neu-
man’s theory was also developed to identify a nurse’s actions and the focus of such actions. It pro-
vides a comprehensive description of nursing clients and a framework to describe nursing
interventions. It describes knowledge of order; that is, it provides a descriptive account of the nor-
mal structure of client’s systems, the patterns by which stress tends to attack human beings, and
the layers of resistance and defenses that ward off stress. The theory lacks a framework to identify,
describe, and explain the different patterns of responses to stress.
Neuman’s theory is logically developed, as demonstrated in her conceptualization of a client
system as having several parts, with these parts interacting and relating to form a larger whole, and
the system grows more complex through the addition of new parts (Barnum, 1998). Three preven-
tions as interventions (primary, secondary, and tertiary) are identified, leaving the question of why
other intervention actions are excluded, or, if included, where they should be placed within the
conceptualization of prevention as intervention. Are there interventions that are not for preven-
tion? Caring for patients in a critical situation may prompt questions about the rationale and
assumptions for including all nursing interventions within a prevention framework. There are
other critical questions to consider in reviewing this theory. Neuman addresses antithetical and
mutually exclusive concepts without addressing their complementarity and supplementarity.
Examples are stability and dynamism, the conscious and unconscious environments, and holism
and isolated responses (e.g., psychological responses of denial). The relationship between these
opposites and the ways in which they are synthesized could be considered by others who are
attempting to extend and develop the theory further.
This theory has many strengths, acknowledged by its scope of utilization. One of these
strengths is Neuman’s use of clear diagrams. These diagrams, used in all the descriptions of her
theory, make it visually appealing; they enhance its clarity and provide nurses with opportunities
to consider the logic and interrelationships between theory concepts.
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Theory Critique
Neuman clearly identified some assumptions on which her theory is built (Fawcett, 2005).
However, some implicit assumptions are not well defined, such as valuing the individuality of
clients (Lancaster and Whall, 1989, p. 262), which was not addressed in her later work (Neuman,
2002a). In addition, although a client or a client system is defined as families and communities,
Neuman does not identify assumptions related to such potential. Values inherent in nursing in
relationship to the role of patients in maintaining and promoting their own health and their respon-
sibility in seeking and utilizing health care are also not well addressed.
The central concepts of Neuman’s theory have, over the years, been clarified conceptually.
Utilizers of the theory have added to that clarity (e.g., Lowry and Anderson, 1993; Neuman and
Fawcett, 2002), and her theory is used as a framework for concept analysis and development.
Reed (2003) clarified the concept of grief by using Neuman’s theory as a framework, finding
it more suitable to uncover and identify the attributes of the concept. By using Neuman’s theory,
Reed defined antecedents, modifiers to grief responses, consequences, and nursing intervention
strategies to help with reconstitution of client systems, and she identified ranges of normal
responses that Neuman (1995) called the wellness–illness continuum. Various degrees of grief
responses could occur depending on the balanced effect on the client system and the management
of resources. Neuman’s theory, from Reed’s (2003) analysis, allows the outcome to be the devel-
opment of new reality and new identity in the client system through interactions that occur with
the environment.
Neuman discusses her conception of health in terms of living energy, met needs, the degree to
which the five client variables are harmonious, and by the amount of energy required to seek and
maintain system stability. Although she relates this conception to the World Health Organization’s
definition of health (Haggart, 1993), this relationship can only be inferred. Similarly, wellness and
health are used interchangeably.
Neuman (1989c) describes a wide circle of contagiousness for the theory that spans the
United States and other countries (also see Fawcett, 2005). Use of her theory encompasses all edu-
cational and a variety of nursing programs. She details an impressive list of utilizers of her theory
during the 1970s and 1980s (Neuman, 1989c, pp. 460–466), as well as during the 1990s and
2000s (Neuman and Fawcett, 2002; Fawcett, 2005). According to the board of trustees of Neuman
System Model International (NSMI), many global collaborations have utilized this theory. One
example is its use in Holland as a guide for the administration of nursing services (Lowry, Beckman,
Gehrling, and Fawcett, 2007).
In addition, as Fawcett (2005, pp. 166–282) described and documented, this theory is well
presented but perhaps not as well refined and extended. Many books, monographs, and confer-
ences reflect its use in many corners of the world. There are also symposia held every 2 to 3 years
in which those who use the theory are stimulated, inspired, and challenged by one another’s work.
The dialogues created by those who provided integrative analysis of the research generated
by the theory (Fawcett and Giangrande, 2001; Breckenridge, 2002) are vital for its continuing
refinement and extension. Similarly, critical reviewers of tests for middle-range theories (Gigliotti,
2003), identifying and critiquing instruments used for concepts generated from the theory
(Gigliotti and Fawcett, 2002), as well as analysis of the international research based on Neuman’s
theory (Pothiban, 2002; McDowell, Chang, and Choi, 2003) are fostering a process of building
knowledge to describe the client system and its defense mechanism against stressors. The use of
this theory could enhance research program development, which in turn could advance knowl-
edge, but only if the theory informs all aspects of the research process, including interpretation of
results. This is not always the case in the utilization of Neuman’s theory in research, as is illus-
trated in this section.
The utility of Neuman’s theory has been demonstrated in the diversity of its use (Campbell
and Keller, 1989). Neuman (1989b) describes patient situations in which her theory could be used
in suicide counseling, and Lillis and Cora (1989) provide an analysis of its use in a case study.
Neuman’s theory has been used in community health nursing settings (Beddome, 1989; Benedict
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308 PART FOUR Reviewing and Evaluating: Pioneering Theories
and Sproles, 1982; Newman, 2005), as a framework for family assessment (Reed, 1989), as a
guide for assessing and intervening in dysfunctional families (Herrick and Goodykoontz, 1989),
for preventing abuse in the elderly (Delunas, 1990), in caring for patients in hospital settings
(Brink, Neuman, and Wynn, 1992; Burke, Capers, O’Connell, Quinn, and Sinnott, 1989), as a
framework for perinatal nursing (Dunn and Trepanier, 1989), for assessing renal patients (Brecken-
ridge, 1989), for interstitial cystitis symptom control (Kubsch, Linten, Hankerson, and Wichowski,
2008), in critical care (Bergstrom, 1992; Heffline, 1991), as a framework for patients recovering at
home from myocardial infarction (Ross and Bourbonnais, 1985; Smith, 1989), in the care of
patients positive for human immunodeficiency virus (Pierce and Hutton, 1992), and for nursing dur-
ing the acute stage of spinal cord injury (Foote, Piazza, and Schultz, 1990; Hoeman and Winters,
1990; Sullivan, 1986). Neuman’s theory also was adopted in the community to integrate services for
the elderly (Neuman, Newman, and Holder, 2000).
What is distinctive about this theory is that it is used as a holistic framework, and many types
of interventions can be grouped together to use for patients, nurses, students, and administrators, all
under the rubric of the theory. For example, in designing an intervention for managing symptoms of
interstitial cystitis, the authors proposed a variety of interventions to promote system equilibrium
including centering, lived experience interview, journaling, progressive muscle relaxation, guided
imagery, acupressure, reflexology, and meditation. In developing the framework for intervention,
the authors contended that a holistic approach based on Neuman’s theory provides opportunities
for primary prevention/intervention to strengthen the patient’s flexible line of defense, thus pre-
venting stressors from entering the system (relaxation and meditation). Other modalities are for
other lines of defense and for prevention (Kubsch, Linton, Handerson, and Wichowski, 2008).
Buchanan (1987) offers a modification of the theory for use with aggregates, families, and
communities. She clarified and added an extension to each of the central theory concepts; how-
ever, the major additional contribution appears to be the collaborative decision-making process.
These additions are congruent with Neuman’s rationale for the development of her ideas, which is
the development of a framework to be used by different members of the health care team. The the-
ory has been used to anticipate vulnerability to nursing education, to identify stressors on stu-
dents, and to develop intervention strategies to help them cope with nursing education (Meyer and
Xu, 2005; Moscaritolo, 2009). It is of note that the strategies developed to ward off the anxiety
and stress that nursing students experience due to the challenges they confront during their educa-
tional years—a threat to their success—are holistic. Reflecting and being true to Neuman’s frame-
work, these strategies include humor and mindfulness, yoga, meditation, and body scan awareness
exercises. The Neuman theory provided a comprehensive framework for faculty and students to
increase their wellness and mobilize their normal lines of defense as they entered practice
(Moscaritolo, 2009). The extensions to many populations are also congruent with the theory’s
assumptions and the intent of the theorist to provide a framework for clients and caregivers. The
theory’s potential application to the caring of people with different cultural heritages was dis-
cussed by Sohier (1989) and demonstrated in studying the caring for aged parents by African
American daughters (Jones-Cannon and Davis, 2005). Fawcett (2004) demonstrated through
interviews that Neuman’s theory is used internationally (e.g., in Holland).
There are many accounts of the use of Neuman’s theory in curriculum development. These
examples were collected by Neuman in a book of readings (Neuman, 1989a). This collection
demonstrates the extensive utility of her theory for baccalaureate and associate-degree programs,
as well as for a framework for multilevel planning. In addition, an entire section in Neuman and
Fawcett’s 2002 book is devoted to Neuman’s model for utilization in nursing education. In addi-
tion, Newman, Neuman, and Fawcett (2002, pp. 193–215) identified and discussed guidelines for
using the theory in education for health care professions, and they provided a prototype curricu-
lum for each educational level in nursing. How this model differentiates the goals of nursing from
those of other disciplines is not entirely clear.
There are many examples of its utility in developing nursing curricula. Louis and Koertve-
lyessy (1989) surveyed schools of nursing to determine the use of nursing models in curricula and
research. The questionnaires contained specific information related to the use of Neuman’s theory.
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CHAPTER 13 On Outcomes 309
The response rate of 38% was analyzed, and the results indicated that 92% of the responding
schools used one of 26 nursing models in their graduate programs as a framework. The respon-
dents identified 41 different models studied by graduate students, and Neuman’s was one of the
most cited models.
Neuman’s theory is also reported to have guided the development of curricula in the United
States (Cammuso and Wallen, 2002; Lowry, 2002) and in other countries. For example, it is used
in Neuman’s college (Mirenda, 1986), as well as in a framework for programs in transition from
associate to baccalaureate programs (Lowry and Jopp, 1989; Sipple and Freese, 1989); as a frame-
work for the experiences of some specific students (Dale and Savala, 1990); as a framework for
cooperative (two-school) baccalaureate programs (Nelson, Hansen, and McCullagh, 1989); as a
framework for interdisciplinary graduate education; and as a way to think about curricula (Lowry,
2002). The faculty and administrators in most of these programs find Neuman’s theory clear; it
provides a holistic vision of nursing—a clear nursing perspective; and it provides an emphasis on
client’s perceptions—a useful framework for the analysis of clients. One example of this evalua-
tion is provided in Nelson et al. (1989).
There are many indications of the theory’s international use; examples are provided by Ross,
Bourbonnais, and Carroll (1987) and Bourbonnais and Ross’ (1985) descriptive accounts of the
theory’s utility for the fourth and final year of a baccalaureate program in Canada. Story and Ross
(1986) demonstrated the theory’s effective utility in the development and implementation of a
framework for clinical learning experiences for nursing with families of the elderly at home.
These authors also discussed the feasibility of using multiple nursing theories within the same
curriculum to guide different learning experiences.
The theory has also been used in programs that have different organizational affiliations. For
example, Mrkonich, Hessian, and Miller (1989) describe using Neuman’s theory as a framework
for three accredited baccalaureate nursing programs that are situated in private, religious, and lib-
eral arts colleges. The authors report that the theory’s use was enhanced by its common language,
which facilitated communication among health care professionals (p. 93). They also credit the the-
ory for its potential to stimulate research and further development of theory (Mrkonich, Miller,
and Hessian, 1989). Mirenda (1986) describes the Neuman college nursing process tool that was
developed to be used by students in assessing nursing clients. The tool is reported to help students
use Neuman’s theory clinically. A thorough review of the use of Neuman’s model in developing
educational tools is provided by Reed (2002), who concludes that there is a surprising paucity of
educational tools based on Neuman’s model, considering its extensive use in education. The two
potential explanations for this paucity are either that utilizers of her theory are not publishing the
tools they develop, or that the complexity and abstractions of theory make it difficult to translate it
into the development of tools (Reed, 2002). The richness of the diagrammatic representation of
the theory concepts and relationships has helped faculty members in one college devise visual rep-
resentations to assist students in learning about conceptual models (Johnson, 1989) and prompted
the development of slide shows, videotapes, and the Neuman Systems Model Trustee Group, Indi-
vidual, which is charged with the task of seeing that Neuman’s theory flourishes and continues to
be used accurately.
The theory’s utility in administrative practice has also been the subject of many dialogues. In
an integrative analysis of such use, Sanders and Kelley (2002) demonstrated its use in a variety of
health care agencies in the United States, as well as in Canada and Holland (de Munck and Murk,
2002) among other countries (Neuman and Fawcett, 2002, Appendix B, pp. 338–341).
As an example, it was used as a framework for community health administration (Drew,
Craig, and Beynon, 1989), and it was used as a framework for the reorganization of structure and
function of the nursing department at Jefferson Davis Memorial Hospital (Hinton-Walker and
Raborn, 1989). Kelley, Sanders, and Pierce (1989) describe its utility in guiding nurse administra-
tors in their management and leadership roles in educational and practice settings. They also report
the development of a tool for assessing and evaluating “conditions upon which the nurse adminis-
trators’ goals are established and modified” (p. 129). It is also used in developing research in clini-
cal areas, in finding and interpreting evidence for best practices, and to implement evidence-based
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310 PART FOUR Reviewing and Evaluating: Pioneering Theories
practice through the Research Approach in Nursing (RAIN) that was developed and implemented
by Breckenridge (2011).
The Neuman Systems Management Tool, well described and illustrated, is tailored to provide
administrators with a guide for actions and decisions within 3 minutes of use. No reports of valid-
ity or reliability of the tool were provided. Others report its use in the development of nursing care
plans (Capers and Kelly, 1987), as well as its use in the planning and implementation in nursing
practice (Capers, O’Brien, Quinn, Kelly, and Fenerty, 1985). It is also used as a framework for
nursing education and to guide the care in nursing homes in the United States and internationally.
External Components of Theory
Neuman’s theory is congruent with values about holism in nursing and the reciprocal rela-
tionship between environments and client systems. The theory is also highly useful for nurses who
tend to speak in terms of prevention rather than treatment or intervention (Box 13-10). The the-
ory’s focus on involvement of clients and on assessment that includes defense and resistance is an
acceptable nursing focus. The theory is particularly useful for nurses who believe that all health
care professionals share the same goals and actions. In proposing the universality of assessment
and intervention among the different health care professionals, Neuman failed to identify the
unique contributions of nurses to the health care team.
Theory Testing
Several integrative review analyses were done of published research that was done using all
or some components of Neuman’s theory (Louis, 1995; Gigliotti, 2001; Fawcett and Giangrande,
2001; Fawcett and Giangrande, 2002; Gigliotti, 2003). The latter was an extension of earlier
reviews, with the goal of using that integrative review to entice future researchers to fill in gaps in
the refinement and extension of the theory. Louis and Koertvelyessy (1989) report that they were
able to identify 38 research studies that used Neuman’s theory. They concluded that the studies
were descriptive, and that most of the concepts of Neuman’s theory were studied, with the excep-
tion of the spiritual variable. The researchers used the theory as an outline of the phenomenon, as
a framework for the methodology, and as a framework for interpretation and for implications. The
report did not include information on the nature of the studies, the findings, or the implications of
the findings on Neuman’s theory or nursing practice. No citations were provided.
Findings from all other integrative reviews indicate that Neuman’s theory, although generat-
ing increasingly more research studies (Louis, 1995; Harris, Hermiz, Meininger, and Steinkeler,
1989), dissertations, and theories (Fawcett and Giangrande, 2002), either shows study results that
failed to support a proposition in the theory (Ziemer, 1983) or the linkages between the theory,
methods, and operational definitions, or the shows that the discussion of the results are not clear
(Fawcett and Giangrande, 2001, 2002).
To decrease restrictions on clients in a mental health practice and to increase their safety,
Moore (2009) uses Neuman’s and Watson’s theories to identify, organize, and decrease intraper-
sonal, interpersonal, and extrapersonal stressors, and to enhance caring by increasing empathy,
support, and transpersonal care (protect dignity). The preliminary results indicate a decrease in the
average number of restrictions needed (Moore, 2009).
BOX 13-10 EXAMPLES OF PROPOSITIONS—NEUMAN
• Primary prevention prevents stressors from penetration of flexible line of defense.
• Primary prevention prevents stress responses.
• Secondary prevention enhances wellness and decreases stress.
• By supporting strengths of clients’ systems and conserving their energy, nurses can increase level of
wellness.
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CHAPTER 13 On Outcomes 311
In providing a fresh look at the Neuman Systems Model, Lowry (2009), a trustee of the Neu-
man Systems Model group, proposed that future challenges for the theory are the strengthening of
the research agenda and publications, utilizing technology in further developing the theory, and
marketing the theory to magnet hospitals (Lowry, 2009).
Despite the proliferation of the apparent use of the theory in research, there is no evidence for
systematic programs of research, or of how the results are used to refine, extend, or modify the
theory. Furthermore, none of the integrative reports included a meta-analysis of results due to the
lack of programmatic research. As Fawcett and Giangrande (2002, p. 137) conclude, the lack of
systematic and coherent programs of research precludes the potential of meta-analysis, which
decreases the credibility and utility of the theory.
Despite this limitation, Neuman’s theory has provided a useful framework for the study of
different populations and a wide range of phenomena, such as elder abuse (Kottwitz and Bowling,
2003), assessment of community health needs to implement a mini cardiovascular health fair
(Wilson, 2000), and examining the reactions of the elderly with rheumatoid arthritis to stress, lines
of defense, and resistance on their health (Potter and Zauszniewski, 2000).
Neuman’s theory provides a framework to organize information about the client system and
about how such a system may interface with stress through different lines of resistance and defense.
The “what,” “how,” and “why” of responses have yet to be described, explained, and tested.
Despite the limitations of Neuman’s theory in stimulating research, theory building, and
refining findings, its utility in the clinical and educational spheres has been amply documented.
MARTHA ROGERS
Theory Description
Rogers, a nurse leader and significant nursing theorist, specifically identified her theory,
which she called the science of unitary human beings (SUHB) as a conceptual system of nursing
intended to stimulate the development of nursing theories. Nursing theories, Rogers maintained,
could be developed only as a result of nursing research completed within the conceptual system
she conceived. In later work, Rogers relabeled her conceptualization as the science of unitary man
(1980a), and, even later, as a paradigm for nursing (Rogers, 1983a). She also changed the word
“man” to “human beings” and “individuals.” She proposed that the science of human beings is as
applicable to groups as it is to individuals (Rogers, 1992). Groups may be a family, a social group,
a community, a crowd, or any other combinations of individuals.
According to Rogers, examples of theories that may evolve from her paradigm are a “theory
of accelerating evolution,” a “theory for paranormal phenomena,” and “rhythmical correlates of
change” (1980a, 1987, 1992). Consistent with the premises of this book and based on the argu-
ments developed in Chapter 3 on conceptual frameworks and theory, Rogers’ conceptualization
will be treated here as a theory. As has been done with each theory, the analysis and critique are
provided to enhance an understanding of the theory, to explain its role in the development of nurs-
ing’s domain, and to encourage the further use, refinement, and development of the theory.
The central questions that Rogers attempted to answer are:
• What is the focus of nursing?
• What knowledge gives nursing an identity?
• Who is the nursing client?
• What is the relationship between a human being and an environment?
• What are the phenomena of concern in nursing?
• What knowledge is needed to develop the science of nursing?
• What are the outcomes of people’s interactions with their environment?
Rogers’ conceptualization of nursing as a distinct science is based on several explicit
assumptions, presented in Box 13-11, and it encompasses several major concepts, presented in
Box 13-12.
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312 PART FOUR Reviewing and Evaluating: Pioneering Theories
Most of Rogers’ concepts are unique to her conceptualization. The concept of a unitary
human being, with which Rogers’ name has become synonymous, is a primitive concept. All other
concepts are derived from a general systems theory (pattern, organization, negentropy), physics
(electrodynamic), an evolutionary theory (life process, helicy), and adaptation theories (home-
ostasis, adaptation). Her concepts are abstract, general, conceptually defined, and documented,
but they are limited in their operational referents, which may explain the slow wave of utilization
of this theory by nurses, but particularly by nurses who are in practice (Table 13-4). The use of her
theory is increasing over time, creating more diverse areas of knowledge expansion. And,
although there is a definite trend in differentiating her ideas (Fawcett, 2003a), there is another
dialectic trend toward integrating her theory (Watson and Smith, 2002), in developing concepts
BOX 13-11 ASSUMPTIONS—ROGERS
• Nursing is concerned with the life process of a human being, which is irreversible, along a space–time
continuum (Rogers, 1970, p. 59).
• The focus of the science of nursing is the unitary human being, his innovative wholeness, and his inte-
gral and continuous relationship with the environment. That relationship involves energy and matter
exchange. Matter is energy (1970, pp. 47, 54).
• There is pattern and organization in the wholeness of the unitary human being, but causality cannot
explain it (1970, pp. 53, 65).
• Conceptual systems are preludes to theories, and theories are tested in real life with a feedback to the-
ories. The cycle is continuous, open, and changeable based on changes in knowledge (1970, pp. 83–88).
• Unitary human beings are characterized by the ability to use abstraction, imagery, language, thought,
sensation, and emotion (1970, p. 73).
• Reality does not exist but appears to exist as expressed by human beings (1980, p. 333).
• Nursing is based on a humanistic and not a mechanistic model (1970, pp. 87, 138).
• Generalization can only occur from a study of the whole but not any of the parts in isolation.
• Human behavior demonstrates reason and feelings (1970).
• Unitary man possesses the ability to join in the process of change deliberately and with probability
(1983b, p. 222, 1986).
• The human field and its environmental field are postulated to be coextensive with the universe
(1983b, p. 222).
Implicit Assumptions
• Human behavior contains probabilistic and unpredictable nonrepeating elements that linear models
cannot grasp. These are usually referred to as “error variance” (Winstead-Fry, 2000, p. 280).
BOX 13-12 CONCEPTS—ROGERS
Unitary human being Life process
Human field Rhythmicity
Unitary environment Self-regulation
Environment field Negentrophy
Energy field Evolutionary emergence
Open Unitary human processes
Pattern and organization Helicy
Pandimensionality Resonancy
Unidirectionality Integrality
Sentience Unpredictability
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CHAPTER 13 On Outcomes 313
TABLE 13-4 DEFINITION OF DOMAIN CONCEPTS—ROGERS
Nursing A learned profession, a science of unitary human beings, and the art of “imaginative
and creative use of this knowledge in human service” (Rogers, 1980b, p. 122). It is
concerned with living and dying. Fields of practice span the gamut of in and out of
hospital, community, and outer space (Rogers, 1992). The central phenomenon of
concern is “the study of unitary irreducible human beings and their respective envi-
ronments” (Rogers, 1990, p. 108).
Goal of nursing To bring and promote symphonic interaction between a human being and his environ-
ment through participation in a process of change. This is done to “strengthen the
coherence and integrity of the human field and to direct and redirect patterning of
the human and environmental fields” (1970, p. 122).
Maximum health potential (p. 86).
“Meaningful life and meaningful transition from life to death” (1970, p. 125).
Health Health and illness are not dichotomous but continuous, are part of the same contin-
uum, and are an expression of the life process; they are socially defined. Health is
“characteristics and behaviors emerging out of the mutual, simultaneous interac-
tion of the human and environment fields” (1980b). One can extrapolate that
Rogers’ view of health could be the greater developmental coherence that evolves
from human being–environment energy fields that are novel, emerging, and more
diverse in pattern and organization. Health and illness are not differentiated, nor are
there any norms of health (Madrid and Winstead-Fry, 1986).
Environment “An irreducible, pandimensional, negentropic energy field, identified by pattern and
manifesting characteristics different from those of the parts and encompassing all
that is other than any given human field” (1983b, p. 222; modified in Rogers, 1992).
Human being “An irreducible, irreversible, pandimensional, negentropic energy field identified by
pattern and manifesting characteristics that are different from those of the parts and
which cannot be predicted from knowledge of the parts” (1983a, glossary). Unitary
human being develops through three principles: helicy, resonancy, and integrality.
Nursing client Human being–environment energy fields relationship (1970, p. 127).
Nursing problem Not specifically addressed because Rogers believes labels of problems and illness
are tentative and based on societal definition. Problems may denote changes in
wave patterns and organization and in rhythmical correlates of change (1980a,
pp. 334–335). Disharmony or lack of integrity in human being–environment energy
fields.
Nursing process Not specifically addressed. However, what Rogers says about scientific process
applies here: “The subjective world of human feelings must be incorporated into
so-called ‘objective science’” (1970, p. 87).
Nurse–patient relations Not addressed.
Nursing therapeutics “Repatterning of man and environment for more effective fulfillment of life’s capabili-
ties” (1970, p. 127). Beliefs in innovative therapeutic modalities such as therapeutic
touch (1985).
Focus “Activities of daily living” must be considered within the context of the opportunities
for human being–environment interchange that would stimulate the “flow of
repatterning commensurate with the openness of nature” (1970, p. 123).
Unitary human being in interaction with unitary environment. Human beings and
environment are energy fields.
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314 PART FOUR Reviewing and Evaluating: Pioneering Theories
(Plummer and Molzahn, 2009), and in developing and testing alternative and complementary ther-
apies (Ring, 2009a).
To Rogers, a unitary human being is an irreducible, indivisible energy field in constant inter-
action with the environment, which is a unitary energy field. Energy fields are not reducible or
divisible, nor are they the sum total of their parts, which may be physical, social, psychological, or
biologic in nature. In fact, human beings and environments do not have energy fields; they are
energy fields. They are open to exchange and extend to infinity. Energy fields are identifiable
through dynamic–nonstatic wave patterns, and through organization that changes from “lower fre-
quency, longer wave pattern to high frequency, shorter wave pattern” based on the principle of res-
onancy. Energy fields are pandimensional, transcend time and space, and therefore may have
imaginary boundaries that are unique and changeable (Rogers, 1980a, 1983b, 1986, 1992).
Rogers considers fields as open “unifying concepts.” Energy for her “signifies the dynamic nature
of the field” (Rogers, 1992, p. 30). Four concepts are basic to Rogers in her own last writings:
energy fields, pattern, openness, and pandimensionality (Barrett, 1990a). Change is one of the
basic tenets of her theory. Change is innovative, probabilistic, continuous, and relative. It furthers
the differentiation of human and environmental fields from lower to higher diversity. Change is
based on continuous interaction between a unitary human being’s energy field and the environmen-
tal energy field. Human development was cited as a goal (Rogers, 1970) and rejected later (Malinski,
1986). The end point is not balance or equilibrium; rather than an actual end point, there is a har-
mony that evolves and manifests in mutuality or integrality of the person–environment–energy
fields. These states of integrality, if we can call them states, are identified through patterns. Field pat-
tern, which has been a central idea for Rogers since the beginning of the formulation of her theory is:
. . . an abstraction. It gives identity to the field. The nature of the pattern changes continu-
ously. Each human field pattern is unique and is integral with its own unique environmental
field pattern. (Rogers, 1986, p. 5)
Rogers postulated three principles to describe the patterns of human being and environment
interactions and change (Rogers, 1986). These replaced an earlier conceptualization of the princi-
ples of reciprocity, synchrony, helicy, and resonancy (Rogers, 1970). To understand the nature,
direction, and power of change, one has to consider motion and changes in energy fields through
these principles, which were the cornerstones of her theory at its inception: resonancy, helicy, and
integrality. Resonancy describes the direction of change from lower to higher wave patterns. The
principle of helicy postulates that change manifested in increasing diversity and nonrepeating
rhythmicity is continuous and unpredictable. Integrality describes the nature and process of mutu-
ality between the human and environmental energy fields that negates a separation between those
fields (Fawcett, 2005, p. 316). All three principles are characterized by their continuity and are
manifested through patterns. Human and environmental fields are also characterized by their
“pandimensionality,” which replaced her earlier concepts of “four-dimensional” and “multi-
dimensional” (Rogers, 1992, p. 31). The change in this concept does not reflect a change in defini-
tions, only a change in label. Pandimensionality “is a way of perceiving reality,” “it expresses the
idea of a unitary whole,” and it reinforces the nonlinearity and lack of spatial and temporal charac-
teristics (Rogers, 1992, p. 32). The changes that the human and environmental fields experience
are continuous; they emerge out of nonequilibrium and are continuously accelerating.
Theory Analysis
The Theorist
It is difficult to think of the New York University nursing program without thinking of the
late Martha Rogers (who died in Arizona in 1994). It is equally impossible to consider environ-
ment as a central concept in nursing without immediately thinking of Florence Nightingale and
Martha Rogers. Both have left their imprints on nursing in more ways than one, but certainly on
theoretical nursing and, more particularly, on the meaning of environment and its centrality to
nursing.
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CHAPTER 13 On Outcomes 315
Martha Rogers is one of the pioneers who envisioned a science of nursing in the late 1950s
and early 1960s and advocated for nursing to have its own body of knowledge. She maintained
that the science of nursing is unique and not a synthesis of all sciences—it is more than that.
Although synthesis may occur, the result is an integrated whole, as different from the parts as a
unitary human being is different from the sum total of its parts. Martha Rogers began advocating
that view in 1952.
Rogers received a diploma in nursing from Knoxville General Hospital School of Nursing,
Knoxville, Tennessee, in 1936. She earned a bachelor of science degree from George Peabody
College, Nashville, in 1937. From Teachers’ College, she received a master’s degree in nursing in
1945, and she also received a master’s degree in public health from Johns Hopkins University in
1952 (Rogers, 1983b). She worked as a public health nurse in rural Michigan and Connecticut and
established the first visiting nurse service in Arizona (Hektor, 1989).
Rogers completed the requirements for her doctorate degree in science at Johns Hopkins in
1954, boarded a train, and one day later, was head of the nursing program at New York University.
One of her first acts was to teach doctoral student seminars. She noted that the dissertation students
in nursing were part and parcel of dissertation seminars in the education department. Rogers’ belief
in the uniqueness of nursing and its science prompted her to design a separate seminar for nursing
students. She quickly realized that the parameters of that unique knowledge had not yet been iden-
tified. That became Rogers’ mission in nursing (P. Winstead-Fry, personal communication, 1984).
As an advocate of diversity of thought, Rogers demonstrated it in her personal life through
her love of music and science fiction; in her writing, which incorporated philosophy, music, futur-
ology, and physics; and the special talent with which she combined wit, humor, science, and art in
speaking about nursing. Martha Rogers was one of the few scholars in nursing who will transcend
her time and the profession. On a personal note, I invited Martha on behalf of the University of
Alexandria in Egypt to give a keynote address for an international nursing conference. Her love of
history, cultures, people, and life was evident in this last international trip before her death in
1994. I will always treasure having shared that long and tiring trip with a great and courageous
nurse scholar. As in her many other public lectures and appearances, she inspired all, baffled some
with her ideas, challenged many, and drove others to question and argue.
Paradigmatic Origins
Rogers developed her theory from a number of paradigms; concepts were synthesized into
what is now a whole around unitary human being, unitary environment, energy fields, continuous
interaction with the environment as an energy field, patterns, and change. Understanding of
Rogers’ theory is enhanced by the study of general systems theory (Rogers, 1985). The constant
interaction between human beings and environment, the interrelationships of the energy field, and
the openness of both to continuous exchange of matter and energy are based on Bertalanffy’s
(1968) definition of an open system. Although Rogers uses some of the terminology of systems
theory, she denies the study of subsystems and isolated behavior as representing the whole of the
unitary human being. Rogers also draws on the assumptions and concepts of the general systems
theory in two other ways: the unitary human being as an organization of the whole, which is more
than the sum of the parts, and the individuality and uniqueness of human beings as reflected in this
pattern and organization and in their wholeness. Furthermore, Rogers uses the concept of negen-
tropy—a general systems theory concept—to develop helicy, which is the “continuous innovative,
probabilistic, increasing diversity of human and environmental field patterns characterized by
nonrepeating rhythmicities” (Rogers, 1980a). Negentropy is a property of both the human being
and his environment. Probabilism was later changed to unpredictability (Rogers, 1992).
Physics and electromagnetic theory provide some of the basic premises and concepts of
Rogers’ theory. The energy field of the unitary human being and the environment are dynamic,
irreducible, unbound, extends to infinity, and is identifiable by waves and patterns. Physicists pro-
vide the rationale for the existence of such energy fields and for the understanding of resonancy as
the “continuous change from lower frequency to higher frequency wave patterns” in human and
environmental fields (Rogers, 1980b, p. 2).
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316 PART FOUR Reviewing and Evaluating: Pioneering Theories
The electrodynamic theory of life (Burr and Northrop, 1935) was used by Rogers as the link
between physics and life processes in nursing. Rogers used the tenets of evolution theory to
explain the increase in diversity, differentiation, complexity, and patterning in developing human
and environmental behaviors. A unitary human being is always in the process of “becoming”
rather than “being”; at any point, he is more than he has been because all his previous actions,
experiences, interactions, and being are incorporated into his present being. A unitary human
being is a homeodynamic being and is not homeostatic (Rogers, 1980c, 1992). The process from
an evolutionary standpoint, therefore, is toward more complexity; dynamic equilibrium, which
characterizes adaptation theory, is not possible as a goal in life.
Rogers was influenced by the early Greek philosophers and by modern theory and philoso-
phy. Her writings drew on Burr and Northrop (1935), Chardin (1961), Polanyi (1958), and Lewin
(1964), among others. Hanchett (1992) pointed out the relationship between Rogers’ ideas and
some of Buddhist principles. In addition, she drew on her vast fiction reading, and interest in clas-
sical music and modern physics to describe her concept of nursing science. She was one of the few
early thinkers in nursing who conceptualized nursing clients from a holistic perspective (Barnum,
1994), although she initially rejected the concept of holism (Rogers, 1992) because it was
“ambiguous” and has “varied meanings” (Fawcett, 2005, p. 319). Similarly, Rogers rejected
stimulus–response theories, reductionism, mechanism, causality, the separation of person and
environment, the effect of negative environmental influences on human beings, and the notion that
nursing deals with health problems (Rogers, 1970, 1987, 1989).
Fawcett (2005), in addition to agreeing that Rogers’ theory is predominately based on systems
theory, believes that it contains content related to developmental categories of knowledge. The
rationale for this classification is that Rogers’ principles of helicy and resonancy, which postulate
that patterns in the human and environmental fields are characterized by continuous, unpredictable,
and increasingly diverse change, shares characteristics with growth, development, maturation, and
change, as well as with direction of change.
Internal Dimensions
Rogers used the dialectic method of reasoning in developing her theory, as manifested in the
way that higher-level principles are subsumed under lower-level concepts (Barnum, 1994).
The theory is basically concatenated and has a hypothetical constructive beginning, evolving from
the synthesis of concepts from a number of fields, the core of which are a number of concepts that
are central to nursing. These are unitary human being, unitary environment, energy field, open
systems, patterns, pandimensionality, and human development. The relationships between con-
cepts are still at a tentative stage.
Rogers’ theory is a monadic, deductive theory. It has several irreducible units, but it is macro
in content and wide in scope, as it purports to describe life processes that result from person–
environment–energy field interactions. The theory’s intent is to explain these continuous, evolv-
ing, but unpredictable patterns. It provides a framework to describe the life process of unitary
human beings and could provide knowledge of order. The theory does not offer conceptual guide-
lines for knowledge of disorder or control. The concepts lead to the description of patterns, rhyth-
micities, symphonic harmony, and evaluation of change in whatever direction human beings may
think they are going (Rogers, 1987 as cited in Fawcett, 2005, p. 320).
Theory Critique
The discipline of nursing deals with phenomena related to the life process of unitary human
beings and their environments, which are expressed in health and illness. The discipline of nursing
contains science and art, and nursing is a profession learned through education. The science of
nursing is basic. It is the “organized body of abstract knowledge arrived at by scientific research
and logical analysis” (Rogers, 1992, p. 28). The art of nursing, on the other hand, encompasses the
innovative ways by which the science is used to enhance the lives of human beings. “The aim of nurs-
ing is to assist people in achieving their maximum health potential . . . their maximum well-being
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CHAPTER 13 On Outcomes 317
within the capability of each person” (Rogers, 1970, pp. 86, 135). Rogers defined the goal of pro-
fessional nursing as follows:
Professional practice in nursing seeks to promote symphonic interaction between man and
environment, to strengthen the conference and integrity of the human field, and to direct and
redirect patterning of the human and environment fields for realization of maximum health
potentials. (Rogers, 1970, p. 122)
She also proposed that the purpose of nursing “is to promote health and well being for all per-
sons wherever they are” (Rogers, 1992, p. 28). A nurse using Rogers’ theory works on mobilizing
individual or family resources, heightening her integrity, and strengthening the human being–
environment or family–environment relationships (Barrett, 1990a; Rogers, 1988).
The scope of Rogers’ theory is broad, and it has the potential to encompass the phenomena of
the nursing domain. However, although it articulates the central phenomena, it does not define dif-
ferent patterns of human being–environment interactions or energy field manifestations. The the-
ory appears too abstract; concepts—although defined theoretically—do not lend themselves
readily to the practice arena or to measurable variables for research. Rogers never claimed her
conceptualization to be a theory, and her thinking and ideas preceded all current attempts at theory
building. This may be why she has not offered a systematic operationalization of her concepts for
use in practice and research. Nevertheless, the notion of considering the individual as a whole and
of placing the focus of nursing on the human being–environment relationship is appealing to nurs-
ing and lends itself to a theory of human being–environment interaction.
Others have extended Rogers’ theory and have postulated that the characteristics of a unitary
human being could be related to needs and activities of daily living. Because unitary human
beings can feel, exchange, be awake, move, choose, value, and relate, a group of nurses (theoreti-
cians, clinicians, and researchers) have developed such a conception and delineated a number of
nursing diagnoses according to these characteristics (Kim and Moritz, 1982) (Table 13-5).
Rogers’ theory stimulated research in the use of integrative and complementary therapies and
those that are grouped under the rubric of alternative types of interventions, traditional healing
practices, or indigenous holistic perspectives. Using a quasi-experimental design, the use of med-
itation was found to facilitate the achievement of a sense of well-being, as well as of a perception
TABLE 13-5 CHARACTERISTICS OF UNITARY HUMAN BEING—ROGERS
Factor I. Interaction
A. Exchanging
1. Eating and drinking
2. Eliminating
3. Breathing
4. Giving and receiving
B. Communicating
1. Verbal
2. Nonverbal
C. Relating
1. Spacing
2. Touching
3. Eye contact
4. Belonging
5. Referencing
6. Family response to patient illness
Adapted from Field, L. and Newman, M., Clinical application of the unitary man: Case study analysis. In Kim, M.J. and Moritz, D.A. (Eds.).
(1982). Classification of nursing diagnosis: Proceedings of the third and fourth national conferences. New York: McGraw-Hill; copyright C.V.
Mosby Co., St. Louis.
Factor II. Action
A. Valuing
1. Philosophical beliefs about health, human interactions,
and spirituality
B. Choosing (human beings knowingly making choices—wise,
unwise, or detrimental)
1. Judgment and decision making capacity regarding alter-
natives, consequences, commitments
C. Moving
1. Mobility (rhythm and patterns)
Factor III. Awareness
A. Waking (sleep behavior, patterns, and quality)
B. Feeling (as perceived and as manifested)
C. Knowing (health knowledge, abstractions, motor skills)
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318 PART FOUR Reviewing and Evaluating: Pioneering Theories
of power as knowing in a sample of well Korean adults (Kim, Park, and Kim, 2008). Healing
touch or therapeutic touch—developed by Dolores Krieger and based on Dr. Martha Rogers’ the-
ory of continuous exchanges between individuals and their environment—is another intervention
modality with extensive literature. For example, touch therapy was used in an intervention to
determine its effect on both physiological and subjective anxiety. The results indicated that the
participants experienced less stress and were more relaxed, as demonstrated by a number of phys-
iological measures (Maville, Bowen, and Benham, 2008). Others used her theory to propose
research hypotheses related to complementary therapies. Aromas produced through essential oils
that carry plant vibrations and memories may facilitate changes in life patterns and processes and
may lead to the integration of human–environment relationship (Smith and Kyle, 2008). Similar
hypothesis reflecting alternative and complementary therapies and based on Rogers’ theory were
formulated about the outcomes of using Reiki as well as puppetry in enhancing the capacity for
health (Ring, 2009a), and in health promotion and suicide prevention (Jacono and Jacono, 2008).
Diagnoses such as noncompliance (choosing), anxiety (feeling), respiratory dysfunction
(exchanging), impairment of mobility (moving), spiritual concern (valuing), alterations in sleep–
rest activity (waking), and alterations in patterns of sexuality (relating) have been defined in rela-
tion to a unitary human being (Kim and Moritz, 1982; Rossi and Krekeler, 1982, pp. 276–277).
These definitions enhance the theory’s clarity for clinicians, decrease its level of abstraction, and
render it more amenable to testing. Alternative models of care were used to enhance healing for
these types of alterations, to bring about harmony between individuals and their environments.
Several writers have demonstrated some of the theory’s utility in practice. Barrett (1990a)
and Madrid and Winstead-Fry (1986) proposed a useful assessment framework derived from
Rogers’ focus on patterns. One component of this framework is living in the relative present,
experiencing comfort with the past and present of the individual. Shared communication, a sense
of rhythm (a flow in daily life), a connection to environment (a sense of place in a community),
personal myth (a sense of self-identity), and system integrity (survival) are other components of
the assessment framework. For each of the components, the authors offer a range of intervention
options. Carboni (1995a) extended Rogers’ ideas for practice and developed a theory of Rogerian
nursing practice as an enfolding of health with wholeness and harmony as components. In this
theory, nurses and clients participate knowingly in patterning the human and environmental
energy fields to create health and wholeness.
Rogers is considered a pioneer in nursing by introducing the concept of energy into the
nursing theoretical language. Although this concept is central to Rogers’ theory, its definition
and utilization to advance fundamental nursing knowledge has been limited. “Energy” is also
central in many sciences; however, viewed from a nursing perspective, it is a phenomenon that
may not be quantifiable and measurable (Todaro-Franceschi, 2001). This concept, once proposed
as central to human science discipline, is elusive in its patterns and characteristics and may (and
has) pose issues for researchers and clinicians. Analyses, critiques, and extensions of such con-
cepts (e.g., Todaro-Franceschi, 2001) are essential for clarifying this theory and making it more
user-friendly.
Whelton (1979) synthesized Rogers’ theory with nursing process theory in delivering care to
patients with decreased cardiac input and impaired neurological function. Others have demon-
strated the theory’s principles in therapeutic touch (Krieger, 1976), its positive outcomes on injury
(Herdtner, 2000), and its use in conceptualizing hyperactivity in children within the framework of
synergism as being merely changes in a person’s pattern of interaction with the environment
(Blair, 1979). Rogers provided the potential for understanding aging and hyperactivity (1980a),
offering more positive evolutionary changes to explain outcomes through her theory. Minimal sleep
needs of the hyperactive child are considered by Rogers as a normal response to the increasing
complexity and diversity of wave patterns and frequencies of environmental fields. Hyperactivity,
therefore, if not viewed from unitary human being–environment interactions, tends to be labeled as
a disease. Mason and Patterson (1990) used Rogers’ theory to assess a problematic middle-aged
man with 33 previous admissions to psychiatric hospitals; although they discussed some limita-
tions, such as their inability to use some holistic principles (such as touch), they concluded that the
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CHAPTER 13 On Outcomes 319
theory helped them break traditional practices and provided them with support to use visionary
and innovative practices to help the patient.
Rogers’ theory has inspired the development of assessment tools (Tettero, Jackson, and Wil-
son, 1993) and provided a framework to assess the perception and meaning of passage of time and
the need for diversional activities for the elderly (Biley, 1992). It was used as a framework for
many practices (Leddy, 2003; Bultemeier, 2002).
Despite many examples of clinical operationalization and utilization, the general sentiment in
practice, education, and administration remains the same: this theory has application limitations.
The potential is there, but the complex nature of its concepts and propositions, the esoteric con-
cepts and level of abstraction, and the overlap between concepts due to lack of definition all ren-
der the use of Rogers’ theory limited in practice. Not only is it difficult to operationalize and
measure the characteristics and actions of unitary human beings and energy fields, to identify
manifestations of patterns of energy fields, but one is also faced with the limitations of the existing
English language in describing the pandimensionality of a human being field and the influence of
the tremendous acceleration of change on humanity (Rogers, 1980a). Rogers’ approach, however,
is more meaningful in the 1990s than it was in the previous three decades. It is more congruent
with accelerating changes, fascination with outer space, acceptance of lack of predictability, and
chaos theories. It is also a theory that resonates with current thinking about family dynamics.
Winstead-Fry (2000) provides compelling support of how “helicy” reflects many of the family
theorists’ ideas that have evolved over 40 years. She therefore suggests that Roger’s visionary
thought was ahead of its time and has become more mainstream in family theory. Furthermore,
she proposed that extensions of Rogerian ideas by her disciples, such as Barrett’s (1990b) work on
power as knowing participant, could inform researchers in other fields who are interested in fam-
ily research.
External Components of Theory
From the 1960s through the 1980s, Rogers’ theory was an unknown; it was esoteric and not
reflective of nursing. The changes in prevailing views of health, developments in physics, and the
movement toward holism have facilitated nurses’ acceptance to further explore her theory. The
view that the discipline of nursing deals with unitary human beings who are in constant interaction
with the environment has gained momentum and support, particularly when it is equated erro-
neously with holism. There is indication that nursing practice is more positive about the potential
of Rogers’ theory (Garon, 1992; Rossi and Krekeler, 1982).
Each nurse–patient interaction is an interaction of energy fields that evolves into repatterning
and reorganizing waves in the direction of increasing differentiation and diversity (Bultemeier,
1997). Each encounter is unique; it moves forward and becomes more complex. Feelings,
thoughts, experiences, and awareness of the nurse and patient and their environments blend
together, each one emerging not entirely the same as before. Repatterning is a new pattern evolv-
ing from a previous pattern; it requires investigation into the “nature of field patterns and organi-
zation.” These views are valued by nurses, consumers, and, indeed, more and more by other health
professionals. Her work inspired many educators (Barrett, 1990c).
Interactions are also empowering. Using an empowerment intervention to build a person–
environment relationship utilizing a nurse–patient participation model facilitated the achievement
of desired outcomes in managing the care needs of patients with heart failure (Shearer, et al.,
2007). This was manifested in adherence to such treatment plans as edema checks, low salt diet,
and weighing self on a daily basis. However, the use of this Rogerian-based intervention did not
result in such variables as increasing awareness, choices, freedom to act, and involvement in creat-
ing change as measured by an instrument designed for these variables (Shearer et al., 2007).
Rogers’ theory proposed that change is unpredictable; therefore, a nurse using this frame-
work focuses on building a relationship, in order to access the unitary field by performing thera-
peutic touch to help patients to center and become more self-aware of their intention and role in
healing. By using these principles, Farren (2009) demonstrated, in a case study of one oncology
patient, how she did better in her relationship, coping, self-concept, and mood. Her overall sense
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320 PART FOUR Reviewing and Evaluating: Pioneering Theories
of personal well-being improved. Thus, Farren (2009) concludes that the use of Rogers’ frame-
work could enhance patient quality of life. Quality of life has been defined in many different ways
in nursing. Implicit in Rogers’ theory is a focus on quality care as manifested in having a dynamic
life, life satisfaction, and valuation of life processes (Rogers, 1970, 1990; Plummer and Molzahn,
2009).
Theory Testing
Gill and Atwood (1981) attempted to use Rogers’ theory as the basis for a study of wound
healing in animals, but were legitimately criticized by Kim (1983) for reductionism, causality, and
inappropriate use of the animal model. Others have successfully explained some of Rogers’
propositions without resorting to reductionism or mechanistic approaches. For example, Rogers’
proposition that unitary human beings and environments are dynamic fields of energy, always
sending and receiving messages that change both the human and environmental fields in complex-
ity and diversity, has been tested and has received some support (Katz, 1971). Although Katz, a
graduate of New York University, did not link her findings to Rogers’ theory per se, her findings
lend support to this proposition. Katz’s experimental subjects, premature infants who were sub-
jected to a patterned regimen of auditory stimulation from tape recordings of the maternal voice,
achieved greater motor and tactile adaptive maturation.
Porter’s (1972) findings support Katz’s (1971) and Rogers’ proposition that environmentally
imposed motions speed up infant growth and development. Goldberg and Fitzpatrick (1980)
hypothesized that movement therapy for institutionalized individuals, as a holistic nursing inter-
vention derived from Rogerian theory, would improve psychological well-being as demonstrated
in morale and in attitudes toward aging. The hypothesis was supported, lending further support to
Rogers’ theoretical propositions. Heidt (1981), testing another intervention based on Rogerian
premises, found that subjects who received nursing intervention through therapeutic touch had
greater reduction in posttest anxiety scores than did those who received it through casual or no
touch.
Other studies reformulated and deduced a theorem regarding environmental disruption and
sleep–wakefulness rhythms, and tested it on a general population and a clinic population. More
specifically, the theorem stated:
Persons experiencing a deviation in the rhythmic relationship with their environment will
manifest greater complexity and diversity in their sleep–wakefulness patterns than persons
who are not experiencing a deviation in the rhythmic relationship with their environment.
(Floyd, 1983, p. 43)
Although the findings demonstrated a significant difference in “increasing diversity” (total
wakefulness time was greater for rotating shift workers than for nonrotating shift workers), there
was minimal support for “increasing complexity” (rotating shift workers slept less than nonrotat-
ing shift workers). The study lends support to the theorem, but raises some questions when the
study used a clinical sample. Floyd’s (1983) study represents an example of the potential innova-
tion in testing Rogers’ propositions and the significance of systematic study of propositions ema-
nating from nursing theory.
Developmental stages and time orientation were the foci of another study based on Rogerian
theory, which concluded that there is “support for the developmentally based nature of specific
dimensions of temporality” (Johnston, Fitzpatrick, and Donovan, 1982, p. 120). These studies,
together with Newman’s (1979, 1986) theory of health, are based on the interrelationships
between time, space, consciousness, and movement, and are fine extensions of Rogers’ ideas.
Despite such progress, there are still major gaps in our methodology for unitary human
beings/unitary environments and their energy fields (Butcher, 1993). Should such gaps in our
present knowledge halt all research investigations using Rogers’ theory? Is it possible to develop
investigations accounting for all Rogers’ premises and concepts using our present limited knowl-
edge? The answer is “no” to both questions. As demonstrated previously, researchers who have
been inspired by Rogers’ theory and theoretical propositions have found innovative ways to test
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CHAPTER 13 On Outcomes 321
and support some theory propositions without adhering to or accounting for all assumptions and
principles of the theory. For example, well-being in Goldberg and Fitzpatrick’s (1980) study was
measured in terms of psychological well-being rather than in terms of the greater developmental
coherence that involves human being–environment energy fields, as Rogers would emphasize.
There are indications of increasing congruency between her ideas and methods used for research,
either because tools have been developed based on the theory assumptions (such as the person–
environment participation tool developed by Leddy [1995]), or because creative processes of
inquiry are proposed and developed (Carboni, 1995b). And as Winstead-Fry (personal communi-
cation, 1984) indicated, Rogers’ students, colleagues, and others continue to work on developing
congruent measures related to meditation, to measure development as defined by Rogers, and to
engage in studies on creativity, differentiation, and parent–child interactions.
A valuable resource that contains comprehensive analyses of tests completed on Rogers’ the-
ory is edited by Malinski (1986). This compilation, in addition to a review of literature based on
Rogers’ theory, may indicate several conclusions about the theory, including:
• A worldview is emerging in nursing that is congruent with Rogers’ principles (Malinski,
1986).
• There are some universal questions about Rogers’ worldview (Meleis, 1988).
• Research work that uses Rogers’ principles is increasing (Benonis, 1989; Quinn, 1989;
Schodt, 1989).
• Existing methodological approaches are not entirely useful in investigating principles pos-
tulated in her theory (Moccia, 1985; Phillips, 1989; Smith, 1986, 1988), and, therefore,
“there is an essential need for methodological studies aimed at development, validation,
and evaluation research tools and strategies for the unitary science framework” (Cowling,
1986, p. 74).
• There is a definite evaluation in the types of studies completed to test or further develop
Rogers’ principles (Clarke, 1986; Ference, 1986; Fitzpatrick, 1988).
Ference (1986) describes the mid-1960s studies, which are mainly doctoral dissertations, as
studies of human development; in the 1970s, the studies revolved around the principle of comple-
mentarity, which was later relabeled integrality. Concurrently, several of Rogers’ students studied
body image in an attempt to explain human and environmental fields. The variable of time domi-
nated investigations in the mid-1970s; for example, Newman (1976, 1989) researched perception
of time in relationship to gait tempo. According to Ference (1986, p. 38), “these studies helped
future researchers to define the meaning of time in a space–time context.”
According to Ference (1986), other studies during that period focused on locus of control,
field independence, and differentiation. Several instruments unique to Rogers’ theory have been
developed. Two have been reported. These are the Human Field Motion Test (Ference, 1986) and
the Human Field Power Test (Barrett, 1986).
Barrett (1990c) developed a measure of power as knowing participation in change. This
measure has been used in many studies. For example, Caroselli (1995) demonstrated that, among
female nurse executives, a weak relationship exists between power and feminism, as measured by
the power as knowing participation in change instrument. A group of Korean and Korean Ameri-
can scholars used Rogers’ theory as the framework to examine the relationship in healthy Korean
adults between power defined as knowing participation in change and well-being. They found out
that these two concepts are positively correlated. They concluded that Roger’s theory is applicable
to their culture (Kim, Kim, Park, et al., 2008). Observable manifestations of human patterning that
Rogers (1986) describes as correlates were examined by Yarcheski and Mahon (1991) in a study
comparing early, middle, and late adolescent boys and girls. The authors selected perceived field
motion, human field rhythms, creativity, sentience, perception of time, and waking and sleeping
periods. The findings, although not supporting the relationships proposed in Rogers’ theory, sug-
gest that age may be related to the correlates. This, according to the researchers, suggests some
linearity that may have been deleted prematurely from Rogers’ theory. Other researchers
attempted to define and test the proposal of increasing frequency patterning in explaining the
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322 PART FOUR Reviewing and Evaluating: Pioneering Theories
healing processes involved in recovery (Schneider, 1995) and patterns of perceived field motion
and health status (Yarcheski and Mahon, 1995).
Smith (1995) compared patterns of power and spirituality in people who have survived polio
and those who never had polio. Polio survivors show similar power and more spirituality than par-
ticipants who did not have polio. This finding suggests that patterns of human field change were
related to surviving polio. The study suggests that nurses’ awareness of spirituality as a human
potential may drive more attention to enhancing the different potentials of patients, and they could
facilitate the patients’ ability to connect with other aspects of their energy fields. The investigators
used Rogers’ theory to drive the research questions and propose continuity to develop spirituality
with this theory.
Another significant test of any theory is the extent to which it has stimulated theoretical pub-
lished discourse. Rogers’ theory inspired the development of other theories, such as Newman’s
theory of health (Newman, 1986).
Hills and Hanchett (2001) developed a middle-range theory of “enlightenment” based on the
three principles of helicy, resonancy, and integrality. Their theory evolved from clinical observa-
tions. They proposed that awareness, wakefulness, and human field motion could result in higher
levels of well-being through a process of change and individuation. The clinical exemplar the
authors provide illustrate this abstract relation. They observed 250 parents who had children with
the birth defect of myelomeningocele, and noted that although the parents struggled with the
meaning of this birth defect, when obstacles were overcome, the parents
. . .would report deeper insights and awareness, a greater sense of harmony, and an enthusiastic
commitment to actively participate in their own process of individuation. (Hills and Hanchett,
2001, p. 8)
The enlightenment experience was defined as:
Anything which [fosters reflection and] involves a compassionate commitment to others, or to
both self and others. (Hills, 1998, p. 12, as cited in Hills and Hanchett [2001], p. 8)
Others, particularly graduate students from Wayne State University, Case Western Reserve
University, the University of Rochester, and New York University are engaged in researching
propositions derived from Rogers’ theory, which has been operationalized for educational set-
tings. The curriculum of nursing at New York University is not the only one based on Rogers’ the-
ory. Her theory has been used to develop curricula at Duquesne, College of Mount St. Vincent,
and Fairleigh Dickinson University (P. Winstead-Fry, personal communication, 1984).
This is a theory whose complexity of primitive concepts has undermined the clarity of the rela-
tionship between the concepts as well as the boundaries. Can energy fields of a human being be
defined distinctly from that of an environment? If helicy is unpredictable (Rogers, 1990), what use is
it in science, which presumes certain order and predictability? What Rogers succeeded in doing—
creating a rich environment of uncertainty for intellectual discourse—has failed to attract a rich dia-
logue except among the select few who either studied under her guidance at New York University, or
joined the Rogerian society (the believers), a community that needs no urging to use her ideas.
A critical evaluation of the fit between her theory and therapeutic touch by a number of UK
scholars, became an important contribution to stimulate a discourse and a debate (O’Mathuna,
Pryjmachuk, Spencer, Stanwick, and Matthiesen, 2002).
Although many have written about touch or therapeutic touch and its outcomes, as driven by
Rogerian Science of Unitary Man (Herdtner, 2000; Kelly, Sullivan, Fawcett, and Samarel, 2004;
Lowry, 2002; Smith, Kemp, Hemphill, and Vojir, 2002; Ugarriza, 2002), O’Mathuna et al. (2002)
eloquently refuted the connection of Rogerian energy fields with the mechanisms and the prem-
ises of therapeutic touch. They provided arguments demonstrating the lack of evidence of poten-
tial negative or positive effects of therapeutic touch on patients’ outcomes.
Rogers’ theory stimulated robust dialogues on several concepts germane to the discipline of
nursing and for which, prior to Rogers, there were no productive frameworks. Examples are devel-
oping and testing energy (Todaro-Franceschi, 2001), and use of therapeutic music in enhancing
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CHAPTER 13 On Outcomes 323
coping skills in patients with psychiatric disorders (Covington, 2001). Rogers’ theory inspired
Barrett to develop her investigation of the principle of helicy by focusing on the relationship of
human field motion and power as knowing (Barrett, 1986; Barrett and Caroselli, 1998; Caroselli
and Barrett, 1998). In addition, subsequently, her operationalization of power from a Rogerian
theory provided a framework to study it in relationship to pain and trust (Kim, 2001;
Lewandowski, 2002; Wright, 2004) in relationship to hope and exercise (Wall, 2000), in studying
people’s experiences (Phillips, 2000), in relationship to humor and health (Yarcheski, Mahon, and
Yarcheski, 2002), and in perception of time as an ever-evolving process (Ring, 2009b).
Another recent area of exploration is the degree of spirituality in health care. Rogers’ theory
has been used as a framework to conceptualize the relationship between spirituality and a number
of outcomes. Cox (2003) provided exemplars of using spiritual intervention by advanced practice
nurses, and Hardin (2003) explained spirituality as a pattern manifestation of the principle of inte-
grality, both claiming that spirituality is an aspect of quality of life. Closely related to spirituality,
but differentiated by the principle of helicy, is the meaning and role of compassion, unpredictabil-
ity, and participating knowingly in mutual and reciprocal processes (Butcher, 2002).
Finally, in another integrative review of research studies based on Rogers’ science of uni-
tary human being, Kim (2008), concluded that Rogers’ theory continues to provide a valuable
theoretical framework. However, the need continues for clarification of concepts and methods
and of the congruency between them. Energy, one of Rogers’ core concepts, was not well
defined in her work, and it continues to draw nurses into philosophical dialogues. Among them
is Todaro-Franceschi (2008), who compares and contrasts a mechanistic view of energy as a
part of causal process with that of Roger’s humanistic and wholistic views. In the first, energy is
exchanged, transmitted, lost and/or gained through various change processes. Rogers’ view of
energy, as clarified by Todaro-Franceschi (2008), is a phenomenon that denotes universal life
energy that is more congruent with Eastern philosophies, from which such concepts as chi and
prana evolved. It is important to note that, whether Rogers would agree with this view or not,
her concepts continue to inspire dialogues, clarification, and development. Rogers, however,
would agree that the science of unitary human beings is subject to the dynamic and continuous
process of development (Wright, 2007).
Two discourses could stimulate debates and critical consideration. The first is a published
interview conducted by Jacqueline Fawcett with Ann Manhart Barrett (2002), Violet M. Malinski
(1986), and John Phillips (2000) related to a 21st-century update (Fawcett, 2003b). The interview
provides an effective summary of how scholars well-versed and trained within a school of thought
view the tenets of the theory (with conviction), the supporters of the theory (with no skepticism),
and the future of our discipline (with fear of demise for lack of theory or for attempting to inte-
grate different schools of thought). A nonbeliever could have rendered this interview more power-
ful and more useful in generating a true critical intellectual discourse.
The second important discourse is provided by Watson and Smith, who described two pre-
vailing themes in theoretical thinking in nursing: unitary direction in nursing (Rogers Science of
Unitary Human Beings) and caring science. These two schools of thought appear controversial,
separate, and parallel. After a critical review, they proposed a synthesis between the unitary view
of humans with relational caring ontology and ethics. They believe that the result is likely to be a
“trans-theoretical, trans-disciplinary view for nursing knowledge development” (Watson and
Smith, 2002, p. 452). Newman (2003), another Rogerian theorist and a theorist in her own right,
would agree that we have entered an era with no disciplinary boundaries. Theorists and utilizers
with a sense of theoretical purity would expect to disagree with this integrative discourse.
Rogers’ theory is complex, is somewhat tautological (she acknowledges an overlap between
concepts), and has an aura of coherent truth, but presents a challenge to operationalization.
Although difficult for the American practitioner, it is understandable in the international arena. Its
view of humanity and environment, and the lack of separation between mind and body, is congru-
ent with the Eastern view, and it is expected that its circle of contagiousness will increase more
rapidly than ever anticipated in the decade ahead. It is congruent with professional values in nurs-
ing and with the emerging perceptions of humanity.
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324 PART FOUR Reviewing and Evaluating: Pioneering Theories
SISTER CALLISTA ROY
Theory Description
The central questions of Sister Callista Roy’s theory, which is known as the Roy Adaptation
Model (RAM), are: What is the target of nursing care? When is nursing care indicated? And what
is the ultimate goal of nursing care? As with theories that evolved early in the history of theoretical
nursing, the intent was to differentiate the discipline of nursing from medicine and to provide it
with it owns focus. Over the years, Roy, her colleagues, and theory utilizers have developed differ-
ent aspects of the theory that specifically deal with adaptation levels as changing points that are
influenced by the situation as well as by available inner resources.
Roy’s first ideas appeared in 1964, in a graduate course paper written at UCLA in one of
Dorothy Johnson’s classes. Roy published these ideas in 1970, and subsequently, different com-
ponents of her framework crystallized during the 1970s, 1980s, 1990s, and into the 21st century.
Over the years, Roy identified the assumptions on which her theory is based (Box 13-13), starting
with scientific assumptions, then incorporating humanistic and veritivity assumptions regarding
the dignity of human beings and the role of nurses in promoting integrity in life and death.
Increasingly, her theory is defining and connecting spirituality and religiosity to experiencing and
coping with illness (Roy and Andrews, 1999; Roy, 2000a; Roy, 2000b). One can see the integra-
tion of her religious background in her more recent writings (Roy, 2008).
Roy’s assumptions in general are in agreement with current views in nursing regarding adap-
tations, human beings, and nursing. Her assumptions are based on humanism and veritivity
BOX 13-13 ASSUMPTIONS—ROY
Explicit Assumptions (Roy and Andrews, 1999, p. 35; Roy, 2000a, p. 7; Roy, 2000b, p. 127)
Scientific
• “Systems of matter and energy progress to higher levels of complex self-organization.”
• “Consciousness and meaning are constitutive of person and environmental 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 of interdependence.”
• “People and the earth have common patterns and integral relations.”
• “Person and environment transformations are created in human consciousness.”
• “Integration of human and environment meaning results in adaptation.”
Philosophical
• “Persons have mutual relationships with the world and with a God figure.”
• “Human meaning is rooted in an omega point convergence of the universe.”
• “God is ultimately 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 the process of deriving, sustaining, and transforming the universe.”
Implicit Assumptions
• “Individual persons, their perceptions, and their experiences are the starting point of nursing” (Whitte-
more and Roy, 2002).
• A person can be reduced to parts for study and care.
• Nursing is based on causality.
• Patients’ values and opinions are to be considered and respected.
• “A state of adaptation frees an individual’s energy to respond to other stimuli” (Roy, 1984, p. 38).
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CHAPTER 13 On Outcomes 325
(Hanna and Roy, 2001). Her implicit assumptions attest to the totality of the individual, as mani-
fested in behavior, active participation of individuals in life, and an individual’s potential for self-
actualization. Humanistic values have been identified in Roy’s theory (1984, 1987, 1988a; Roy
and Andrews, 1991, 1999), followed by values related to truth, and oneness with the truth, “also
known as a creator, God” (Roy, 2000b, p. 127). The principles of humanism are creative power,
holism, subjectivity, purposefulness in life, interpersonal relations, and activity. Although others
have tended to view the holistic nature of the theory (Mastal and Hammond, 1980), it was not until
1984 that Roy emphasized the holistic nature of a person and the humanistic care of nurses. In
1987 and 1988, these humanistic values were described, and in 1988, the philosophical stand
moving beyond rationalism and relativity toward veritivity was explicated (Roy and Andrews,
1999). Roy and Corliss (1993) presented a set of revised assumptions for Roy’s theory that
included attention to holism, interdependence, central processes of systems, information feed-
back, and the complexity inherent in living systems. These assumptions reflected a general sys-
tems theory approach to viewing her theory and clarified the philosophical origins of Roy’s
theory. In her revisions, theorist Roy combines scientific rationalist assumptions with those based
on personal and religious convictions (Roy and Andrews, 1999, p. 35).
According to Roy’s theory, a person—a biopsychosocial being, an adaptive system, a human
being—is in constant interaction with a changing environment; therefore, a person is continually
changing and attempting to adapt. When the person is not adapting positively and is therefore
manifesting ineffective responses, he or she is of concern to nursing; however, once a person man-
ifests effective behavior, he or she no longer needs nursing attention. A person uses both innate
and acquired mechanisms to ready himself to adapt to his environment (Andrews and Roy, 1986;
Roy and Andrews, 1999). A person is also defined in terms of purposefulness of existence and as
reflecting the context of humankind’s unity of purpose and the common good, as well as the value
and meaning inherent in life (Roy, 1988a). In addition, Roy views the innate creative powers as
essential to understanding the nature of a human being. In an adaptive person, she calls these pow-
ers “veritivity,” which she uses to mean the truth of human nature, and which reflects activity, cre-
ativity, unity, purposefulness, and value (Roy, 1987; Roy, 2000a).
A person is an adaptive system with two major internal central mechanisms used for adapting.
These are the regulator and the cognator subsystems, which are viewed as innate or acquired cop-
ing mechanisms. These innate or acquired mechanisms are used to deal with a constantly changing
environment (Roy, 1991; Roy and Andrews, 1999). The regulator mechanism works primarily
through the autonomic nervous system to organize a reflex action that prepares the individual to
respond and adapt to the environment. The major parts of the regulator subsystem are the neural,
endocrine, and perception–psychomotor parts (Roy and McLeod, 1981). The regulator mechanism
receives stimuli from the internal and external environments, both of which are basically chemical
or neural, and receives all input into the central nervous system. Body responses observed by the
nurse are effects of autonomic responses, responsiveness of endocrine glands, and the perception
process. The latter is altered by cultural and social factors (external stimuli) and “must remain in
short-term memory long enough for a psychomotor choice or response to be made” (Roy and
McLeod, 1981, p. 60). The bodily responses, brought about through chemical–neural–endocrine
channels, are fed back as additional stimuli to the regulator system (Roy, 1984, pp. 28–36).
The second mechanism is the cognator subsystem, which identifies, stores, and relates stim-
uli so that a symbolic meaning can be attached to the behavior. The cognator mechanism is com-
posed of several parts and corresponding processes: (1) perceptual/information processing
manifested in the processes of selective attention, coding, and memory; (2) learning, manifested
in imitation, reinforcement, and insight; (3) judgment, which involves the process of problem
solving and decision making; and (4) emotion, which is manifested in defenses to seek relief and
affective appraisal and attachment (Roy, 1988b; Roy and Andrews, 1999). These processes are
influenced by internal and external stimuli and affect the psychomotor choice of response of ori-
entation, approach, avoidance, flight, or hiding as demonstrated in the form of spoken or unspo-
ken words. Failure in either the regulator or the cognator mechanisms results in maladaptation
(Roy, 1984).
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326 PART FOUR Reviewing and Evaluating: Pioneering Theories
All input is channeled through the processes of the regulator and the cognator and produces
responses through four effector modes. Roy’s theory has been expanded and extended to use in
family and group relationships encompassing their coping processes, adaptive modes, and their
adaptation levels (Hanna and Roy, 2001, p. 9). The four modes have also expanded to encompass
groups (p. 48). Roy specifies terminology for collective human systems—physical, group identity,
role function, and interdependence—to correspond with the four adaptive modes associated with
the individual. The collective is regarded as a whole, and the nursing process is applied in relation
to the whole, just as it is applied to individual circumstances (p. 102). Therefore, the four modes
are: physiological–physical needs, self–concept–group identity, role function, and interdepend-
ence. The two subsystems are related to each other through perception, and are related to each
effector mode differently, whereas the regulator is related predominantly to the physiologic/phys-
ical mode.
[S]ince very little is known physiologically about the process of perception formation, mem-
ory, and choice of psychomotor responses, the other modes of self-concept, role function, and
interdependence must relate to the meaning of a given perception for the individual human
system. The meaning of the perception will, therefore, influence the body response. (Roy and
McLeod, 1981, p. 67)
Conversely, the cognator subsystem is related to all adaptive modes. Processes such as
selective attention, imitation, problem solving, and appraisal influence nutritional intake in the
physiologic mode, role function, self-concept, and interdependence. Within each mode, all cog-
nator processes could be manifested; for example, attachment, reinforcement, and memory are
integral parts of role cues selected by a person. The physiological–physical mode for individuals
and groups is a result of the needs of individuals for physiological integrity and the ways humans
interact as physical beings with the environment. Behavior in this mode reflects physiological
processes of cells, tissues, organs, and body systems. There are five basic physiological needs
and four regulator processes in this mode. The physiological needs are activity and rest, nutri-
tion, elimination, oxygenation, and protection. The regulator processes are described as the
senses, fluids, and electrolytes, acid–base balance, neurological functions, and endocrine func-
tions. The concept “physical” is more appropriate for use for humans in groups. This is the first
adaptive mode for groups. Basic needs for groups in the physical mode are resource adequacy, or
wholeness, which is achieved by adapting to change in needs for physical resources (Roy and
Andrews, 1999).
The self-concept mode is related to the need for psychic and spiritual integrity (Roy and
Andrews, 1999). Self-concept is defined by a person through the definitions of significant others,
and it includes perceptions of self and others. It also includes an integrative view of the physical and
personal selves. The physical self is manifested in body sensations (feelings and experience) and
image (view of self). The components of the personal self are self-consistency (continuity of self),
self-ideal (expectations), and the moral–ethical–spiritual self (values) (Andrews and Roy, 1986;
Roy, 1987; Roy and Andrews, 1999). Self-esteem is a component of self-concept and is defined as
the extent to which individuals perceive their self-worth (Andrews, 1991). Group identity is used
for the self-concept mode related to groups, and it is composed of interpersonal relations, group
self-image, social milieu, and culture (Roy and Andrews, 1999).
The role function and interdependence mode for both individuals and groups is focused on the
need for social integrity. Role is viewed in Roy’s theory as a set of expectations of individuals toward
each other. She classified roles as primary (based on age, sex, and development), secondary (acquired
through relations with others and made permanent), and tertiary (activities that are more temporary)
(Andrews and Roy, 1986). The interdependence between individuals is expressed in the ability to
love, respect, and value, and to receive love and respect and to be valued. Roles within groups provide
mechanisms for achieving social system goals (Roy and Andrews, 1999). These include functions of
managers and administrators and systems for maintaining order and making decisions.
Stimuli affecting modes and mechanisms are identifiable as focal stimuli (those that are
immediate in an individual’s life), residual stimuli (attitudes and previous experiences), and
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CHAPTER 13 On Outcomes 327
contextual stimuli (all other stimuli, e.g., heat aggravating a rash, or noise that is irritating to a
person in pain).
In early writings, Roy and McLeod (1981) proposed that a theory of the person as an adaptive
system (i.e., regulator and cognator mechanisms) should be used in conjunction with the Roy
adaptation model. This was later modified and synthesized, so that there was no differentiation
between the model and the theory (Roy, 1984). A person is conceptualized as an adaptive system
that includes input (stimuli and an adaptation level), control processes (the regulator and the cog-
nator as coping mechanisms), effectors (four modes), and output (adaptive and ineffective
responses) (Roy, 1984, p. 30) (Box 13-14, pp. 328–329).
Later developments in Roy’s theory have helped to clarify her view of a person. However,
some concepts remain ambiguous and overlapping. Although concepts are mainly derived from
other paradigms, the primitive ones (regulator and cognator) are not as precisely identified and
defined. Concept boundaries are not clear. For example, effector modes and focal stimuli overlap
(overlap persists in some effector modes, such as in interdependence role, self-concept, and role
function). Overlap also occurs between adaptive modes and mechanisms, and the definitions lack
clarity (Mastal and Hammond, 1980), allowing utilizers of the theory to derive their own defini-
tions, which in some ways marks the theory’s strength and versatility. Environment and internal
stimuli remain operationally undifferentiated (Tiedeman, 1983) (Table 13-6, pp. 330–331). How-
ever, when Roy (2009) defined environment as “all conditions that may influence people’s behav-
ior including all those circumstances generated by human and earth resources,” then such an
inclusive definition can be operationalized more readily.
Roy and McLeod (1981), Roy and Roberts (1981), Roy and Andrews (1991), and Roy and
Corliss (1993) have provided a useful systematic presentation of all possible links between vari-
ables, resulting in a multitude of theoretical propositions. This is clearly a theory that lends itself
to the development of propositions and hypotheses. The propositions provided by the theorist are
theoretically sound, structurally adequate, systematic, and relational. The researcher’s task is in
operationalizing propositions for research projects and in generating many research studies. The
propositions tend to focus on biologic events (physiological response, intact neural pathways)
rather than nursing phenomena. The propositions are linear and bivariate, but Roy is striving for
nonlinear and multivariate relationships (Roy and Roberts, 1981, p. xiv). Others have also used
the theory to develop more propositions specific to particular groups of patients, such as those suf-
fering from bulimia nervosa (Hannon-Engel, 2008).
Roy’s theory has a high descriptive and explanatory power of the individual as an adaptive
system, but the theory has limited predictive and prescriptive powers. The descriptive and
explanatory potential could be further enhanced with existence propositions that could then drive
correlational and controlled studies. In addition to clarifying and operationalizing concepts, devel-
oping middle-range and situation-specific theories are activities needed for the further develop-
ment and refinement of this theory. Although Roy has attempted to establish the theoretical
validity of each coping system and effector mode, establishing their empirical validity has yet to
be achieved. However, several research studies demonstrated and supported the relationships pro-
posed by Roy’s theory of environment and adaptive modes (Shyu et al., 2004; Yeh, 2003).
Theory Analysis
The Theorist
After receiving a master of science degree in pediatric nursing, Sister Callista Roy, who was a
pediatric nurse by training, studied sociology at UCLA, where she received her doctorate in 1976.
The impetus of her theory was inspired by her having been the advisee and student of Dorothy
Johnson. Roy’s first manuscript, conceptualizing man as an adaptive system, was based on
Helson’s (1964) theory of adaptation level and was written for Johnson’s graduate class on con-
ceptual models in nursing (Roy, 1970). Later influenced by Ralph Turner, a professor of sociology
and a prominent scholar in collective behavior and role theory, Roy derived her explication of self-
concept and role function.
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328 PART FOUR Reviewing and Evaluating: Pioneering Theories
BOX 13-14 CONCEPTS—ROY
Adaptation
Adaptation level
Adaptation zone
Adaptive response
Client: An Adaptive System
Biologic
Anatomy
Physiology
Psychological
Perceiving
Learning
Acting
Social
Family
Community
Work group
Society
Adaptive System
Cognator
Regulator
Adaptive Stimuli
Focal
Contextual
Residual
Physical, personal, moral–ethical–spiritual self
Self-consistency
Self-ideal/self-expectancy
Learning
Inner self and self-concept
Self-esteem
Veritivity “pertains to the principle of human nature that affirms a common purposefulness of human
existence” (Hanna and Roy, 2001, p. 10).
Components
(a) purposefulness of human existence
(b) unity of purpose of humankind
(c) activity and creativity for the common good
(d) value and meaning of life
Humans: adaptive systems
Behavior: output of human systems
Adaptive responses
Ineffective responses
Environment: stimuli
Focal
Contextual
Residual
Stimuli: provoking a response
External
Internal
Adaptation level: the condition of the life processes
Integrated
Compensatory
Compromised
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CHAPTER 13 On Outcomes 329
Forces in the development of her model have been her administrative position at Mount St.
Mary’s College (Los Angeles, Calif.), which allowed her to further develop her theory through
operationalizing it as a framework for the school’s curriculum and allowed her the use of the
expertise and support of faculty members who taught at that institution. Sister Callista Roy is an
eloquent speaker and prolific writer, with a great deal of energy that has helped spread her ideas
nationally and internationally. After completing a postdoctoral fellowship at the University of
California, San Francisco School of Nursing (where she was trained as a clinical scholar on a
Robert Wood Johnson fellowship in 1985), she embarked on a new phase in her research/prac-
tice theory career. As a clinical scholar and while in the program, she used her theory in a clini-
cal neurology setting. During the 1990s, she also directed the doctoral program at Boston
College, where she continues to be a faculty member. Roy continues to work on the further
development of her theory, as well as on extensions through research (Whittemore et al.,
2002) and proposals of middle-range theory (Whittemore and Roy, 2002). The formation of
BOX 13-14 CONCEPTS—ROY (Continued )
Adaptive modes
Physiologic–physical mode (pp. 103–104)
Physiologic
Five needs: oxygenation, nutrition, elimination, activity and rest, protection
Four complex processes: senses, fluid (electrolyte and acid–base balance), neurologic function,
endocrine function
Physical
Basic need: operating integrity
Components: participants, capacities, physical facilities
Self-concept–group identity mode (pp. 107–108, 383–385)
Self-concept—individual
Basic need: psychic and spiritual integrity
Components: physical self (body sensation, body image), personal self (self-consistency,
self-ideal, moral–ethical–spiritual self)
Group identity
Basic need: identity integrity
Components: shared relations, goals and values, social milieu and culture, group self-image and
co-responsibility for goal achievement
Role function mode (pp. 109–110, 432–433)
Basic need: social integrity (individual level), role clarity (group level)
Components: role set and aggregate role set, structural approach (instrumental behavior,
expressive behavior), interactional approach (role-taking), developing roles (primary, secondary,
tertiary), integrating roles (collective patterns)
Interdependence mode (pp. 111–112, 475–480)
Basic need: relational integrity
Components (individual level): affectional adequacy, developmental adequacy, resource adequacy
Components (group level): context, infrastructure, participants
Focus: relationship with significant others, support systems
Coping processes: innate or acquired ways
Individual
Regulatory subsystem
Cognator subsystem
Group
Stabilizer subsystem
Innovator subsystem
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330 PART FOUR Reviewing and Evaluating: Pioneering Theories
TABLE 13-6 DEFINITION OF DOMAIN CONCEPTS—ROY
When nursing is needed The adaptive system of a person who is ill or has the potential of illness “when
unusual stresses or weakened coping mechanisms make the person’s usual
attempts to cope ineffective.”
Goal of nursing To enhance the adaptation of the patient in the four modes to free energy to
respond to other stimuli. Freed energy promotes healing abilities and wellness
(Roy and Roberts, 1981). “To promote adaptation” (Roy, 1984, p. 36) and “to
decrease ineffective responses” (Roy, 1984, pp. 37–38).
• Goal of nursing is defined “as the promotion of adaptation in each for the four
modes, thereby contributing to health, quality of life, or dying with dignity” Roy
and Andrews (1999, p. 55).
Nursing client A person, family, group, or community. Biopsychosocial adaptive systems with two
processor subsystems that are mechanisms for adapting or coping—the regulator
and the cognator. The system has four affecters of adaptation, or the adaptive
modes: physiologic needs, self-concept, role function, and interdependence (Roy
and Roberts, 1981, p. 43). A holistic, adaptive system (Roy, 1984, p. 36).
Human being Functions holistically (Roy, 1984, p. 36), highest possible fulfillment of human
potential (Andrews and Roy, 1986).
• “Humans (a) are individuals and groups share in creative power; (b) behave
purposefully, (c) possess intrinsic holism, and (d) strive to maintain integrity
and to realize the need for relationships” Hanna and Roy (2001).
• “Persons as individuals and members of families also are interrelated with all of
creation and are accountable for deriving, sustaining, and transforming the uni-
verse” Hanna and Roy (2001).
Nursing process A “particular format” used in nursing that uses the problem solving approach. It
comprises the six steps of assessment of behaviors, assessment of influencing
factors, nursing diagnosis, goal setting, intervention, and evaluation (Roy, 1984,
pp. 42–62; Andrews and Roy, 1991).
• “Nursing process consists of six steps, assessment of behavior, of stimuli,
nursing diagnosis, goal setting, intervention and evaluation” Roy and Andrews
(1999, pp. 63–96).
• “The nursing process involves an active search by the nurse to identify, interpret,
and respond to human coping processes” Roy and Andrews (1999, pp. 63–96).
Nursing problem The source of difficulty is coping activity that is inadequate to maintain integrity in
the face of a need deficit or excess (Roy, 1980, p. 184).
Nurse–patient relations Acknowledged in 1984 as important, but not defined. Defined in 1987 through nurs-
ing process.
Nursing diagnosis “Changes in internal or external environment can trigger need deficits or excesses.
Within the appropriate adaptive mode, coping activation is stimulated. When the
coping mechanism is ineffective in meeting the demand, ineffective behavior
results” (Roy and Roberts, 1981, p. 47).
“The behavior with its predominant stimulus” (Roy and Roberts, 1981, p. 47).
• Nursing diagnosis is a “judgment process resulting in statements conveying the
adaptation status of the human adaptive system” Roy and Andrews (1999, p. 77).
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CHAPTER 13 On Outcomes 331
the Roy Adaptation Association (RAA, 2007), which followed the formation of the Boston Based
Adaptation Research in Nursing Society (BBARNS, 1999), supported the continuity of scholar-
ship and dissemination of publications and presentations based on RAM.
Paradigmatic Origins
Roy’s theory is a synthesis of concepts developed outside the domain of nursing and rede-
fined within the context of nursing. Although Helson’s adaptation-level theory appears to be the
impetus for the central concept in this theory—adaptation as a process—Roy clearly and admit-
tedly was also influenced by her mentor and teacher, Dorothy Johnson. Johnson conceptualized a
person as a behavioral system with seven subsystems, and Roy conceptualized a person as a sys-
tem with two subsystems, as coping mechanisms, and four modes of coping. The similarities con-
tinue to encompass goals of nursing (homeostasis), focus (external regulatory mechanisms), the
patients (maladaptive or potentially maladaptive people), and later, a person with ineffective
behavior.
Roy’s doctoral education in sociology and her work with Ralph Turner, a prominent role
theorist, influenced her development of the role, interdependence, and self-concept (an interac-
tionist approach) as effector modes. In the interactionist school of thought, one’s self-concept is
TABLE 13-6 DEFINITION OF DOMAIN CONCEPTS—ROY (Continued )
Nursing therapeutics Traditional techniques such as comfort measures or health teaching, or entirely
new activities that have not been discovered, all with the goal of promoting
adaptation (Roy and Roberts, 1981, pp. 47–48).
• “Nursing intervention is described as the selection of nursing approaches to pro-
mote adaptation by changing stimuli or strengthening adaptive processes” Roy
and Andrews (1999, p. 86).
• “The response of the nurse has been either to provide or support adaptive behav-
iors, or to compensate for behaviors that may lead to compromised adaptation,
often using interpersonal strategies such as teaching” Roy and Andrews (1999,
p. 87).
Health A state of adaptation that is manifested in free energy to deal with other stimuli. A
process of promoting integrity and wholeness (Roy, 1984, p. 39). A continuous
process of being and becoming integrated (Roy and Gliss, 1993).
• “Coping processes are primary in terms of understanding individual people and
relational people, their adaptation, and the nurse’s role in enhancing adaptation”
Roy and Andrews (1999, p.87).
Environment Internal and external stimuli. There are three classes of stimuli: the focal stimuli
(immediately confronting a patient); contextual (all stimuli); residual (pertinent stim-
uli), but cannot validate effect on current situation. In other words, it is “all condi-
tions, circumstances, and influences surrounding and affecting the development
and behavior of humans as adaptive systems with particular consideration of per-
son and earth resource” (Roy, 1984, p. 39; Roy and Gliss, 1993; Swimme and Berry,
1992; Roy and Andrews, 1999).
Focus On persons, groups, families, communities, or societies with ineffective behavior, and
on manipulation of stimuli so that they would fall within the patient’s zone of posi-
tive coping. Increase, modify, decrease internal or external stimuli. Traditional inter-
ventions such as providing comfort or health teaching, or new undiscovered
interventions (Roy, 1984, p. 28).
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332 PART FOUR Reviewing and Evaluating: Pioneering Theories
defined by interaction with others and, therefore, roles enacted by a person and significant others
are predicated on their interdependence. These roles and their interdependence shape the concept
of self. One-to-one interactions between individuals are characterized by the use of verbal and
nonverbal symbolic communication, and it is through these symbolic interactions that roles are
shaped. Adjusting this interactionist paradigm shaped a major component of Roy’s theory, which
she integrated with Helson’s adaptation theory to form her conceptualization.
To be specific, Roy’s theory evolved from a synthesis of concepts from the adaptation, sys-
tems, and interactional paradigms. Parallels exist between the list of concepts and the physiologi-
cal modes, Johnson’s subsystems of behaviors, Henderson’s activities of daily living, and unmet
needs (e.g., rest, elimination, and circulation). Elements of systems theory influenced the develop-
ment of the subsystems (Bertalanffy, 1968). Roy (1970) and Roy and Corliss (1993), acknowledge
the influences of Levine (1966), Henderson (1960), Nightingale (1859), and Chardin (1965),
among other theorists and philosophers.
The development of Roy’s theory progressed rather rapidly to meet the curricular needs of
Mount St. Mary’s College. Therefore, some sense of urgency, as well as the backgrounds of exist-
ing faculty, may have contributed to some of the seemingly fragmented and overlapping concepts
in its early development. This expediency may have created content to be used in a curriculum,
rather than content that would enhance the development of nursing knowledge through question-
ing and refinement (Roy, 1989). All these influences and forces have been acknowledged in later
writings (Andrews and Roy, 1986). The shift to more clinical focus is apparent in the later writ-
ings of Roy (Roy and Andrews, 1991; Roy and Corliss, 1993; Roy, 2009) and is credited to her
postdoctoral education. At the turn of the century, a new phase in Roy’s theory has been well
established to advance, refine, and extend it. This is clearly the research phase of Roy’s theory.
Many utilizers of her theory operationalized concepts, developed research projects based on her
theory, and ventured into developing middle-range theories.
Internal Dimensions
Roy’s theory is a moderately abstract, logically deductive microtheory of the nursing client
developed around descriptions of concepts; therefore, it is a concatenated theory developed
around adaptation and its modes. Roy uses a field approach, connecting human beings with
environment through interactions, although her approach started as monadic. The theory has a
broad scope. It provides a framework with the potential of addressing a broad range of problem
areas related to the client who has demonstrated ineffective responses to internal and external
stimuli. The theory’s goal is to conceptualize the nursing client (in Roy’s early writings) as four
coping modes, and (in later writing) as a system with two subsystems—the regulator and the
cognator—and even later as input, two subsystems, four effector modes, and output (Roy, 1984;
Roy and Andrews, 1999). Roy and Roberts (1981) proposed the Roy theory as “a nursing prac-
tice theory . . . which is the knowledge of disorder” (p. 24); however, it provides a framework to
organize knowledge that addresses modes and mechanisms of adaptation of effective as well as
ineffective behavior.
Theory Critique
Roy’s theory evolved from mental imagery of what nursing is, who the nursing client is, and
what the goal of nursing care is. It was deductively derived from other theoretical formulations but
was not based on research findings, nor did it generate many published research findings historically
(Roy, 1976, p. 691; Roy and McLeod, 1981). This changed in the 1990s, when a decisive shift
occurred from a focus on curriculum development to generating research and findings to lend sup-
port to theoretical propositions that evolved from theory. During years of theory development, Roy
has clarified her own philosophical assumptions and discussed them (Roy, 1988a; Roy and Corliss,
1993). Some of her assumptions could be propositions and therefore could be tested. One example is
the conceptualization of human beings as having four coping modes. Furthermore, which behaviors
are components of what mode of coping also needs to be subjected to evaluation. Roy acknowledges
such directions in formulating propositions (Roy, 1980; Roy and Andrews, 1999) (Box 13-15).
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CHAPTER 13 On Outcomes 333
Roy systematically developed theoretical propositions to promote research projects. Initially,
the propositions were based more on neurological and biologic sciences. Some of these proposi-
tions tended to reduce the person to responding to chemical or neural stimuli through neural
inputs (Roy and Roberts, 1981, pp. 62–66). However, as she continued to develop her theory, the
nursing perspective is demonstrated, with more attention paid to propositions that are more con-
gruent with the nature of nursing, and that thereby incorporate a more wholistic aspect of human
beings. Based on assumptions of wholism, spirituality, and lived experiences, she promoted quali-
tative studies to uncover how clients tend to manifest models and mechanisms of adaptation (e.g.,
Gagliardi, Frederickson, and Shanley, 2002). Concept clarity could be enhanced by defining the
theoretical distinctiveness of such related concepts as role, interdependence, and self-concept, as
well as by providing valid empirical referents and reliable data related to each. The clarity of a
theory in nursing could be enhanced by explicit relatedness between its central concepts. Roy’s
physiological mode requires more clarity to better relate it to the other three modes of adaptation.
Many studies were conducted using Roy’s theory, and a number of integrative analyses
have contributed to advancing knowledge related to adaptation (Dobratz, 2008; Frederickson,
2000); some were directed to exploring and further developing concepts that are not as central
to the theory, such as perceptions of the nursing clients. However, the patient’s perceptions of
her own situation were not central to the conceptualization of a person. Nevertheless, the earli-
est research projects focused on perceived adaptation levels of the elderly client (Idle, 1978)
and perceptions of decision making (Roy, 1977), rather than on empirically describing systems,
effectors, or ineffective responses. When she later developed her theory, “perception” emerged
as a central concept linking the regulator and cognator mechanisms (Bunting, 1988). Others,
such as Randall, Poush-Tedrow, and Van Landingham (1982), provided support for the central-
ity of perceptions in understanding the experience and manifestations of adaptation. Although
Roy acknowledged and supported the notion of client involvement in care, as alluded to in the
following early quote, “According to this nursing model, the person is to be respected as an
active participant in his care . . . The goal arrived at is one of mutual agreement between the
nurse and patient. Intervention[s] are the options that the nurse provides for the patient” (Roy
and Roberts, 1981, p. 47), the lack of integration of the concept perception in theory continued
to be an issue. Several major recommendations for revising the theory were subsequently pro-
vided by the Boston Based Adaptation Research in Nursing Society in 1999 (BBARNS); among
them is the need to give special attention to the roles of the concepts of perception and time in
the theory. In an integrative review of the qualitative research based on Roy’s theory, Perrett
(2007) concluded that the studies reviewed provided support for the propositions that time and
perception influence adaptation. However, further thought should be given to how these concepts
are interwoven into the theory’s fabric. Theoretical propositions driven by the tenets of the the-
ory and inclusive of these vital concepts to adaptation may enhance the potential of intervention-
based research.
Many authors consider Roy’s theory useful in integrating findings related to a particular
patient’s condition or set of problems. By providing a coherent framework to review findings, new
meanings emerge and gaps in knowledge are identified. An example is Nayback (2009), who
examined the post-traumatic stress disorders among military veterans and concluded that using
Roy’s theory is a more effective way to identify gaps in knowledge.
BOX 13-15 PROPOSITIONS—ROY
• Nursing actions promote a person’s adaptive responses.
• Nursing actions can decrease a person’s ineffective adaptive responses.
• People interact with changing environment in an attempt to achieve adaptation and health.
• Nursing actions enhance the interaction of persons with environment.
• Enhanced interactions of persons with environment promote adaptation.
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334 PART FOUR Reviewing and Evaluating: Pioneering Theories
Roy’s theory was used to develop research instruments, to describe responses to different
health/illness concepts, and to evaluate interventions. Tools were developed early in the theory’s
history to measure perceptions of adaptation levels (Idle, 1978), perceptions of powerlessness in
decision making (Roy, 1979), health care outcomes for cancer patients (Lewis, Firsich, and
Parsell, 1978, 1979), and regaining functional abilities after delivery (Tulman and Fawcett,
1988). In total, and as of this writing, according to a very thorough review and critique of instru-
ments developed and driven by the theory, 123 instruments were used in 231 studies over 30
years (Barone, Roy, and Frederickson, 2008). These instruments were developed to study the
four adaptive modes and the cognator processing mechanism; other instruments were used with
multiple adaptive modes. Of all these instruments, 21 met criteria for analysis by Barone, Roy,
and Frederickson (2008). The authors identified 14 of them that are highly useful and should be
used in the future to advance theory-based knowledge.
Roy’s theory was used as a framework for descriptive and exploratory research, as well as in
testing propositions. In addition, it was used as a framework to study the experiences and
responses of clients to parental touch of preterm infants (Harrison, Leeper, and Yoon, 1990), of
spinal cord–injured women during pregnancy (Craig, 1990), of adult survivors of multiple trau-
mas (Strohmyer, Noroian, Patterson, and Carlin, 1993), and spousal adaptation to mates’ coronary
artery bypass surgery (Artinian, 1991, 1992).
In the 21st century, Roy’s theory continues to enjoy unusual research activity in describing
relations between concepts as a framework for nursing intervention and for interpretation of
results. It has been used to explain factors that enhance healing after coronary artery bypass graft-
ing (DiMattio and Tulman, 2003), and the concerns and adaptation of new mothers after caesarean
birth (Weiss, Fawcett, and Aber, 2009).
Another type of intervention that is well explained by Roy’s theoretical framework is that of
“touch.” Certain types of touch (a focal stimulus in Roy’s theory) were found to enhance the
effectiveness of both the regulator and cognator adaptive systems in preterm infants. These then
infer the preterm infant’s ability to cope, as manifested in the physiological and interdependence
modes. Infants’ responses included heart rate and oxygen saturation stability; decreased motor abil-
ity, which preserves energy; decreased behavioral stress cues; and quiet sleep (Modrcin-Talbott
et al., 2003).
Wendler (2003) used Roy’s theory for another type of touch intervention for healthy adults
receiving venipuncture (a noxious focal stimulus). “Tellington touch” (redefined as a contextual
stimulus) is a type of touch that was adapted from an approach used to calm horses. Wendler
(2003) concluded that the touch intervention enhanced the regulator system and thus enhanced
adaptation.
Different theories provide frameworks to study nursing needs and outcomes in different set-
tings, as well as for clients at different times in the life span. Roy’s theory has been used to study
children (Waweru, Reynolds, & Buckner, 2008), adolescents (Ramini, Brown, & Buckner, 2008),
and elders (Chen, 2005; Chen, Chang, et al., 2005). It was used for acute and chronic conditions,
and for adaptation to hospital and community settings.
In another group of studies, the researchers used Roy’s theory as a framework to interpret
data and connect findings with other similar findings (e.g., Gagliardi, 2003). Dobratz (2003)
found that using a theoretical framework to teach undergraduate students about research helped
the students integrate their research experience. Similarly, the theory was used as a foundation
from which the dynamics of quality of life was researched and interpreted from the intersection of
relationships between patients who had lung transplants and their caregivers (Lefaiver, Keough,
et al., 2007).
In addition to research utilization, it was used in practice, education, and for administration
of health care systems. It was integrated with the process of clinical judgment, and it offered an
excellent checklist for the assessment of variables responsible for problematic behavior resulting
from environmental stimuli (i.e., focal, contextual, and residual stimuli) and the setting of priori-
ties for action, for example for understanding the lack of motivation to quit smoking (Villareal,
2003). The theory was also used in assessing and planning care for patients in surgical settings
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CHAPTER 13 On Outcomes 335
(Roy, 1971), in community settings (Cunningham, 2002; Hanchett, 1990; Schmitz, 1980), and in
obstetric and pediatric settings—in short, in distributive and episodic settings (Wagner, 1976).
The setting that created the most difficulty was the intensive care setting (Wagner, 1976). The
theory has demonstrated its usefulness in assessing gerontology patients (Farkas, 1981; Janelli,
1980), young children (Galligan, 1979), cardiac patients (Gordon, 1974), patients with organic
brain damage (Hamer, 1991), postpartum patients (Kehoe, 1981), and fathers whose mates
undergo cesarean delivery (Fawcett, 1981a). It has been useful in neonatal care (Downey, 1974),
in demonstrating depression and life satisfaction among a group of retired people (Hoch, 1987),
and for acute psychiatric patients (Kurek-Ovshinsky, 1991). Although the theory discussed
human development, human aging processes are not clarified (Wadensten and Carlsson, 2003).
Despite these clinical examples of effective theory utilization in practice, there are indications of
a lack of boundary clarity between role function, interdependence, and self-concept (Wagner,
1976).
In all these studies, the utility of a checklist to identify normal behavior and deviations from
normal behavior was demonstrated, and the theory’s potential for identifying outcomes criteria to
be used for quality assurance was also demonstrated (Laros, 1977). At the same time, however,
these studies demonstrated a lack of concept boundaries, which is a limitation of the theory’s
framework for understanding the nature of person–environment interactions, other than providing
descriptive accounts of correlations between stimuli and individuals’ responses (Young-
McCaughan et al., 2003). There are some thoughtful and useful directions for developing nursing
therapeutics based on theory.
The theory’s circle of contagiousness in education is wide and extensive compared with other
theories. Conferences were planned in the 1970s through 2010 for educators interested in using
the theory as a framework for their curriculum. The annual conference planned by Mount
St. Mary’s College is another indication of the wide interest that continues for the theory
(Wallace, 1993). For educational settings faced with the need to develop a conceptual framework
for curricula, the availability of a theory that has been operationalized at Mount St. Mary’s Col-
lege School of Nursing, including the textbooks and literature to use, made for enthusiastic adop-
tion of the theory. Roy’s theory has been used in 11 states (27 schools) and also in Canada and
Switzerland (Fawcett, 1984). The theory has also been used in specialty curricula (Brower and
Baker, 1976). The challenges inherent in operationalizing and implementing Roy’s theory drive
faculty to develop some innovative approaches to promote a more adaptive implementation
(Morales-Mann and Logan, 1990), ideas that have been extended internationally (Fawcett, 2003).
Clinical setting administrators have also attempted a further operationalization of the theory
in several settings. In each instance, it provided a framework for assessment of patient needs in
each of the modes and a ready-made, usable classification system for the stimuli. Recording of
patient care needs was rendered more organized and simple, and there were indications of
increased patient satisfaction and expanded professional practice (Laros, 1977; Mastal, Hammond,
and Roberts, 1982). In a case study analysis, Gless (1995) demonstrated the clinical utility of
Roy’s theory in supporting and promoting a quadriplegic patient’s ability to cope with living in a
long-term care facility.
All concepts related to the physiological mode, or effectors, are concrete and are most
directly related to observable data; data related to this mode tend to predominate in the findings.
Perhaps this is partially because concepts from the other three modes are generally abstract, less
operationalized, and beset with unclear boundaries. The concepts are theoretically defined but
lack both boundary validity and operational definition. Adaptation, the consequence of nursing
care—a process and an end result—lacks both theoretical and operational definition and validity.
Exemplars of adapted patients and patients with ineffective behavior (process and product) could
help in advancing the theoretical development of concept definitions.
Concepts tend to be somewhat tautological, such as focal stimuli, which are also identified
behaviors in each of the modes. The view of a person as an open interacting system and the view
of input and output appear to be inconsistent, even though Roy, in her later writings, incorporated
both input and output within her conceptualization of a person.
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336 PART FOUR Reviewing and Evaluating: Pioneering Theories
External Components of Theory
Society and other health care professionals would agree that nursing deals with the physiolog-
ical needs of the patient and the goal of adaptation in that mode, but there may be less agreement on
the role of nursing in relation to other modes. Perhaps this is due to the decreasing time that nurses
spend with patients in hospitals and the still-limited development of theory for utilization in home
and community care. It is also due to the focus of the health care system on biologic and physiolog-
ical aspects of care. The systematic assessment potential that Roy’s theory offers is congruent with
the prevailing view of a need for an organized system in assessment and intervention, and utility of
the nursing process in patient care.
The theory’s simplicity and the available operationalized teaching-oriented literature
enhanced its wide geographical spread but limited its more thoughtful and inquisitive use; coping
mechanisms of cognator and regulator continue to require clarification. The complexity of the
propositions has initially slowed the theory’s operationalization for research projects. Educators
and clinicians, however, in search of a coherent way to readily present and discuss their care or
teaching, found the theory useful and provided more face validity to the theory’s concepts. Con-
versely, researchers initially ignored the theory, found the complexity of the propositions and their
physiological perspective cumbersome or unrepresentative of the nursing perspective, or tended to
use the theory as a framework without connecting its concepts to the whole research process from
conceptualization to interpretation; these researchers, therefore, turned to other perspectives. For
whatever reasons, creative projects proceeded from face validity studies to construct criterion
validity, and, at the beginning of the 21st century, to relational research. This progression repre-
sents a strength of this theory.
Another major strength of Roy’s theory lies in its exemplary nature of theory development.
The theory evolved from a belief that nursing makes a unique contribution to patient care and that
the recipient of care is an open adaptive system. After structurally identifying major components
of theory, assumptions, and concepts, Roy and many others who have used the theory, provided
evidence for its utility as a framework for the different missions in the discipline of nursing.
Theory Testing
Studies were conducted by Roy during her postdoctoral Robert Wood Johnson fellowship at
the University of California, San Francisco, to determine the cognitive processes in patients with
head injury and to test different propositions of the theory (Roy and Andrews, 1991). The results
provided detailed descriptions of patterns of information processing of patients over the course of
their illness due to head injury. Results also supported the proposition that nursing interventions
using Roy’s theory tended to improve cognitive processing of these patients (Roy and Andrews,
1991). Others have used the theory to describe responses to chronic illness (Pollock, 1986), per-
ceptions of stressors of children in an intensive care unit (Munn and Tichy, 1987), the needs of
spouses of surgical patients (Silva, 1987), and the differences between recovery rates in the func-
tional abilities of postpartum vaginal and cesarean delivery patients (Tulman and Fawcett, 1988).
Studies were conducted to test the relationships among several of the theory’s concepts. Find-
ings indicate that the four response modes (physiologic, self-concepts, interdependence, and roles)
are not interrelated (Nuamah, Cooley, Fawcett, and McCorkle, 1999). Other findings provide sup-
port that focal, contextual, and one of the components of coping mechanisms, the passive–avoid-
ance coping strategies, were related to psychological stress, which is one of the indicators for
adaptation in the self-concept mode (Levesque, Ricard, Ducharme, Duquette, and Bonin, 1998).
Roy’s propositions related to spirituality also received some attention (Malinski, 2002). Put-
ting trust in God and speaking of religion during illness and recovery was found to be an impor-
tant coping strategy for black patients on hemodialysis (Burns, 2004). Conceptualizing spirituality
as a residual stimulus was associated with adjustment to end-stage renal diseases for women
(Tanyi and Werner, 2003).
The effects of interventions designed within an adaptation framework were evaluated in sev-
eral studies. Examples are evaluation of the effects of using a birth chair on mothers and infants
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CHAPTER 13 On Outcomes 337
(Cottrell and Shannahan, 1986, 1987) and of prenatal education on unplanned cesarean birthing
(Fawcett and Henklein, 1987). Fawcett’s (1981b) research in identifying the needs of parents fac-
ing cesarean section is an example of significant research offering support to Roy’s modes of
adaptation as a primary assessment framework. An example of particular significance is a study to
identify the adaptation modes and needs of postpartum women after a caesarean birth, considering
how common caesarean surgeries have become globally (Weiss, Fawcett, and Aber, 2009). Levels
of adaptation have been an elusive consequence but a most significant aid in understanding the
nursing care process and its intended goals. The study of Lewis et al. (1979), geared toward devel-
oping an instrument to measure the adaptation level of chemotherapy patients, is a step in the right
direction in the empirical definition of adaptation. Studies using experimental design to test the
effectiveness of Roy-driven intervention by school nurses to empower adolescents with attention
deficit–hyperactivity disorder (Frame, 2003) and human touch to enhance the well-being of
preterm infants (decreased motor activity, decreased behavior stress cues, increased quiet sleep,
and stabilized heart rate and oxygen saturation) supported the proposition that by intervening in
the regulator and cognator subsystem, coping response modes are enhanced (Modcrin-Talbott
et al., 2003).
Roy’s studies, reported in Roy and Andrews (1999), also support the effectiveness of inter-
ventions driven by her theory in improving cognitive functioning in patients with head injury.
Bakan and Akyol (2008) used the theory as a framework to develop and test Roy-based interven-
tions to improve the quality of life and functional capacity of heart failure patients and found the
intervention effective. Contributions of research findings synthesized by Pollock, Frederickson,
Carson, Massey, and Roy (1994) provided guidelines for further testing of the theory and the
rationale for collaboration of researchers who are using the same theory. Relationships between
study variables and theory concepts need further analysis (see Table 13-6 and Box 13-15). The
Boston Based Adaptation Research in Nursing Society (BBARNS), renamed the Roy Adaptation
Association in 2001, enhanced the systematic testing and further development of Roy’s theory
(Fawcett, 2002). Roy’s theory was used to test the relationship between constant interaction with
changing environment through an exercise program and its effect on sleep and quality of life
(Young-McCaughan et al., 2003), and to test family adaptation to spinal cord injury (DeSanto-
Madeya, 2006, 2009).
There was also support for the use of Roy’s intervention-based theory that empowered pread-
olescents with attention deficit–hyperactivity disorder and enhanced their perception of self-worth
(Frame, 2003; Frame, Kelly, and Bayley, 2003). Likewise, it was used with adolescents in an
asthma camp to change adaptive outcomes related to taking responsibility for one’s own care. The
results indicated that adolescents demonstrated responsibility in management in the interdepend-
ence mode (Buckner, Simmons, et al., 2007).
Roy provides a useful framework for testing environmental stimuli barriers and mobility.
Shyu et al. (2004) found evidence in their study on the mobility of Taiwanese patients who had
undergone hip surgery to support the proposed theoretical relationship that links environment and
individual adaptive modes. On the other hand, Samarel, Tulman, and Fawcett’s (2002) study on
testing different types of support and education on adaptation to early-stage breast cancer did not
yield significant differences between the different groups of women receiving different Roy-based
interventions.
Roy’s theory has been dynamic and actively pursued for the development of middle-range
theories by many utilizers in two areas: (1) caregivers’ effectiveness and well-being and (2) cop-
ing with pain and chronicity. Five middle-range theories were developed based on Roy’s theory.
Tsai (2003) developed a theory to describe stress of caregivers who are relatives of chronically ill
individuals. A similar middle-range theory was developed by Smith and her colleagues to describe
and predict family caregiving effectiveness and patient and caregivers’ well-being (Smith, Pace,
Kochinda, Kleinbeck, Koehler, and Popkess-Vawter, 2002).
Roy’s theory has been also used as a framework to develop and test a middle-range theory
about chronic pain in older people with arthritis (Tsai, Tak, Moore, and Palencia, 2003). A similar
middle-range theory was modified to describe adaptation to chronic pain (Dunn, 2004), and to
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338 PART FOUR Reviewing and Evaluating: Pioneering Theories
help women better manage their chronic illness (Weinert, Cudney, and Spring, 2008). Roy herself,
in collaboration with Whittemore, developed a middle-range theory that extends her adaptation
framework to explain coping with diabetes mellitus through theory, concept synthesis, and the use
of empirical evidence (Whittemore and Roy, 2002).
Roy’s theory has been used as a framework to further develop concepts such as social isola-
tion in older adults, in which five attributes were identified: number of contacts, feeling of belong-
ing, fulfilling relationships, engagement wishes, and quality of network. The author concludes
that, as conceptualized, social isolation may be a productive variable in research if incorporated
with the Roy Adaptation Model (Nicholson, 2009). Another example is its use in developing the
concept of quality of life as perceived by lung transplant candidates and their caregivers (Lefaiver,
Keough, et al., 2007).
The theory enjoys a global presence. It has been used to describe the perceptions of children
suffering from HIV/AIDS in Kenya (Waweru, Reynolds, and Buckner, 2008). It was adapted as a
framework for a nursing curriculum in Colombia (Moreno, Durán, and Hernandez, 2009), and it
was used to develop interventions to enhance the adaptation of patients with heart failure in
Turkey (Bakan, Akyol, 2008). Yeh (2002, 2003) used Roy’s theory to test the relationship between
environmental stimuli and biopsychosocial responses of children with cancer in Taiwan. She
found the theory translatable and the proposition that links environments with responses well sup-
ported. Others provided mixed reviews of translating the concepts of self-concept, interdepend-
ence, and role function into other cultures (Chung, 2004). However, a general review of the
theory’s international utilization reveals that it is effective for use in different cultures (Roy Adap-
tation Association, 2007), and that eastern and Latin American countries have used the theory
extensively. Roy Adaptation Associations have been formed in Japan, Columbia, and Mexico
(Roy, Whetsell, and Frederickson, 2009).
CONCLUSION
There is a growing contemporary dialogue in health care fields on patient-centered care and out-
comes of care. This dialogue makes the client the focus of health care and health care outcomes
the ultimate goal and test for quality care. The emphasis in nursing practice has always been on
the client, in historical as well as contemporary times. Whether the client is an individual, a fam-
ily, or a community, the nurse’s work begins with a careful assessment of the client and plans for
the appropriate intervention by focusing on the needs, resources, the problems, or the responses
experienced and/or observed in the client. In this chapter, five nursing theorists spanning the
decades of the 1950s, ’60s, and ’70s demonstrate an emphasis on client-centered care in their the-
ories. There is also a focus on outcomes of care. Johnson defines a client as a behavioral system
with seven subsystems, and a nurse’s role and goal is to regulate and preserve the organization and
integration of the patients’ behaviors, particularly when the subsystems are threatened. Levine
focuses on conserving and mobilizing energy. To Roy, the client is a person, a family, a group, or a
community, and is a biopsychosocial adaptive system with two processor subsystems. The client
is capable of adapting through the regulator and cognator processes. The goal of nursing is to
enhance adaptation through four modes—the physiological–physical mode, the self concept
mode, the role function mode, and the interdependent mode. To Neuman, nurses are concerned
about keeping clients’ systems stable. They do that through first addressing the concentric lines of
resistance, then penetrating lines of defense, all to keep the client’s central structure intact. The
nurse’s role is to prevent stressors from penetrating flexible lines of defense, preserve lines of
resistance, and support a client’s resources.
Although these theorists did not ignore the environment (environment is the focus for Rogers),
it is clear that the core of their theories was to provide a framework to understand who the client is.
The questions that these theories generated addressed stability and instability, adaptation, coping,
and the consequences of nurses’ interventions that facilitate and promote these processes.
In addition to Florence Nightingale, who introduced nursing to the notion of the centrality of
environment in nurses’ domain of practice, Martha Rogers is the person–environment relationship
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CHAPTER 13 On Outcomes 339
guru. Furthermore, her theory supports the essentiality of patterns and patterning in understanding
the experiences of health and illness. She also reinforced the idea that nursing is based on science.
She pioneered the connection between physics and nursing, and she provided the optimistic view
of health that empowers the individual as well as the professional nurse. She was a visionary
thinker, an inspiring leader, and a theorist who was ahead of her time. She saw the world of nurs-
ing very differently, and provided a framework for others to experience this perspective. Despite
many critics, many of her concepts and propositions continue to stimulate innovative nursing
research.
These theories continue to generate fundamental as well as translational questions that could
enhance nursing science, as well as enrich nursing practice.
REFLECTIVE QUESTIONS
1. Why were these theorists grouped
together in this chapter?
2. Compare and contrast how “client”
was conceptualized by each of the
five theorists presented in this chapter.
What are some common propositions,
and in what ways do they differ drasti-
cally?
3. Which, if any, of these definitions and
views of client persist in contemporary
nursing practice?
4. Compare and contrast the outcomes in
each theory.
5. What are some paradigmatic origins
shared by the five theorists discussed
in this chapter and which appear to be
contradictory?
6. Critics differ on how Martha Rogers’
theory has influenced progress in the
discipline of nursing. A group of critics
considers her theory to completely miss
the substance and goals of nursing.
Others believe that she was a theorist
who was ahead of her time. Where do
you stand on your views of her theory?
Be specific, support your analysis, and
indicate why.
7. How does Rogers define the concepts
of energy and interaction? Develop
research questions that could advance
knowledge about these two concepts.
8. Identify one research instrument that
needs development to test one vital
proposition in each theory.
9. Make a case for a different approach to
categorizing the five theorists discussed
in this chapter. Provide the rationale for
the proposed categorization.
10. Select one of the theorists and develop
a research project to test two or three
propositions that could extend knowl-
edge in your field of practice. In what
ways would the results of the selected
research questions extend the theory?
11. Identify three ways by which any of the
theories may extend nursing knowledge
in your field.
12. Rogers rejected reductionism, causality,
the separation of person and environ-
ment, and what else? What scientific
value did she embrace and in what
ways did these values inform her the-
ory? Compare and contrast her
approach with Johnson’s.
13. How would Rogers’ theory explain
hyperactivity, type A behavior, attention
deficit hyperactivity, and sleep disor-
ders? What research propositions may
help support or refute her possible
explanation?
14. Describe a program of research within
your field of interest that is informed by
any one of the theories.
15. Identify two middle-range theories that
evolved from Rogers’ and Roy’s theo-
ries. Critically assess their congruence
with explicit and implicit assumptions
in Rogers’ theory.
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340 PART FOUR Reviewing and Evaluating: Pioneering Theories
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Our Theoretical Future
IN Part 4, three categories of theories were presented: the needs, the interaction, and
the outcome theories. Another category of theory not presented in this book but
equally as important in advancing knowledge is that of the group of theorists who
focused on the caring and humanistic aspects of nursing. (One theory that has aspects
of humanism was included as part of the interactionist theories.) From this rich her-
itage of capturing the essence, the goals, and the outcomes of nursing, the question
that we should be addressing is “how do we use this significant stage in the develop-
ment of the discipline as a stepping stone for the future?” In this part of the book, I use
our historical development as the basis for looking ahead toward a theoretical future.
In Chapter 14, I present some of the major challenges and opportunities that
could be a context for advancing the discipline. Addressing, accepting, rejecting, or
utilizing the paradoxes presented in this chapter, as well as others that continue to
emerge, is vital for making progress. Chapters 15, 16, and 17 provide strategies to con-
tinue to develop our theoretical future. Building on strategies that have been used by
scholars in our discipline, as well as in other disciplines, I present different strategies
to advance our theoretical future from concept development to developing situation-
specific theories. Finally, in Chapter 18, I propose an answer to the question we fre-
quently ask, “How do we determine progress in a discipline?” In other words, how
do we, or others, come to understand a discipline’s progress? Alternatively, what are
the markers for a stagnating discipline? Different theories are proposed
to analyze the levels of the progress and development of the discipline. The meaning
of each of these theories and the contribution they make to the discipline and its
scientific base are discussed.
P A R T F I V E
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Members of any discipline must be able to clearly articulate a coherent view of the discipline, its
values, goals, and areas for future development. Similarly, members of any discipline must
develop and maintain a strong sense of identity to a discipline, as manifested also in utilizing dis-
ciplinary knowledge and taking responsibility in continuing to advance this knowledge (Fawcett,
2006; Willis, Grace, and Roy, 2008).
The task of developing theoretical frameworks that reflect clinical practice and that could
better inform practice and drive the research agenda in the discipline of nursing is not complete
yet, nor will it ever be finished in dynamic and responsive disciplines. Theory as the link between
research findings and practice utilization is dynamic, changing, and constantly evolving. Clini-
cians need and use theory to inform their practice. What helps clinicians is not only that patients’
uncertainty about diagnosis and prognosis may be positively and directly related to slow progress
in wound healing; it is also knowing that uncertainty in those patients who have lifestyles based
on planning and certainty, or who function better with a sense of control over their environments,
tend to have different recovery patterns than others who have had lives of more uncertainty. The
first is a research hypothesis; the second is a theoretical proposition (Meleis, 1992).
Theory is also the link between fragmented research and a coherent research program. How
patients experience symptoms and interpret them, and the strategies they use to care for their
symptoms in particular, and their health in general, is a theoretical question that may drive a num-
ber of research studies with populations who have experiences with different symptoms. The
results of these studies add knowledge to self-care theories, provide support to develop new theo-
ries, and may refine existing theories on managing a number of illness experiences, such as pain
and shortness of breath, among other symptoms.
Theory provides the contextual interpretation of research findings and the framework to con-
nect the different experiences nurses encounter. A theory on transition and health may alert nurses
to use knowledge related to facilitating admission transition to inform their caring for patients
undergoing other transitions. These experiences may, in turn, modify some of the theoretical inter-
pretations regarding the admission transition. Theories allow the more complex interrelationships
to be considered and, therefore, responses could be viewed more within a context of antecedents
and consequences, as well as patterns, rather than isolated relationships, events, or responses.
Although theory has been instrumental in the general progress of the discipline of nursing,
the most cogent and significant contribution that the nursing theorists have made is the promotion
of theoretical thinking. Theoretical thinking is characterized by the ability to use frameworks to
promote understanding, as well as the ability to be skeptical about the frameworks and their utility
in exploring any, all, or part of health–illness situations. It is the ability to connect seemingly dis-
crete, unconnected thoughts, observations, or facts, and to see a coherent whole. It is abstract
thinking grounded in exemplars from practice. A theoretical thinker is a reflective thinker who
suspends “fragmentedness” to allow for the exploring, explaining, and reinterpreting of wholes. A
critical thinker is someone who is able to explore and describe patterns, not only discrete facts,
and who engages in individual ontological dialogues, as well as similar dialogues with others. A
theoretical thinker is a critical thinker with a goal of discerning patterns, connecting ideas, and
developing explanatory models; to ask and answer the “whats,” “why nots,” and “what ifs.” A
critical thinker is one who is inquisitive, truth seeking, systematic, and analytical (Dewey, 1982;
Facione, Facione, and Sanchez, 1994). A theoretical thinker does not allow procedures and rules
alone to drive his or her focus or explorations; rather, he or she uses them only as tools that must
Challenges and Opportunities
for a Theoretical Future
C H A P T E R 14
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be considered, revisited, and revised. Theoretical thinking includes critical consideration of the
discipline’s central phenomena and questions. Theories are dynamic and always changing, and, as
Levine (1995) admonished, they “are not written in stone.”
A theoretical thinker questions the prevailing models that have governed his or her nursing
care. An example of a model that has been critically analyzed is the biomedical model. The bio-
medical model, as a framework for health care, has been challenged because of its limited effec-
tiveness (Engel, 1977), and has been challenged by nurses as inappropriate for the mission of
nursing (Allan and Hall, 1988; Shaver, 1985). Others have described the differences in perspec-
tives between nursing and other health fields and the uniqueness of the nursing perspective,
despite its dependent and interdependent functions (Visintainer, 1986).
Nursing theorists have demonstrated theoretical thinking and are among those nurses who
not only challenged the biomedical model, but who also proactively conceptualized different
aspects of the territory of nursing. Their conceptualizations provided the bases for identifying
nursing perspectives and for defining our nursing domain. It is because of their pioneering work
that members of the discipline continue to discuss the theoretical bases of practice and pose and
answer theoretically driven questions. This theoretical thinking must continue to be promoted in
nursing education, administration, and research.
Nursing theories of the past, present, or the future do not answer all the questions that nurses
may ask; neither do sociological, psychological, physiologic, or engineering theories. Different
theories in each of these disciplines answer different questions, and yet some questions still have
not been answered satisfactorily. Other questions that appeared to have been answered satisfacto-
rily have been challenged by new data and new competing explanations; for example, Margaret
Mead’s cultural determinism and Sigmund Freud’s seduction theories. Therefore, theories are
dynamic and should not be judged in terms of total support for all their propositions.
OPPORTUNITIES WITHIN PARADOXES
To continue with the phenomenal progress that has been made in advancing nursing knowledge,
discussions and dialogues must include a healthy tension among several challenges and para-
doxes. Being aware, mindful, and open to these paradoxes will be essential for agents of knowl-
edge to decide on the most productive path in continuing on the discipline’s journey of theoretical
development. I offer no solutions; I merely offer the rudimentary beginning of many crossroads.
You, the reader, who has come so far in reading this book, will chart the future course of develop-
ment in our discipline. So read on, dialogue, debate, and continue with your journey in knowledge
development.
Disciplinary or Interdisciplinary Knowledge
The 21st century will be known as the century in which the hybridization of disciplines
evolved and became the norm. It is the century when realization about pressing questions in
health, illness, interventions, and recovery could not be tackled from the lens of one discipline or
one science. It will be known as the century of partnership, collaboration, and interdisciplinarity.
Members of disciplines who have existed in silos and who created boundaries, real or imaginary,
could no longer compete in advancing the knowledge base of their discipline. The National Insti-
tutes of Health developed road maps for the future based on interdisciplinary science and teams.
The Institute of Medicine deliberated and advocated for quality care through partnership (Grey and
Mitchell, 2008). Nursing and medical organizations developed competitive projects to promote the
formulation of interdisciplinary teams. Universities developed such hybrid areas of knowledge as
urban institutes, like that developed at the University of Pennsylvania in 2005, and genetic toxicol-
ogy (Frickel, 2004) among others. Forward-looking organizations, such as the Macy Foundation,
invited scientists and scholars to dialogue about integrating the disciplines of neuroscience, psychol-
ogy, nursing, and behavioral science to better understand human responses (Macy Foundation, per-
sonal communication, 2004). Similarly, the Macy Foundation assembled a group representing many
health professions to discuss best practices in providing primary care and in deciding who should
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provide it (Cronenwett and Dzau, 2010). Interdisciplinarity also connotes researchers from differ-
ent fields working together and utilizing integrated theoretical frameworks. A consequence may
be the development of a new discipline—transdisciplinarity (Grey and Connolly, 2008), which is
considered the future of science. Interdisciplinarity requires “permeable boundaries” (Frickel,
2004). However, it also requires disciplines with strong boundaries, disciplines that have achieved
a certain level of maturity in their science base and knowledge development, as well as a strong
disciplinary identity in their scientists. If members of a discipline embark on a journey of interdis-
ciplinarity before such maturity is achieved, the central phenomena and the significant questions
of such a discipline and the approach to investigating them may be totally overshadowed by other,
more mature disciplines. Funding and support may follow the dominant discipline. Interdiscipli-
narity allows knowledge from different disciplines to be synthesized and integrated. How such
integration is achieved and what can be gained and lost will depend on the level of a discipline’s
scientific maturity. The tension between the promise of interdisciplinarity and the development of
productive discipline careers will also need to be considered (Rhoten and Parker, 2004). Similarly,
tension exists in the paradox of the need for disciplinary specialization and subspecialization and
interdisciplinarity (Strober, 2006).
In addition, what I fear is that the phenomena of nursing discipline, the pressing questions of
our profession, will be minimized, ignored, or replaced by the pressing questions of other disci-
plines (Chinn, 2007; Fawcett, 2008). This fear is also echoed by others who have dialogued about
interdisciplinarity (Grey and Connelly, 2008). So, the questions to consider are: What does it
mean to have a disciplinary domain and perspective? And, how do we preserve that core of the
discipline as we become more interdisciplinary? What should members of the discipline guard as
they become interdisciplinary? Advantages to interdisciplinarity are obvious. It provides more
comprehensive answers to questions about quality care. Answers to pressing questions related to
health care involve biobehavior as well as sociocultural bases and hence require interdisciplinary
teams to address their complexity. Interdisciplinarity can work without undermining one disci-
pline or another through the principles of equality; partnership; synthesis; reciprocity; equality in
viewing multiple sources and bodies of knowledge; partnership of members of different disci-
plines; reciprocity in training, utilizing, and evaluating findings, and knowledge; and synthesis
and integration with a whole that is better than the parts of each discipline separately. To what
extent will nurses who are emerging from a history of inequity and oppression be able to honor
and value the core values and mission of our discipline as interdisciplinarity becomes the norm?
Global or Local Theories
One of the principles that could empower nurses is to participate in the development of cross-
national knowledge that benefits from participation by colleagues from different parts of the
world. Although certain aspects of nursing interventions are culturally contexted, the phenomena
themselves transcend cultures and societies (Falk–Rafael, 2006). Comforting patients, helping
wounds heal, feeding the elderly, increasing mobility and activity, rehydrating populations, pre-
serving the integrity of clients, promoting health, developing healthy environments, promoting
rest, supporting sleep, intubating, monitoring, managing symptoms, and decreasing pain are
examples of phenomena that nurses deal with around the globe.
Covering the various dimensions about the nature of phenomena through international work
creates knowledge that is more culturally sensitive and empowers nurses to influence policy
changes related to health care. Committing to globally relevant topics, particularly ones with rele-
vance to social problems, produces passionate scholars and may increase scholarly productivity
(Heinrich, 2010). Sharing and reciprocating findings about phenomena increases nurses’ reper-
toires of therapeutics that would, in turn, enhance their effectiveness in caring for diverse popula-
tions. The principle of a global view could ensure that nurses’ efforts in knowledge development
become more cumulative, more culturally sensitive, more attuned to oppressive power relations,
and more responsive to the concerns of the world (Georges, 2008). Culturally sensitive theories
help nurses become more culturally competent in a world that is constantly in transition, one in
which patients tend to reflect diversity. This principle mandates thinking internationally in every
356 PART FIVE Our Theoretical Future
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aspect of our work and in the theories that we attempt to develop, with attention to the common
good. A framework of social and economic justice geared toward addressing disparities is more
congruent with global concerns (Crigger, 2008). Yet relativism in developing knowledge, limited
resources, and constraints in creating global teams may act as barriers to developing global theo-
ries. Our international colleagues continue to remain skeptical about the ability of nurses to col-
laborate on an equal basis to develop theories that address nursing phenomena from a global
perspective. They remind us that theories developed in the United Kingdom, Sweden, Finland,
Brazil, and France are barely recognizable in the United States. Our knowledge is U.S.-based, but
the empowerment of nurses and enhancing quality care requires a global application and therefore
such application should be informed by global theories. How will we be able to reconcile these
differences in the future? What will it be—local or global theories? Robust dialogues between
East and West and North and South must be the norm in the future (Salas, 2005).
Marginalized or Privileged Populations
Dr. Hiroshi Nakajima, the Director General of the World Health Organization (WHO),
warned us that history will judge the 20th century as the “era when human development faltered
and gave rise to a wave of poverty” (Nakajima, 1995, p. 25). Growing inequality between and
within countries is, in his words, “a matter of life and death.” There is an urgent need to develop
knowledge about marginalization and about responses to that marginalization on the quality of
health care delivered to and received by marginalized people. Several components of marginaliza-
tion are pertinent to nursing. At the core is a quest to eliminate social and economic disparities
(Crigger, 2008). The definition of marginalization highlights the effects of being in stigmatized
jobs, being from another culture, having a sexual preference different from the prevailing norms,
lacking those mainstream characteristics that represent those who are at the center of communi-
ties, and being at the peripheries of communities. The elderly who live alone, or who have mem-
ory loss, are marginalized. These are the people who “fall between the cracks”; for example in
earthquakes, rescue workers and bystanders may not be direct victims, but they nevertheless expe-
rience traumas that have profound impact on their well-being (Taylor and Frazer, 1982). When
people are marginalized, they are stripped of their voices, stripped of their power, and stripped of
their rights to resources. Marginalized people tend to be reflective about their own situations and
develop their own symbols and language, and these marginalize them even further. Having unique
symbols, languages, dress codes, and places to meet further marginalizes them. Having delayed
reactions may marginalize people. Although they may not represent another culture, their lan-
guage, responses, and reactions reflect their own lexicon and their own symbols. This lexicon and
the symbolism in it may not be well understood by others, and this marginalized group is pushed
to the periphery even further and becomes even less powerful. Marginalized people tend to be
more sensitive to the needs of others, know more about nonmarginalized people, and to be less
demanding of other people, but the reverse is not always true (Hall, Stevens, and Meleis, 1994).
Future theories must address the situation of marginalized clients in the health care system and
reflect health and illness responses within a context of marginalization.
However, nursing clients are from every walk of life and hold privileged statuses as well.
With growing theoretical discussions in nursing on women’s health, the elderly population, the
poor, the underrepresented minorities, and the homeless population, are we marginalizing those
who hold privileged status? Sellman (2005) argues that all individuals who are patients are “more
than ordinarily vulnerable.” In what ways are we developing knowledge that reflects and
addresses the experiences of minorities—vulnerable, underserved, and marginalized—and the
privileged? What arguments do we hold for either or for both? A social justice framework and
engagement in diverse dialogues may promote and develop concepts and theories that reflect
global situations (Anderson, Rodney, et al., 2009).
Technical Nursing or Expert Nursing Practice
The nature of nursing practice is profoundly influenced by the sociocultural and political
events in any society, as well as its technological advancements. Major changes have occurred in
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the health care system during the 1990s that will continue to influence the types of theories that
nurses may develop, as well as the utility of these theories. The movements to primary health care
and managed care increase the potential of maintaining a primary caregiver, but also decrease the
amount of time that nurses spend with patients. Theories of the late 1990s—which provided
guidelines for developing trust and strong interpersonal ties with patients, the role of the self in the
healing processes, and the extensive assessment and monitoring that nurses were able to perform
during long hospitalizations or repeated visits—will be limited. Models to promote patient–nurse
relationships within the constraints dictated by time, technology, and more economically driven
health care encounters will be developed. Therefore, the nature of relationships that incorporates
technology needs to be redefined, and ways by which such relationships may be established must
be reconsidered (Betts, 2005).
Most of the theories that have been developed have started from the premise that the nursing
client is a hospitalized person. Over the years, patients have moved out of the hospitals earlier,
and, whenever possible, are cared for on an outpatient basis. Although public health nurses have
always given care to patients in communities and in their homes, the practice of public health
nursing is undergoing drastic changes simultaneously, and patients are also going home with more
acute conditions and with a need for monitoring of their critical needs, within the limitations of
time and budgetary constraints.
The nature of practice is also changing in another major way. International mandates (World
Health Organization [WHO], 1978) for better health care have advocated community-based pri-
mary health care as the practice of choice to ensure better health care for people and better access
to health care. Community-based health care requires the development of models for care that are
more complex and contextual and that are created with clients’ involvement.
The nature of practice is also being influenced by the changing roles of advanced nursing
practice clinicians, which may require rethinking theories needed for their practice (Davies and
Hughes, 1995). An additional example is the increasing number of generalists and primary health
care providers in medicine and the changes in their educational preparation and training. Another
is the increasing number of care assistants and physician’s assistants. Similarly, the interface
between technology, genomic technology, and nursing practice is changing, and this requires
careful development of theories that incorporate this progress (Loescher and Merkle, 2005).
It has been advocated that the development of theories in the future must avoid what Bradshaw
(1995) warns against—ignoring the nursing tradition of practical tasks and the techniques of phys-
ical care and focusing only on a psychosocial approach to patient care and knowledge develop-
ment. She proposes that nurses engaged in the development of knowledge must consider
rediscovering theories that hold together the personal, the relational, the scientific, and the techno-
logical aspects of patient care. Similarly, a focus only on what nurses do rather than on what nurses
know and on the context in which they practice contributes to disempower and silence nurses
(Canam, 2008). Development of the discipline and members of the discipline must include the
pragmatics of what nurses do and the expansive scope of knowledge that incorporates past, present,
and future (Litchfield and Jónsdóttir, 2008). The significance of theories in answering the pressing
questions in nursing will depend on the extent to which these theories reflect the history and prac-
tice of nursing and the extent to which they include the principles outlined in the subsequent text.
Are we able to develop theories that honor the technical aspects of nursing and continue to inform
equally the psychosocial and biobehavioral aspects of nursing? Can a theory comprehensively
address these different components of human beings?
Nursing Informatics or Medical Informatics
Future theories will be influenced profoundly by the nature of technological development
and by how technology is used in practice, research, teaching, and administration. We are moving
steadfastly into an era of client-centered information systems and organized data sets, and where
many aspects of people’s lives will be dominated by computers, thereby increasing the availability
of health care information to the public that will be disseminated through network systems. Our
challenge is to address ways by which theoretical frameworks and informatics will interface,
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especially while nurses continue to adopt pluralistic philosophies in defining, connecting, and
using data for nursing practice, research, and policy development. Although there is equal concern
in prematurely selecting one theory or classification system to guide these processes, the risks
may be higher in not settling on one shared framework. The challenge is to resolve these conflicts
and to settle on a framework or frameworks that will facilitate exchanges and drive a more com-
mon and congruent set of outcomes. The challenge to face in the future is in the development of
processes to integrate the development of informatics and theoretical nursing and to guide and
develop informatics within the mission, goals, and theories that reflect the discipline and the goals
of health care (Hays, Norris, Martin, and Androwich, 1994).
Because of the increased use of technology, insurance-driven policies related to hospitaliza-
tion and discharge, and increased costs of hospitalization worldwide, patients tend to leave hospi-
tals earlier and continue their recovery and rehabilitation transition at home. Therefore, the
transition to recovery is somewhat more protracted, and patients need expert and competent care at
home. These trends will drive the development of theories to reflect a new set of emerging care
needs for patients. However, many of the medical information systems continue to reflect more on
biomedical questions and less on what is essential for nursing care processors. In what ways will
the nursing perspective and domain inform informatics?
Taxonomies or Interpretations
A tendency to develop taxonomies characterized the disciplinary analyses of the last decade of
the 20th century and the beginning of the 21st century. Two types of taxonomies were developed—
nursing diagnosis and nursing intervention. The work on defining and identifying nursing diag-
nosis began in 1950 (Gordon, 1979; McManus, 1950) and on nursing intervention in Iowa in the
1980s (Iowa Intervention Project, 1993, 1995). The taxonomic definitions were seriously con-
sidered after the pioneering efforts of Gebbie and Lavin, who initiated the first national confer-
ence on classification of nursing diagnosis in St. Louis in 1971 (Gebbie and Lavin, 1975). The
results of seven such conferences have been the identification of 50 to 70 labels for nursing diag-
noses and an increasing number of research projects in which the authors designed studies to
validate nursing diagnoses, as well as other studies to identify nursing diagnoses in diverse
groups (Gordon, 1985; Kim, 1989). The result also has been an acceptance of nursing diagnoses
as a significant step in clinical judgment and as a concept with great utility in nursing practice, as
evidenced by the number of clinical writings about the concept, its appearance on agendas for
nursing conferences, and its inclusion in the definition of nursing (American Nurses Association,
1995). Taxonomies will continue to shape the nature of knowledge developed. To project into the
future, let’s step back into the past to analyze how nursing diagnosis and theory were connected.
There are two ways to consider the relationship between nursing theory and nursing diagnosis:
first, one can consider how nursing theory has influenced the development of nursing diagnosis;
and second, one can consider how nursing diagnosis has contributed to the development of
nursing theory.
Nursing Theory’s Influence on Nursing Diagnosis
The impetus for the development of nursing diagnosis has some theoretical characteristics
when viewed from the perspective of identifying and defining labels for judgments that nurses
make in their daily practice. As Kritek (1978) indicated, these judgments about assessments are
examples of factor-isolating theories, which were defined by Dickoff, James, and Wiedenbach in
1968. This type of theory specifies, describes, defines, and classifies concepts.
The process of identifying what nurses assess and what judgments they make is also charac-
terized by some features that later nursing philosophers and theorists advocated. Nurses were
asked to look at their own practice, to trust their assessments, to uncover their judgments, and to
collaborate in a long process of specifying, defining, and identifying. The processes that organiz-
ers of nursing diagnosis conferences, attendees, and all others who participated in the nursing
diagnosis movement have used are processes of theoretical thinking geared toward the goal of the
theoretical development of the discipline.
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Nursing diagnoses or nursing interventions, however, did not emerge from a coherent philo-
sophical approach or from a theoretically defined domain. Although they represent the realities of
those nurses who participated in developing the taxonomies and the classifications, they do not
represent the majority of nurses who have been caring for clients and communities for years and
whose levels of expertise range from the novice to the expert, nor could they do that. Assumptions
held by nurses and shared assumptions of the domain have not been adequately, carefully, or sys-
tematically discussed, nor have they reflected on the nursing diagnosis and intervention literature.
Therefore, to summarize comments on ways by which nursing theory has influenced nursing
diagnosis and interventions, I would say that the quest for theoretical development of the disci-
pline may have guided the process of attempting to classify labels used in judging the condition of
nursing clients and nurses’ actions, but it did not guide the content of these labels. The content of
the classification categories was predicated on diverse values, assumptions, and visions of the
mission of nursing that remain to be identified and defined; they were also predicated on a prob-
lem orientation to care, rather than on an asset approach to care. A theoretical approach based on
assets, health maintenance, and health promotion is a more congruent approach to the mission of
nursing. This approach continues to be limited in the current framework for nursing diagnosis and
intervention.
Attempts at relating existing nursing theories to the accepted diagnoses and interventions and to
the development of useful, coherent, and supported nursing theories that may create new diagnoses
and interventions should be of interest to theory students. One approach to theory development may
be more useful than the other; however, with the level of enthusiasm in the classification of nursing
diagnosis and nursing intervention movements, I propose that we carefully chart mechanisms to
ensure that the former approach (accepted diagnoses and interventions) should not overshadow the
latter (the development of theory leading to new diagnoses and interventions).
A second way by which the relationship between nursing theory and nursing diagnosis and
intervention could be considered is to analyze the contributions of the classification systems to the
development of nursing theory. I will focus here on the nursing diagnoses as an example. Similar
analysis could be applied to nursing interventions. There are at least three consequences of the
nursing diagnosis movement to theoretical nursing.
First, nursing diagnosis created a theoretical discourse in the literature that is useful in ana-
lyzing philosophical bases and values and potentially useful in the further development and
progress of theoretical nursing. Examples are the Shamansky and Yanni (1983) and Kritek (1985)
debates about assumptions regarding the development of nursing diagnosis, the role of nursing
diagnosis in knowledge development in the discipline, and the implicit limitations of the concept
of nursing diagnosis. Other examples are the analysis of implicit values inherent in nursing diag-
nosis and in the dependent and independent roles of nurses (Jacoby, 1985; Kim, 1985; Kritek,
1979).
Second, the publication and use of nursing diagnoses have prompted a reevaluation of some
of the labels and their meanings, a theoretical process that is defined as concept classification
(Dennison and Keeling, 1989; Jenny, 1987).
Third, the nursing diagnosis movement has stimulated nursing researchers to initiate studies
to identify nursing diagnoses and to validate existing ones (Gordon, 1985; Kim, 1989). A next
step beyond the analysis of research findings is the initiation of further dialogue to interpret the
theoretical and philosophical implications of these findings.
A taxonomy of nursing diagnoses and nursing interventions does not represent a theory; it is
simply a classification system. Each of the diagnostic labels, and each of the intervention’s labels
represent a concept that may be a building block for a potential nursing theory related to that
concept—if and when the concept is defined within a context of assumptions, values, nursing mis-
sion, and other concepts representing the domain of nursing—and when it is related to health and
well-being as the goals of nursing. Two types of theories could be developed: descriptive/explana-
tory and prescriptive theories. The nursing diagnosis label of “comfort” (alterations in), for exam-
ple, is only meaningful within a theory that describes comfort and its relationship to the health of
clients as viewed from the perspective of the nursing domain, with its focus on person–environment
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TABLE 14-1 PATTERNS OF THEORIZING
Component Clinical Conceptual Empirical
Phenomena Discovered Discovered Created
Concepts Emerge from phenomenon Used as per theory or Used as is redefined Modified
redefined due to research
Propositions Linkages evolve from Theoretical properties Deduced from theory
experience evolve from theory
Theory Descriptive/explanatory Descriptive Descriptive
Prescriptive Explanatory Predictive
Purpose Explain Explain Explain
Prescribe Development of theory Development of theory
Development of theory Researcher
Clinical practice
Approach Clinical experience Conceptualization Measurement testing
Evaluation Guided by practice situation Guided by theory Guided by research
interaction and responses to health and illness. Taxonomies are also useful when they are based on
well-defined and shared ontological beliefs and dialogues about the epistemology used to inform
and form the taxonomies.
To what extent will the development and testing of taxonomies inform or constrain the devel-
opment of interpretive theories in nursing? This remains one of the questions that must be
addressed in continuing theory development and progress.
Clinical, Conceptual, or Empirical Theorizing
What will drive theorizing in nursing in the future? And what will determine acceptance or
nonacceptance of these theories? When nurses were observed and asked about the sources of their
knowledge, they categorized the sources of their practice knowledge into four broad groups:
social interactions, experiential knowledge, documentary sources, and a priori knowledge
(Estabrooks, Rutakumwa, O’Leary, et al., 2005). Three patterns of theoretical formulations were
proposed by Schultz and Meleis (1988), who maintained that the development of theory could not
be, and in reality is not, dependent on any particular source or perspective. Practice, theory, and
empirical findings could all be theory sources, and empiricism, feminism, and critical perspec-
tives could all drive the development of nursing theory. (See Chapter 7 for sources of theory and
Chapters 15 and 16 for strategies for concept and theory development from related sources.)
Therefore, clinical, conceptual, and empirical theories are the types of theories to develop in nurs-
ing. The three patterns of theorizing are not totally distinct or mutually exclusive; they should
be treated only as prototypes. The emphasis on the differences does not preclude hybrid theorizing
that is developed from knowledge emanating from any or all sources. Table 14-1 compares these
three types of theories.
Thus, theorizing in nursing evolves from extending other theories, abstracting from prac-
tice, or synthesizing research findings, or any combination of these types. The differences are in
how the phenomena are identified, the nature of the concepts, and the origins of the proposi-
tions. Although all theory may be developed to describe, explain, prescribe, or predict, there are
differences in the purposes of each type, as well as in the approaches to the development of each
type. Evaluation and testing of each theory type would be expected to correspond with its
nature and use. The challenge for members of the discipline is in the development of patterns to
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establish credibility for each type. Each type of theory is briefly described in the following
sections.
Clinical Theories
Clinical knowledge results from engaging in the gestalt of doing and caring. Florence
Nightingale developed her ideas from her work with the wounded soldiers in the Crimean War;
her theory of environment evolved from clinical work. Clinical knowledge could be the result of
personal and subjective knowing. Numerous examples in the literature, particularly in the clinical
literature, describe clinical examples that are the sum total of the wisdom of clinicians. The ques-
tion is: How can we enhance that knowledge and establish its credibility? In the past, this credibil-
ity may have been based on the fact that a given practice or procedure worked. However, because
we are trying to establish a case for the significance of this knowledge, we need to develop and
provide the credibility of this clinical evidence by establishing ways that will render this clinical
knowledge acceptable.
Clinical theories used what feminist psychologists call “connected knowing,” that is, devel-
oping theories collaboratively through interpersonal relations with clients and through being con-
nected with what another person may be experiencing. These theories have been described in
different ways by different authors. They have been defined as narrative, naturalistic, or clinical
concepts. Theories that evolve from a clinical setting have richer clinical context and a longer
lifespan; their credibility may be enhanced for other clinicians, and they are developed from con-
crete experiences.
Conceptual Theories
The second type of theory is one that is abstracted and generalized from other theories and
goes beyond personal experiences. Nursing theorists have provided us with many examples of this
type of theorizing. Their work is a product of their reflecting about phenomena they consider cen-
tral to the discipline of nursing; their theories are products of theoretical reflections based on other
prototype theories. The criteria for accepting theories have been described by a number of
metatheorists as falling within the norms of coherence and corroboration. The criteria for accept-
ing theories that are developed from conceptual knowledge involve the extent to which members
of the discipline find them useful in illuminating the discipline of nursing. Therefore, a set of cri-
teria for evaluating these theories is expected to evolve from their origins and objectives.
Empirical Theories
The third type of theory is knowledge that results from research, whether that research is his-
torical, phenomenological, interpretive, or empiricist. Criteria for establishing the credibility of the-
ories that evolve from each of these research traditions have yet to be developed. Empirical theories
are among the most accepted types and are usually the better established.
Knowing Through Research and Knowing Through Theory
What approaches will drive theory development, and how will these types of approaches
influence progress in the discipline? The combination of philosophical perspectives discussed in
Chapter 8, ways of knowing, and the different perspectives on knowing suggest the evolving of
two central, complementary approaches to nursing theory development. These approaches, for
lack of a better description, are called models here and are evolved from our history, our mission,
our propensity for knowing, and our gender orientation. These models are not inclusive of all
approaches to theory development; rather, they appear to represent prototypes that are used in the
theoretical literature. They do not correspond to any particular philosophy in its totality; for exam-
ple, model 1 is not be equated with an empirical, neopositivist stance, nor should model 2 be
exclusively equated with phenomenological or postcolonial feminist approaches. These models
are modified to represent the nature of knowing and understanding in nursing. I propose that we
think of these models as intrinsic to the discipline of nursing and as emerging from its needs and
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goals. The use of these models could provide support for the kind of knowing and understanding
needed in the discipline of nursing. Both models can be analyzed against the social policy state-
ment defining nursing, the nature of nursing as a human science, and the phenomenon that repre-
sents the nursing focus.
The premise on which these two models are developed is that both are equally essential for
the development of the discipline of nursing. To avoid labeling that may cast shadows on either
model, I prefer to call them model 1 and model 2. Table 14-2 on page 364 compares them.
Model 1
The unit of observation for model 1 is more definable than that for model 2; it is more con-
cise, operational, and amenable to being reduced to variables. An example is support. Support is
further defined and operationalized into tangible or intangible support, which is further opera-
tionalized into tangible daily support for family members. Each of these concepts is carefully
defined. The assumptions on which the theory is developed are carefully delineated, and support
for each is provided.
Model 1 theory development evolves from a research tradition, whatever that tradition may
be; therefore, theories are carefully and immediately connected with existing or evolving research.
A theorist using model 1 will not venture sharing her theory until it is completed and supported
and, when it is shared, it is provided to the scholarly community. Its theory development derives
its support through documentation of its central questions and answers. The criteria used for eval-
uating it are its ability to explain and predict phenomena, the centrality of the questions and
answers to the discipline’s cutting edge, and its potential for more universal use.
Model 1 is still based on some shared assumptions that nursing is a human science and that
its mission as a practice-oriented discipline is to care for people. Therefore, theories developed as
a result of the model 1 approach are not the same type of theories that may evolve from empiricist,
neopositivist, phenomenologist, or any other traditions that may be more appropriate for other dis-
ciplines. Model 1 represents the nature of nursing phenomena, nurses’ ways of knowing, and the
mission of nursing. It may represent a synthesis of other disciplines, or it may represent a new
whole, tailored for nursing. It is a model awaiting discovery, created from our history and created
for our future.
Model 2
The units of observation for theorists who choose model 2 are behaviors, events, or situations
that are embedded in a context. This may include but is not limited to the person–environment rela-
tionship. The theorist is an actively engaged participant, and her theory evolves from theory, prac-
tice, and research arenas. The reasoning is connective, the process is collaborative, and the theorist
uses dialogues, diaries, experiences, and the self in developing the theory. The goal of the theory is
to enhance understanding of and actions for changes, and its evaluation is based on the central
questions significant to humanity, to the theorist, or to the discipline. The goals for theory develop-
ment for model 2 are to increase the visibility of the community reflecting the theory and to provide
them with a voice, either their own or that of someone speaking for them.
Some of the same comments made about model 1 are also appropriate for model 2. Model 2
does not emanate from one tradition, such as feminist, interpretive, or critical theory. Rather, it is
informed by these traditions inasmuch as it is informed by nursing history, by nurses’ ways of
knowing, by the nature of nursing’s mission, by the properties of nursing as a human science, and
by the practice orientation of the discipline. Model 2 needs to be created to represent nursing.
As we nurture and support our emerged identity, we need to support more coherent
approaches to knowledge development—ones that encompass knowing, understanding, and car-
ing; ones that support the development of models for knowledge development congruent with our
mission. Support of such identities includes tangible support from granting agencies, as well as
publishing support from editors of nursing journals. Which of these models warrant support?
By being clear about our mission, our values, and the models we choose to use for knowledge
development, we are empowering ourselves to empower our consumers. To become clear and to
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TABLE 14-2 MODELS FOR METATHEORY
Unit of Analysis Model 1 Model 2
Unit of observation Defined, concise, operational Behaviors, events, or situations
Predefined embedded in a context
A particular aspect Human being and environment
Assumptions Axioms Context
Value free Value laden, beliefs, action
Concepts Defined, operationalized a priori Emerge from clinical, research, or theory
Propositions Operationalized Descriptive, explanatory statements
Theory development Relationship between concepts Theory evolves from theory,
Theory evolves from a research practice, research
tradition
Conditions Conciseness, source, facts Perceptions, meanings, patterns, context
Tools for development Observation Collaboration
Research designs Dialogue
Research findings Intuition
Experiences
Diaries
Self
Reasoning Connective
Context Logical development Documentation of discovery
Theorist Documentation of justification Engaged, attached, acting, developing
Distanced, objectified, not active
participant
Purpose Describe, explain, understand
Theory use Explain, predict Congruency with human values
Focus Congruency with evidence Understanding
Knowing Caring
Criteria for evaluation Centrality and closeness to cutting Significance to discipline, to theorist,
of phenomena edge in discipline to humanity
Evaluation Validity, reliability Description
Critique Analysis
Testing Testing
Criteria for analysis Validity and reliability of concepts Theorist experiences
Operationalizability Social structure
Criteria for testing Research Values
Empirical evidence Understanding
Statistical methods Usefulness
Corroboration Intuition
Coherence
Comprehensiveness
Support from experience
Diversity of exemplars
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TABLE 14-2 MODELS FOR METATHEORY (Continued )
Unit of Analysis Model 1 Model 2
Validity Universality
Replicability
Norms Stands the test of time Contextual
Universal Reflection
Observation
Ordered
Time Defined time period Time and historically embedded
Transcends time
Approach Analysis of findings Reflection
Not contextual Analysis
Forward leaps
Historical and structural context
Language Evidence Understanding
Generalizability Intersubjectivity
Replicability Consistency
Consensus
Goals Probability Pattern
Prescription Identification
Liberation
Change
Consciousness-raising
Dissemination Professional audience Subjects
Policy makers
consolidate efforts, we are challenged to further develop and structure knowledge using either one
or both of the models. I believe both models will continue to exist side by side in the 21st century
and perhaps beyond. What are your thoughts on these models? What other models exist? How will
these models influence the progress and development of theoretical nursing?
Integration or Isolation of Theoretical Discourses
At the turn of the 21st century, a movement was made to minimize the role of theoretical
development in the discipline of nursing and in the educational institutions in the United States,
while increasing its presence in curricula in eastern European and southeast Asian countries.
Evidence-based practice discourse tended to substitute for theoretical dialogues (Chinn, 2008),
but without careful attention to ontological analyses of the evidence, clinical practice may not
fully reap the benefit of the integration of theoretical and research evidence (Whall, Sinclair,
and Parahoo, 2006).
Theoretical nursing includes a discourse about the structure of nursing knowledge, the philo-
sophical bases of nursing science, theory development, the history of nursing knowledge, and nurs-
ing theories. Aspects of these components have been included in doctoral nursing programs in the
United States (Jacobs-Kramer and Huether, 1988) and internationally. A more limited version has
been included in master’s programs, with more emphasis placed on presentations and critique of
existing nursing theories (Jacobson, 1987). Although nursing theories have been used as frameworks
for nursing curricula in undergraduate programs during the 1970s and 1980s, only a limited number
have included opportunities to discuss theoretical nursing and approaches to theory development
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(Jacobs-Kramer and Huether, 1988; Meleis and Price, 1988), and increasingly, a paucity of these
discussions have focused on education issues (Fawcett and Alligood, 2005).
Theoretical thinking, the pride that discipline’s member has in the theoretical threads of her
discipline, a belief in the self as a proactive developer of knowledge, and an identity that incorpo-
rates the ability to structure nursing knowledge are values essential for quality care and for the
continuous development of the discipline. The seeds for such values could and should be planted
in students as early as possible in nursing education. It is not enough to promote these values in
doctoral or master’s programs; they should be planted as early as the first year of nursing educa-
tion (Rafferty, Allcock, and Lathlean, 1996). Introducing theoretical nursing to students at the
undergraduate level is not too early (Batra, 1987). Therefore, if nursing expects to have a signifi-
cant impact on health care through development and use of theory, content related to the purpose,
generation, and use of theory must be introduced into the curricula much earlier than it currently is
(Jacobs-Kramer and Huether, 1988, p. 376).
In introducing such content, educators may reflect on the place for such content in future cur-
ricula. When content related to theory and knowledge development is introduced as a separate
component of a nursing curriculum, students and faculty have difficulty in relating this content to
other curricular components. Although this practice may have been necessary during those
decades when the primacy of theoretical nursing was still debated, faculty members and students
may now be ready to integrate that content with the clinical and research components of the cur-
riculum. To capture students’ attention, to sensitize them to the significance of theory in their
practice or research, and to demystify theory, teaching of theory must come out of its closet, and it
must be innovative and integrated (Karmels, 1993). When faculty are skeptical about theoretical
nursing, they cannot persuade students of its importance (Levine, 1995).
Theoretical nursing provides nursing curricula with a perspective that is uniquely nursing’s;
it provides nursing students with frameworks that help them define their values, concepts in their
work, significant problems in their fields, and approaches to structuring and developing knowl-
edge. More importantly, a theoretical nursing perspective promotes the primacy of discovering,
developing, and structuring nursing knowledge.
The relationship between theory and nursing curricula is similar to the relationship between
research and nursing curricula. Educators asked whether research courses should be included in
the curriculum, at what level they should be introduced, and what should be included (Wilson,
1985). The questions related to theory, theoretical nursing, and philosophy are no longer whether
theory should be a component of nursing programs, or at what level it should be introduced;
rather, the questions educators will grapple with during the next decade are what aspects of theory
should be introduced at every educational level, and what are the most effective and meaningful
ways by which they should be included. Similar dialogues must consider the role of theoretical
nursing in nursing administration.
Nursing administrators can directly influence efforts to generate nursing’s knowledge by
providing access to a virtually untapped theory building resource—the non-university service
setting. (DeGroot, Ferketich, and Larson, 1987, p. 38)
This sentiment of the close connection between nursing administration and nursing knowl-
edge, and of the potential of nursing theory construction by or as promoted by nursing administra-
tors, was expressed repeatedly in the late 1980s (an example is the volume edited by Henry, Arndt,
DiVincenti, and Marriner-Tomey, 1989). Until the late 1980s, there was a limited dialogue about
the relationship of nursing theory and nursing administration (Christmyer, Catanzariti, Langford,
and Reiz, 1988). Some addressed the shortcomings of that limited dialogue, indicating that spe-
cialty nursing cannot afford to be distanced from mainstream nursing by claiming that nursing
theories do not represent them (Dashiff, 1988).
Viewing nursing administration from a domain perspective and investigating theoretical and
clinical questions from that perspective could lead to a more coherent approach to structuring
knowledge that is as useful to clinicians as it may be to administrators. Theories for the future
must address the innovative relationship between practice, information, computer usage, skills
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acquisition, and clinical judgments (Anderson, Dobal, and Blessing, 1992). Theoretical aspects of
the nursing domain may provide clinicians and administrators with a unifying framework that
could further contribute to the development of coherent theories to guide nursing care (Jennings
and Meleis, 1988; Meleis and Jennings, 1989).
The question remains: What are the best approaches to incorporating theoretical nursing in
educational and administrative organizations? I propose several approaches for the integration of
theoretical knowledge in educational and clinical institutions.
• A deliberate plan to engage in theoretical dialogues should be developed and imple-
mented in educational and clinical institutions. The extent to which the discipline of nurs-
ing will continue to evolve with a theoretical base depends on the ability of its members to
engage in theoretical discussion and debates at all levels of education and practice (such as
Allen, 1987). Opportunities for theoretical thinking could be found in the daily routines of
students’ lives (classroom teaching as well as clinical mentorship), and in clinicians’ lives
(shift reports as well as supervisory education).
• Analytical and critical consideration of nursing theories should be a cornerstone of curric-
ula in nursing, from community college to doctoral programs, with different goals at each
educational level. For example, the choice of a discussion of human beings as nursing
clients may be organized around nursing theories that discuss human beings and the dif-
ferent goals of the different perspectives.
• Consideration of research and clinical exemplars that are related to different domain con-
cepts and questions and beginning attempts at a thorough review may help in creating
some coherence and may delineate further avenues of investigation.
• The advanced clinicians and clinical specialists can be coached to develop and share wis-
dom gleaned from their clinical practice in the form of exemplars. Exemplars identify,
model, and direct problems of concern to nursing and ways of solving these problems.
• Finally, just as theoretical discourses are provided to compare and contrast models of care
delivery such as total patient care, functional care, team nursing care, and primary care,
similar discourses should be provided on nursing theories that drive patient care interven-
tions (Tiedeman and Lookinland, 2004).
Although philosophical discussions and theoretical exchanges are useful, their utility is lim-
ited without considering related research as an integral part of these discussions (Whall, Sinclair,
and Parahoo, 2006). This view is congruent with the more contemporary view of science (Laudan,
1981). Theorists, researchers, clinicians, and educators should explicitly state the theoretical
underpinnings of their work and engage in dialogues with self and others to help in identifying
relationships or the lack of them within the nursing domain. Such discussions will continue to
help to refine both the domain and the work being done.
Middle-Range or Situation-Specific Theories
Finally, another challenge in driving the progress of knowledge is the extent to which agents
of knowledge development will embrace the nature of theories to be developed and the degree of
specificity in these theories. It may seem paradoxical to speak of global views and worldliness,
and, at the same time, of specificity, as principles to guide progress in theory development.
Although the nature and goals of these two guiding principles are different, they are complemen-
tary rather than mutually exclusive. Whereas global health requires attention to what nurses tend
to diagnose and practice in different countries, specificity calls for the development of situation-
specific theories. Theories developed with the principle of specificity require a focus on describ-
ing, explaining, or predicting a phenomenon within a specific descriptive and explanatory context.
These are also theories that focus on uncovering voices, identifying patterns, and interpreting
themes. These theories are contextualized, and represent many truths about similar situations with
different populations. They help illuminate the experiences of populations, as well as the situation
for nurses. Situation-specific theories respect mind–body wholeness and environment–person con-
nections; they allow for a multiplicity of truth, for tentativeness of interpretation, and for complexity
CHAPTER 14 Challenges and Opportunities for a Theoretical Future 367
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REFLECTIVE QUESTIONS
1. Identify two paradoxes that may promote
or impede advancing nursing knowledge.
2. Take one side of each paradox and
develop compelling arguments to tip the
balance in that paradox.
3. In what ways are the support for
evidence-based practice an indication of
progress in the discipline? Discuss the
pros and cons of using it as a framework
for education and practice.
4. What influence did the nursing diagnosis
and nursing therapeutics taxonomies and
categorization movements, and the ensu-
ing publications and research related to
it, contribute to advancing nursing
knowledge? You could take an opposing
view as well and argue that the reduction
to diagnostic category may have impeded
the acceleration of development in the
discipline. As you argue for either posi-
tion, provide examples and support.
5. What might be some best practices for
incorporating theoretical discourses in
nursing education and nursing practice?
What might be some least effective
practices? Identify and critique one of
these practices.
6. Select one of the challenges presented in
this chapter and discuss ways by which
you may choose to resolve or deal with
the challenge.
7. In your opinion what is the most press-
ing challenge is currently facing the fur-
ther advancement of nursing knowledge?
of contexts. Situation-specific theories are generally used to formulate questions and answer
questions within a context. They help in explaining situations that are limited in scope and in
focus. An example of such theories is symptom-specific theory versus a theory of symptom man-
agement or a theory of unpleasant symptoms. Another example is a theory of identity and health
versus African American identity and the psychotherapeutic environment (Brown, 1996; Lenz,
Suppe, Gift, Pugh, and Milligan, 1995; Meleis, Isenberg, Koerner, Lacey, and Stern, 1995; Uni-
versity of California, San Francisco, School of Nursing Symptom Management Faculty Group,
1994). Middle-range theories have wider scope and tend to answer more questions about a phe-
nomenon. The question is, which type of theory is more conducive to the further development of
the discipline?
While Nightingale, according to Clements and Averill (2006), practiced and supported multi-
ple patterns of knowing, Fawcett (2008), promoting middle-range theories, expresses concerns
about the extent to which theories that evolve from and reflect nursing are rejected or ignored.
Whether the future focus in advancing knowledge will be on concept development or developing
middle-range or situation-specific theories, on empirical or clinical knowledge, the phenomena
and the problematics must be driven by the domain of our discipline.
CONCLUSION
In this chapter, I selected the most important areas of intellectual tensions in the discipline that
may affect progress in nursing scholarship. Several paradoxes will challenge the future develop-
ment of nursing knowledge. It is vital that members of the discipline engage in robust dialogues
about the potential outcomes for knowledge development if either side of each paradox becomes
the more dominant in commanding the attention of scholars in nursing. Equally as important, a
discourse must begin about the best balance in developing programs of research and coherent the-
ories that include both sides of each paradox. The reader may use the paradoxes identified in this
chapter as a model for identifying, defining, and discussing other pressing tensions related to
nursing scholarships, the development of programs of research, the advancement of nursing
knowledge, and in the future development of theories.
368 PART FIVE Our Theoretical Future
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C H A P T E R 15
Concept Development
Advancing knowledge in a discipline is predicated on the clarity of its concepts and their effective
use in research programs, as well as on translation into practice. In continuing to build the scien-
tific base of the discipline of nursing, developing the evidence for quality care, and translating the
evidence into practice models, it is essential to clarify and sharpen the meaning attached to con-
cepts. Defining, clarifying, evaluating, operationalizing, and subjecting concepts to theoretical
and empirical testing are all essential and vital processes in advancing knowledge. Many lessons
in our theoretical and research histories could inform the future of concept development.
The theoretical development of the discipline of nursing began historically with the com-
pelling question of “How should nursing be defined?” Answers to this question resulted in numer-
ous inclusive theories that attempted to identify the mission and goals of nursing, some of the
actions involved in nursing care, and the scope of practice. This was followed by the attempts of a
number of metatheorists to define the structure of the discipline, the strategies, and the tools for
the further development of knowledge. One important stage that followed is concept development.
The identification and development of concepts are vital stages in a discipline’s progress. Concept
development has evolved to take a central position in knowledge development in nursing. Weaver
and Mitcham (2008) identified several forces that have been an impetus for the concept develop-
ment movement in nursing. The first is the quest to define and delineate the boundaries of the
discipline of nursing. The second impetus is the availability of funding that supports doctoral edu-
cation. In identifying this force, they implicitly assure that the preponderance of writing about
concepts is due to advanced degree preparation. The third factor is the organizational requirement
that curricula be guided by conceptual frameworks, and the fourth is the numerous theory confer-
ences that may have stimulated the theoretical development of concepts. In addition to these
forces, the articulation of frameworks and strategies for developing concepts and theories pro-
vided specific and easy-to-follow guidelines. In addition, as nurse scientists turned to developing
the evidence for care, it became apparent that a need exists to clarify assumptions, properties, and
referent parts for concepts and variables (Machado and Silva, 2007). Processes used in the devel-
opment of concepts in nursing have received even more attention from nurse scholars, particularly
in the last 20 years. The use of these strategies made major contributions to advancing the devel-
opment of concepts that reflect the nature of the nursing discipline (Rodgers and Knafl, 2000;
Walker and Avant, 2005). A present-day citation search for concept development yields an impres-
sive body of literature.
One important premise to consider is that concepts, once formulated and labeled, tend to
shape and guide what we see, and they provide order to observations and experiences that enhance
understanding of situations and events. Before we had a concept labeled “burnout,” we did not see
burnout, even though the syndrome may have existed in one form or another. Because we did not
have a label to give to that constellation of behaviors, we did not have a reservoir in which we
could connect and deposit those seemingly discrete feelings and responses of apathy, irritability,
impatience, and the urge to flee and change one’s life. Therefore, describing the varied behaviors
and actions related to them may have been limited and somewhat ineffective. For example, no
burnout is described by people living in the Middle East; that is, no such concept exists, even
though the experiences and the responses may exist and may have always been there, although not
described as concisely or dealt with as effectively. Labeling a concept should not be considered
permanent or static. It should be a dynamic process that is responsive to new knowledge, experi-
ences, perceptions, and data. In a human science discipline, participants should be able to
articulate and label new concepts or redefine existing concepts. Concepts, though, evolve from
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372 PART FIVE Our Theoretical Future
experiences; their definitions and meanings reflect the theorists’ educational background, per-
spectives, and the theoretical frameworks that guide their work. For example, interactionist theo-
rists review a nurse–patient situation and may focus on interaction, role taking, symbols, and
roles. Another theorist who has a psychoanalytical lens may explain and interpret the same situa-
tion through another set of concepts such as denial, repression, latent hostility, and maternal or
paternal conflict.
In spite of the increase in the number of concepts identified, confusion has surrounded con-
cept development. The term concept development has been used interchangeably with concept
analysis and concept clarification. In addition, the philosophical foundations of concepts tended to
be ignored in most of the strategies utilized in defining concepts (Duncan, Cloutier, and Bailey,
2007). There are many different processes for developing concepts, and all of them are vital for
advancing knowledge development. The beginnings of concept analysis in nursing can be traced
to Wilson (1963, 1969), whose processes were used as the only guidelines for nurses’ attempts at
identifying and describing concepts. Walker and Avant’s (1988, 1995, 2005) thoughtful strategies
for concept and theory development, derivation, and integration further clarified the process and
demonstrated its multidimensionality. There are many examples of the use of their strategies in the
literature, for example, Dennis (2003). These pioneering efforts were followed by the introduction
of other options that made the processes of concept development more congruent with the nature
of the discipline of nursing as a human and caring science (Rodgers and Knafl, 2000). Each new
strategy was developed to reflect the perspective of nursing as holistic and interactive, and with
the natural domain of nursing and its dynamic concepts (Rodgers, 1989; Schwartz-Barcott and
Kim, 2000; Wuest, 1994). The introduction of options in the development of concepts allowed for
more congruency with the style and format of agents of knowledge development, as well as with
the goals and levels of existing knowledge in the nursing discipline.
One of the most comprehensive discussions about concept development was provided by
Beth L. Rodgers and Kathleen A. Knafl, first in 1992 and then in 2000. Their seminal text
included chapters by many authors who discussed either the syntax or the substance of concepts
or a combination of both. Several strategies were provided with exemplars of how the strategies
were used. The strategies discussed are the Wilson method of concept analysis, the evolutionary
method of concept analysis, the Hybrid model of concept development, concept clarification,
simultaneous concept analysis, multiphase approach to concept analysis and development, and
concept development within a critical paradigm (Rogers and Knafl, 2000). Within all these differ-
ent strategies are some fundamental processes that could be used as the bases for all types of con-
cept development.
In this chapter, I provide a framework for the most fundamental strategies that lead to advanc-
ing the progress of concept development. I also discuss the different components of concept
development, and I describe those strategies that I believe are essential for advancing nursing sci-
ence and making a difference in the quality of nursing care. The reader will notice that those
strategies described pay specific tribute to the centrality of clinical practice in developing con-
cepts, no matter which strategy is used.
There are four major fundamental strategies for concept development. These are concept
exploration, concept clarification, concept analysis, and integrated concept development. These
strategies are used at various levels of nursing concept development. Each strategy has different
processes to advance the concept to the next level of development.
CONCEPT EXPLORATION
Concept exploration is a strategy for concept development used when new concepts are identified
and before they become an accepted component of the nursing lexicon. Similarly, a concept may
have been accepted in the daily experience of nurses, yet because it is embedded in the nursing
experience, its existence and properties are normalized, thereby camouflaging and limiting the
concept’s growth and meanings. Sacrifice is such a concept; this term was used to describe
nurses’ or patients’ responses to work situations, plans of care, or changes in life styles. However,
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CHAPTER 15 Concept Development 373
the how’s, what’s, when’s, and why’s were not described, and nurses have taken for granted that
we knew its meaning (Florczak, 2004). Views of sacrifice from other fields, as well as from the
humanities, helped provide an initial definition of sacrifice, so that the author could then begin to
imbed this definition in nursing practice situations to further clarify it (Florczak, 2004). Therefore,
concept exploration is a strategy used when a concept has only recently been introduced in the lit-
erature and it is too early to articulate its definite properties and potential explanatory power.
Exploration of a concept presupposes that it is unknown to the readers of nursing literature, or that
it is so familiar that it has been taken for granted, to the extent that members of the discipline are
not aware of its significance to the development of knowledge. Concept exploration is also appro-
priate for concepts that have been uncritically adopted by nursing from other disciplines without
consideration for the values, assumptions, and missions of the discipline (e.g., see the concept
of empathy in Morse, Anderson, Bottorff, Yonge, O’Brien, Solberg, and McIlveen [1992]). Other
examples are branding (Dominiak, 2004) and improvisation (Hanley and Fenton, 2007). Concept
exploration is the process by which a phenomenon is identified and introduced to colleagues to
raise their consciousness about the phenomenon, to claim its importance and significance for
nursing, and to stimulate the members of the discipline to consider it further in their research.
Another goal for concept exploration is to nurture curiosity about a particular concept. When a
concept is introduced into the literature through concept exploration, the author should be raising
and answering questions about its relevance to nursing and its meaning to nursing clients. Concept
exploration is used when concepts are still ambiguous and their relationships to the discipline of
nursing are still at the preliminary stages of consideration.
Concept exploration includes identifying the major components and dimensions of the con-
cept through appropriate questions raised about each component. Then, triggers are proposed to
continue the exploration process. Advantages to the discipline or nursing practice are identified
and defined. The ultimate goal in concept exploration is to demonstrate whether or not there is the
potential for further development of this concept. It is also to build a case for reasons to continue
with or discontinue such explorations. Concept explorations are essential in a dynamic and chang-
ing discipline that is responsive to global, societal, and individual changes. It maintains the
dynamism and responsiveness of the discipline.
Two examples of concept exploration are Norris’ (1985) classic proposal of the concept of
“primitive pleasure” as the basic human need and as a possible goal for nursing to nurture, pre-
serve, and attend to in human beings. In proposing to give attention to primitive pleasure, she
questioned physiologic homeostasis as a goal for nursing practice. She explored primitive pleas-
ure as sensual, sensory, and carnal, as compared to cognitive and aesthetic. She defined pleasure
as bodily pleasure at the basic and reflexive level and less at the intellectual level. Although it may
call on some cognitive processes to perceive these pleasures, it reflects a certain level of aware-
ness and consciousness, and does not require any cognitive processes to experience it or to modify
it. Norris explored the meaning of this concept and its relationship to nursing, indicating that
nurses’ work has always included a focus on enhancing patients’ pleasure by helping them to feel
comfortable through touch and through other sensory stimuli. By offering a clinical exemplar to
demonstrate the potential of better understanding patients’ needs through the concept of primitive
pleasure, she further supported her claim for the need to explore the development of this concept.
However, because her goal was to raise nurses’ consciousness to the competing goal of height-
ened pleasure, as compared with maintaining homeostasis, the major questions that she answered
were: What is pleasure? And, what potential has it for nursing? She proposed that a range of pat-
terned experiences to demonstrate it must be identified and examined. She also looked at other
writings in nursing to document and support her arguments for developing the constellation of
subconcepts related to primitive pleasures. She further explored the concept by examining others’
seminal writing, such as Nightingale, who almost a century earlier proposed promoting the pleas-
ure of her Crimean War patients. The ultimate goal for concept exploration is for a reader or a lis-
tener to say “this is worth considering and developing further.”
Another example of exploration is provided by Laborde (1989), who proposed to consider
the concept of torture as a nursing concern. She described the nature of the concept and situated
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374 PART FIVE Our Theoretical Future
the concept within the domain of nursing and within health care. In reviewing this exploration, a
reader realizes that nurses can have different experiences of torture; they can be the subjects of
torture; they may participate in torture, either willingly or unwillingly; and they may care for
patients who have been tortured. Therefore, there is a need for further development of knowledge
related to this concept, its implications in the health care of tortured individuals, and the roles that
nurses play. With the world events of terrorism and torture in detention camps during the first
decade of the 21st century, this beginning concept exploration points to nurses’ potential roles in
uncovering, understanding, researching, and preventing torture, and caring for patients who have
been exposed to torture.
These two examples demonstrate what I mean by concept exploration. In neither example
was the concept ready for a full-fledged concept analysis or for the development of any proposi-
tions. Both raised consciousness, both made the reader curious about their meanings and implica-
tions, both connected the concepts of nursing to the proposition, both challenged some levels of
the status quo about what nurses need to know, and both provided support for why the concept is
worth further development. These processes are essential for concept exploration, and concept
exploration is a strategy for concept development.
In a dynamic and evolving science such as nursing, it is essential to promote communication
and dialogue about concepts during the exploration phase of development. Concept exploration
may be used more vigorously by different constituents, for example, by clinicians who are devel-
oping concepts based on their clinical practice, but equally by researchers who are discovering
new concepts through their research programs. Concept exploration should be encouraged in
order to enhance uncovering of new ideas.
CONCEPT CLARIFICATION
Concept clarification may be used to refine concepts that have been used in nursing without a
clear, shared, and conscious agreement on the properties or the meanings attributed to them. The
goal of concept clarification is to refine existing definitions, sharpen theoretical definitions, con-
sider interrelationships between the different elements of the concept, discover new relationships,
and discuss these relationships to resolve existing conflicts about meanings and definitions. Con-
cept clarification was proposed by Norris (1982) “to foster the development of increasingly mean-
ingful descriptions of nursing phenomena” (p. xv). It was also defined by Kramer (1993) as “a
highly creative, rigorous, and intuitive process that can generate multiple useful meanings for a
single concept” (p. 407). This strategy includes processes of inclusion and exclusion, in which
attempts are made to define what could be included and what could be excluded in the foundation,
meaning, and attributes of the concept. One useful process is to clarify boundaries, to define con-
texts, and to define other subconcepts surrounding those concepts that are being clarified. Concept
clarification reduces ambiguity; yet clarification includes a critical review of the properties of a
concept, illuminating new dimensions to it that had not been considered beforehand, widening the
sphere of the concept beyond previous views, while narrowing its boundaries for better definition
to support its further development. Processes in concept clarification include comparing, contrast-
ing, delineating and differentiating, providing exemplars, identifying assumptions and philosoph-
ical bases, identifying what events trigger the phenomena, and proposing questions from a nursing
perspective. Answers to these questions help in the further development of a concept. In concept
clarification, the implications for nursing research, theory, and practice are carefully discussed.
According to Norris’ (1982) classical and pioneering article, which endures and transcends
time, concept clarification has five steps:
1. After identification of the concept from within the discipline, as well as consideration of
how it could be considered through the lens of other disciplines, repeatedly describe the
phenomenon inherent in the concept.
2. Systemize the observations and the descriptions of the phenomenon. Establish categories
and hierarchy; continue to observe, discover, communicate, and think about the concept;
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CHAPTER 15 Concept Development 375
develop insights. Look for patterns and sequences of events. Ask and answer such ques-
tions as: What events trigger the phenomenon? What happened before to inspire the phe-
nomenon? What happened as a result of the phenomenon?
3. Develop operational definitions, and ask yourself and others: How will I know the con-
cept when I see it?
4. Construct a model. Models provide a better tool for communication, and help to depict
the relationship between the responses, events, situations being clarified, and other
related concepts.
5. Develop hunches and hypotheses in order to move to an experimental mode.
All strategies and processes for concept development are based on the ability of the developer
to use critical thinking skills. Kramer (1993) and Chinn and Kramer (1999) made a compelling
argument for the connection between critical thinking and concept clarification and for the ration-
ale that concept clarification is a strategy that could enhance critical thinking. They identified sev-
eral steps toward clarifying concepts, each with several processes; these are: formulating the
purposes of clarification, selecting and synthesizing data sources, and developing a conceptualiza-
tion. In clarifying concepts, the theorist identifies and examines assumptions, identifies and ana-
lyzes contexts, provides multiple interpretations, and engages in reflective analysis of the results.
Concept clarification does not require the development of contrary cases, propositions,
hypotheses, antecedents, or consequences, which are essential processes in concept analysis. A
clarified concept stimulates thinking and explains an aspect of nursing (Mairis, 1994). Concept
clarification in nursing must be connected to health and to the goals of nursing. Concept clarifica-
tion includes literature reviews and analysis of the literature to identify values and attributes and to
compare and contrast the properties that may have been defined (Lackey, 2000).
I believe that the processes of concept clarification described in the preceding text may have
contributed to the identification of the different meanings and conceptualizations of caring. Morse,
Solberg, Neander, Bottorff, and Johnson (1990) explored caring and described the different ways in
which it appeared in the literature. They clarified caring by its epistemological perspectives, which
resulted in five conceptualizations: caring as a human trait, as an emotion, as a moral imperative, as
a mutual endeavor, or as a therapeutic intervention. Lewis (2003) further clarified four pathways for
thinking about caring as “being.” The properties identified are spirituality, moving beyond the self,
creating healing environments, and being artistic. This is accomplished through a process of clarifi-
cation that involves transforming the caregiver and the one being cared for.
Hall, Stevens, and Meleis (1994) and Hall (1999) introduced a concept to the nursing literature
that had been taken for granted, and was accepted and used, yet its conscious use was limited. They
defined marginalization as “the process through which persons are peripheralized on the basis of
their identities, associations, experiences, and environments” (p. 25). Marginalization is defined as
being away from the center, being at the borders or the periphery, being a part of the periphery of
social networks. They defined its properties as intermediacy, differentiation, power, secrecy, voice,
and liminality (perceptions of time, world, and self-image and its relationship to experiences). Each
of these properties is defined, discussed, and related to the concept as a whole. They clarified the
central components (peripheralization), some salient properties (associations), and some conditions
(it is a process). They differentiated marginalization from alienation (focused on subjective experi-
ence), from stigmatization (one aspect), and from segregation (more physically oriented). Further-
more, marginalization is differentiated from vulnerability and from oppression.
Absent from this analysis were those processes used in developing exemplars and contrary
cases. However, the authors made a case for the significance of the concept for nursing research,
nursing practice, and the theoretical development of the discipline. The concept is studied in the
discipline of nursing, and a case was made for its relevance to further knowledge development
(Hall, 1999). One significant aspect of this concept is its origin and the process by which it is clar-
ified. It is not a new concept. It has been used interchangeably with a number of other concepts,
including vulnerability; therefore, the authors set out to clarify the concept and to propose its
centrality in nursing. It evolved from individual research programs dealing with low-income
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376 PART FIVE Our Theoretical Future
women or women without incomes and their access to health care, patterns of self-care, lesbians’
patterns of responses and relationships in the health care system, lesbians living with or dealing
with substance abuse, low-income women with human immunodeficiency virus (HIV), and les-
bians dealing with sexual abuse. The common thread in all of these programs of research was the
intense marginalizing experiences of women, which prompted the authors to take a closer look at
the concept and its meanings, and its potential for further development. The other important
aspect of this example of concept clarification is the collaborative effort of the authors/researchers
and its influence on clarifying a concept transcending time, geography, and setting.
A third example of concept clarification is provided by Beeber and Schmitt (1986) in their clar-
ification of the concept of group cohesiveness. Although this is a concept that has been previously
described, discussed, and studied, the authors developed a case for its relevance to nursing, and for
reexamining and redefining the potential contribution of nurses to the development of theory related
to this concept. In clarifying the concept, they added a new perspective that allowed the questioning
of the positive values that were automatically granted to this concept. Their critical examination of a
broader view of the meaning of the concept, allowing the exploration of both the negative and posi-
tive, made the process more one of clarification and less of analysis. The authors provided a history
of the definition, identified the diffusion of the concept and the ambiguities inherent in the existing
definitions, defined its properties, reviewed relevant literature in other disciplines, critically analyzed
the use of group cohesiveness in the nursing literature, and provided alternative uses for the concept
in nursing research and theory building for introducing students to group work, for further develop-
ing precise measures, and for the development of clinical indicators, among other uses.
Some more mature concepts may be better explored by using more than one method. The
concept of hope is an example. With the many definitions in the literature, analyzing existing def-
initions (Wilson) and exploring views from other disciplines (Norris) yielded a more comprehen-
sive definition for one author (Sachse, 2007). Building on these definitions, others continued to
clarify the nature of hope and its relationship to other concepts in nursing (Tutton, Seers, and
Langstaff, 2009). Another form of clarification may require a research study, as was used to clar-
ify the concept of “patient participation,” a concept very often used to describe patients’ involve-
ment in the care process. It is a concept described as well in several nursing theories. By studying
it through a grounded theory design, a group of Swedish authors clarified an important core cate-
gory of mutuality in negotiation to explain how nurses understood participation. A clarification
process added an important dimension to the concept’s many other dimensions (Sahlsten, Larsson,
Sjöstrom, Lindencrona, and Plos, 2007).
CONCEPT ANALYSIS
Concept analysis is a strategy for further developing concepts. In using concept analysis processes
to develop concepts, the assumption is made that the concepts have been introduced in the litera-
ture, that they have been defined and clarified, but that they are in need of further analysis to
advance them to the next level of development. Concepts are analyzed when their significance is
established and their relationship to the discipline of nursing has been clarified. Analysis implies a
breaking down to well-defined components; it reflects building and rebuilding, and presumes the
essential components are identified and defined. The goal of analysis is to bring the concept closer
to being used for research or for clinical practice. Concept analysis contributes also to instrument
development and theory testing (Davis, 1992). Processes inherent in concept analysis include
answering some significant questions and raising some new, pertinent questions.
Several strategies have been used in the nursing literature to analyze concepts: the Wilson
method, the simultaneous concept analysis strategy, and the hybrid method. Each is described briefly.
Wilson’s Method of Concept Analysis
One of the most cited references for concept analysis is Wilson’s (1963/1969) method. The
variations on this method have been described by Chinn and Kramer (1991) and Walker and Avant
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CHAPTER 15 Concept Development 377
(2005), among other scholars in nursing. Examples of the use of the Wilson method in nursing are
given by Avant (2000) and Avant and Abbott (2000). Wilson identified 11 steps to use in concept
analysis.
1. Identify and isolate the questions of the concept. Three different sets of questions are
described. The first set of questions is related to facts. He proposes that these questions
should be answered by existing knowledge about the concept. The second set of ques-
tions involves those related to values about the concept. These need to be answered based
on moral principles of the “shoulds” and “should nots,” as determined by society or other
important bodies that influence moral judgment in a discipline. The third set of questions
is related to meanings; these are best considered in terms of concepts; they do not concern
facts or values. Although questions may appear to belong purely to only one category, in
the broader sense they are not truly pure and may reflect more than one category.
2. Consider the possible answers to the questions and identify the essential elements of
these questions. The goal here is clarity of communication in an attempt to find answers
that are “right.” Right answers are given within a context. Avant (2000) demonstrated
how the “right” answer to a question differs in different contexts by using the concept
“science,” which is defined differently in different disciplines: a process, truth establish-
ment, or a social activity. The “right” answers also change according to the context of
the particular era. For example, titles of “Hispanic,” “Latina,” and “Mexican American”
evolved new meanings over the years.
3. Identify and describe exemplars to reflect the different critical and essential characteris-
tics of the concept. Identify the typical features, as well as those that may not be so typi-
cal. The question he proposes answering here is: “If that is not an example of it, then
nothing is.” These exemplars are considered model cases.
4. Identify “contrary cases,” that is, those exemplars that do not include any of the proper-
ties of the concept. Just as with exemplary cases, contrary cases may be the extreme
opposites of the exemplars, in that the concept is not readily visible or apparent. These
are cases in which the concept and its properties are absent.
5. Identify, describe, and use some related cases in which the concept may be connected
or similar in some way, or as it occurs in similar texts. Analyze which features are
essential and which are not. For example, “change” is a concept related to the concept
of “transitions.”
6. Provide borderline cases as exemplars. Select exemplars that may have some features or
attributes of the concept and in which ambiguity exists about whether the case belongs
to the concept or not. Particularly consider cases that are difficult to classify because
they help in the further development of the concept.
7. Develop and present invented cases. Wilson promoted the idea of developing a invented
situation to exemplify the typical features and properties for the concept. The context
for the invented case may be different, the exemplar may be totally out of the ordinary,
and the method of recounting the case should be innovative. These invented cases are
developed to highlight or enhance the major features of the concept. Examples may be
found in poetry and in fables.
8. Identify and define the social contexts, and analyze concepts with an eye to who
may use it, why it may be used, and how it could be used. Concepts occur within a
social context that includes the past as well as the future. Meanings are derived from
a social context, and interpretations differ across disciplines, time spans, regions,
and cultures.
9. Beware of underlying anxiety related to concepts or generated by the concepts. Wilson
encourages identifying, describing, and analyzing the feelings attached to the concept.
This means identifying any controversy related to the concept, whether it has any stigma
attached to it, and what debates exist related to it. These are the sentiments generated by
the concept due to history, meanings, and unresolved issues.
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378 PART FIVE Our Theoretical Future
10. Define and explain the potential practical results related to the concept. The practical
uses of the concept need to be defined and identified, and a break-down of its essential
elements and their relationship to practice should be defined.
11. Carefully choose the language used to describe the results and label the concept.
Finally, Wilson recommends making a decision on the best words to use to reflect the
concept and its meaning. Because words often have different meanings, as well as
ambiguous interpretations, it is essential to choose one meaning and label to reflect it.
He suggests selecting a label with an eye on usefulness.
There are many variations to Wilson’s method (Avant, 2000) in nursing. An example is analy-
sis of pain management. Pain management is accepted in nursing as an integral component of the
nurses’ mission in providing nursing care to clients. The meaning of this concept is varied, and its
goals are numerous. It could be based on a value system of reciprocity, patriarchy, or collabora-
tion. Davis (1992) used a concept analysis strategy to identify the role of patient involvement in
managing their own pain. Based on Walker and Avant’s (1995) strategies, she examined patients’
perceptions of pain management, explored the different definitions offered in the literature,
defined the concept’s attributes, developed an exemplary case, identified border and related cases,
and identified ways by which pain management could be empirically referenced in clinical situa-
tions. The analysis provided the basis for patient involvement in the caring processes.
Walker and Avant’s (2005) strategies, which are used extensively in developing nursing con-
cepts, are based on Wilson’s strategies. However, theirs differ in that the guidelines and the spe-
cific steps in their strategies are more user-friendly and better suited for nurses’ needs for
well-operationalized steps. By using one of the strategies that they outlined for developing con-
cepts based on the phenomenon of interruption, the authors were able to identify several proper-
ties, including: interruptions could be planned or unplanned human experiences, internally or
externally created, and they create discontinuity. As a process that nurses experience frequently,
understanding the properties and outcomes of interruption could lead to an effective program of
research related to its outcomes on nurses and patients (Brixey, Robinson, Johnson, et al., 2007).
Similarly, Hawks’ (1991) analysis of power resulted in identifying the properties of power as
“power to” versus “power over” and in the development of a conceptual map that contains the
different components inherent in power (sources, skills, and orientation) and the role of self-
confidence in attaining the goals. The systematic analyses of these two concepts may lead to fur-
ther development of the concepts and create the potential for more systematic research, with the
ultimate result of developing client-sensitive and client-responsive theories. Many other examples
in the literature utilize Walker and Avant’s strategies in concept analysis. It is of note that these
strategies have been utilized in Sweden (Allvin, Berg, Idvall, and Nilsson, 2007), Canada (Campbell-
Yeo, Laatimer, and Johnston, 2008), Egypt, Netherlands, Austria, Germany (Boggatz, Dijkstra,
Lohrmann, and Dassen, 2007), Australia (Levett-Jones, Lathlean, Maguire, and McMillan, 2007),
Ireland (Fogarty and Cronin, 2008), and Korea (Shin, Park, Ryu, and Seomun, 2008).
Simultaneous Concept Analysis
Many concepts in nursing are interrelated and overlapping, such as interaction, communica-
tion, relating, and reciprocity, among others. The concepts of change, transition, coping, and
adapting also have many common and uncommon attributes. One innovative and discipline-
congruent strategy for analyzing concepts is the simultaneous analysis strategy used by Haase,
Leidy, Coward, Britt, and Penn (2000) in analyzing spiritual perspective, hope, acceptance, and
self-transcendence. This strategy is based on collaboration, critical thinking, expertise of partici-
pants, complementarity, mutual trust building, and mutual consensus building. These attributes
are congruent with the nature of nursing as a human science and a caring discipline.
Colleagues interested in similar or different concepts may join efforts to clarify their concepts
in relation to a larger whole, and in the process, clarify others’ concepts and increase the clarity of
the concept based on the common root of the related concepts. Although most other strategies
used a more individual approach to concept development, the simultaneous concept analysis is
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CHAPTER 15 Concept Development 379
based on a value system of connectedness and collaboration (Haase, Leidy, Coward, Britt, and
Penn, 2000). Individual analysis, thinking, and conceptualizing form the first building blocks for
this strategy. Antecedents, critical attributes, and outcomes for each concept are first identified and
defined. Similarities and differences in attributes, antecedents, and consequences are then identi-
fied to create what the authors call a validity matrix.
The group reviews, compares, and contrasts the results of their development of similar com-
ponents with each original concept and engages in critical assessment, paying with particular
attention to language, semantics, meanings, and goals. This process continues until some shared
agreement is achieved and a visual diagram or table is constructed to reflect this agreement. This
strategy supports the potential of refining concepts and developing them further. It is a strategy
that is congruent with the nature of human science as dialogue and with the nature of scientific
discovery as collaborative. Several examples illustrate the multiuse of this strategy. One example
is considering a concept through the lens of different philosophical paradigms. This enriches our
ability to uncover the multitude of dimensions of a concept, as well as deepening our understand-
ing of clients’ different perspectives. A second example is considering spirituality from empiri-
cism, interprevitism, and poststructionalism (Tinley and Kinney, 2007), and a third is comparing
and contrasting presence and caring (Finfgeld-Connett, 2008). Finally, another outcome of this
strategy may be the ability to develop a middle-range theory, as demonstrated by a group of
Swedish clinicians who used it to refine and develop a theoretical model of coping for families of
patients in intensive care units (Johansson, Hildingh, Wenneberg, Fridlund, and Ahlström, 2006).
The Hybrid Strategy
This strategy synthesizes empirical with theoretical approaches. Schwartz-Barcott and Kim
(1986, 2000) developed this method. This is another strategy more congruent with the evolving
nature of methodology in nursing research, in that it combines quantitative and qualitative meth-
ods. The hybrid strategy is also based on the concept Wilson’s analysis strategy (1963, 1969) and
the grounded theory approaches of Schatzman and Strauss (1973).
Schwartz-Barcott and Kim (2000) identified three major phases. The first is the theoretical
phase, the second is field work, and the third is the analytical phase. These phases are not sequen-
tial or linear; work can be ongoing in each and all simultaneously. In the theoretical phase, the the-
orist defines a concept, searches the literature, identifies meaning and measurement issues, and
selects a working definition. In the field work phase, the theorist sets the stage for the proposed
work, negotiates, selects participants, and collects and analyzes data. Comparing, contrasting, and
weighing the results, and allowing time to revisit the theoretical and field work phases, constitute
the final analytical phase. Some similarities exist between the simultaneous and hybrid strategies.
Both could deal with clusters of related concepts, and both are multidimensional.
Madden (1990) used this strategy to develop the concept of therapeutic alliance, and the
author supports its utility in distinguishing the properties of one concept from other similar and
related concepts. Similarly, DeNuccio and Schwartz-Barcott (2000) used the hybrid model to ana-
lyze the concept of withdrawal. They began with a review of the pervasiveness of the concept in
nursing and discovered that it is relatively underdeveloped. They then defined the concept as a
flight response used as a defense to an actual or anticipated threat. They described it in terms of
biological adaptation and an instinctive physical response. Then, they discussed how it is meas-
ured in research through a literature review. Subsequently, they observed it clinically, developed a
set of key questions related to observations, developed case studies to reflect the different
responses, and validated earlier notions about withdrawal. It is through these processes that com-
mon factors were identified to describe and refine withdrawal.
Other effective examples of how the three phases of a hybrid strategy—theoretical, empirical,
and analytical—were used is in developing the concepts of being sensitive (Sayers and de Vries,
2008), and dance in mental health nursing (Ravelin, Kylmä, and Korhonen, et al., 2006). In both
cases, the hybrid method for developing the concepts provided step-by-step guidelines, helped
increase the depth of the analysis, and produced rich definitions. In both situations, the authors
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380 PART FIVE Our Theoretical Future
concluded that using multisources to develop the concepts illustrated the significance of the con-
cept, although a need remained for further support and development of the concepts.
AN INTEGRATED APPROACH TO CONCEPT DEVELOPMENT
All of the previously mentioned strategies, in addition to the foresight of metatheorists who pio-
neered the movement toward developing knowledge in nursing (e.g., Walker and Avant [2005] and
Chinn and Kramer [1999]), have made major contributions to elucidating the most appropriate
strategies to use in a human science discipline. New strategies continue to evolve (Rodgers, 1989).
Most of them have been based on Wilson’s approach to concept development. The critics of these
strategies point out the lack of contextualization of the process (Paley, 1996), as well as the ten-
dency to view the concepts as static (Rodgers, 2000). Over the years, I have worked with colleagues
and students to develop concepts, narratives, and theoretical propositions by using an integrated
approach to concept development.
This approach evolved over years of teaching, mentoring, researching, and theorizing. Since
the late 1960s and early 1970s, I have presented students in graduate theory classes with the
request/requirement to participate in developing concepts from phenomena that have captured
their interest and attention.
In reflecting on some of my rationale for not using existing strategies (none of the strategies
was articulated at the time, except for Wilson’s), three reasons become apparent. The first is well
analyzed by Wuest (1994). Existing strategies appear limited in capturing context and are less
direct about biases (sexism, politicism, and racism) that exist in the social structure in which
health care is embedded. The strategies provide limited framework to uncover oppression, to ana-
lyze the status quo and its effect, or to reflect on the different realities and ways by which to
change these situations that perpetrate inequities.
The second reason is their limited guidelines for approaching concept development from the
perspective of clinical practice or from the experiences of clinicians. The strategies are also lim-
ited in their acknowledgment and affirmation of the experiences that students, clinicians,
researchers, and theoreticians bring with them. These experiences affect the way they view and
choose to focus on any particular situation and, therefore, should be part of the analysis and the
development of the concept.
The third rationale is inherent in the “recipe” approach to concept development, which reduces
the process of concept development to a series of ingredients, steps, and phases—rather than focusing
on critical thinking, consciousness raising, and value clarification—which are components of knowl-
edge development. The question that remained to nag me is how to build into any strategy opportuni-
ties for raising consciousness about what is, as well as what ought to be, in understanding, shaping,
and developing concepts (Henderson, 1995). Reed and Leonard (1989) admonished nurses to “move
beyond conceptual ruts” (p. 51) by ethically questioning the frameworks used in analyzing problems,
and by allowing the process of concept analysis and development to raise more questions than it may
answer (Rodwell, 1996). The selection of the phenomena from which concepts are developed is a
process of consciousness raising. These are some of the reasons that have prompted the development
and refinement of an integrated strategy over the years. The starting point for concept development
using the integrated strategy could be from any source, research, practice, or literature review.
With the level of maturity that the discipline of nursing has achieved, developing concepts
could begin from different sources, as well as from a combination of sources. The impetus may be
clinical observations, undefined phenomena from other theories (Peck, 2008), an existing concept
(Takase, 2010), a synthesis from the literature (Cypress, 2010; Bonis, 2009; Weaver, Morse, and
Mitcham, 2008), or from research (Wiseman, 2007; Izumi, Baggs, and Knafl, 2010). While one of
the strategies described in this chapter may be the primary framework, increasingly, a combina-
tion of sources is essential for advancing knowledge about concepts. As we think about a future
for knowledge development that is more informed and based on a solid foundation of evidence,
using a combination of strategies will become the norm. A similar approach to using a combina-
tion of strategies is reflected in the use of the evolutionary strategy to concept development that
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CHAPTER 15 Concept Development 381
was developed by Rodgers (2000) and well utilized in developing such concepts as community
health (Baisch, 2009), social isolation (Nicholson, 2009), and cancer survivorship (Doyle, 2008).
Just as there are more indications that we are moving toward more interdisciplinarity, interprofes-
sional education and collaboration, more interconnection between disciplines and fewer silos, I
propose that there should be less silos between the different strategies.
In this section, I propose a strategy for developing concepts from different starting points,
and I demonstrate the process from phenomenon to concept. There is no one way or approach for
identifying phenomena. There is no one way of doing it, and there is no way by which the richness
and haphazardness of the process can be fully captured. Conceptualizing is never reducible to a
linear set of components or to a neat and tidy set of processes. A conceptualization could happen
all at once, or it could take years and never quite evolve into a useful integrated view of reality.
There are, however, six stages and several processes that are useful in engaging in the whole activ-
ity of theorization, whether theorization is used as a framework for research, for data interpreta-
tion, for concept development, for statistical model building, or for the development of a theory.
The stages are: (1) sensing and taking in a phenomenon, (2) describing a phenomenon, (3) label-
ing, (4) concept development, (5) statement development, (6) explicating assumptions, and (7)
sharing and communicating. Although these stages and processes are presented here linearly and
sequentially, they could occur simultaneously, out of sequence, or in conjunction with other, yet
undelineated, stages. It is useful for students of theory to deliberately and consciously experience
each of these stages, even when such experiences are based on only a rehearsal of what they
would use in the development of theory.
Sensing and Taking in a Phenomenon
Sensing, pausing, and taking in are processes of sizing up a situation that has attracted our
attention for whatever reason, whether that reason is cognitive, affective, objective, or subjective,
or whether it is a hunch or just an uneasy feeling. A phenomenon may attract and hold the atten-
tion of the observer, making her pause to think about it and reflect on its nature. This attention
grabbing may happen when the phenomenon is occurring, or it may evolve retrospectively. A cli-
nician may air the room whenever she changes a dressing without pausing to think about the rela-
tionship of increased fresh air in the room and healing. A clinician may want a family to be present
during a painful procedure for a patient, or might change a patient’s position, believing that either
or both may decrease suffering and/or enhance well-being. These actions or their consequences
may have been the reasons a clinician continues to practice them, but, because they have not
grabbed her attention, she has not been able to develop them further. Attention grabbing includes
observations, mental labor, and personal involvement, all so closely intertwined that it makes it
hard to reduce them to linearity: What happens first? What happens next?
Observation is a complex process, more of a sensory experience than merely seeing. Accu-
rate observation is difficult because of the tendency for selective observations and selective inat-
tention. To know when one is observing with the eyes and when one is observing through mental
activity helps to clarify and distinguish the dimensions of observation (Zderad and Belcher,
1968). Both activities are part of attention grabbing and are essential in developing theories, but
they need to be deconstructed into components and distinguished from one another. We cannot
totally separate what we observe from what we want to see or what we observe from our experi-
ences; nor do we want to. However, we can allow ourselves to observe what we do not know,
what we, at this time, do not understand, and what is out of the realm of our experience. Observa-
tion occurs both with the “naked eye” and within a “matrix of theory.” Beveridge (1957) reminds
us that:
Accurate observation of complex situations is extremely difficult, and observers usually make
many errors of which they are not conscious. Effective observation involves noticing something
and giving it significance by relating it to something else noticed or already known; thus it con-
tains both an element of sense-perception and a mental element. It is impossible to observe every-
thing, and so the observer has to give most of his attention to a selected field, but he should at the
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382 PART FIVE Our Theoretical Future
same time try to watch out for other things, especially for anything odd. . . . Powers of observa-
tion can be developed by cultivating the habit of watching things with an active, inquiring mind.
(pp. 104–105)
A deliberate attempt must be made to experience and practice naked-eye observations, as
well as observations within the matrix of theory or those guided by a paradigm. Observation is not
a new skill to nurses; it has been the cornerstone of practice. As King (1975) put it:
Direct observation has been a primary function of nurses for centuries. Nurses collect volumi-
nous data in their daily activities to gain immediate factual information to plan and give nurs-
ing care. They have been trained to make observations and to measure selected physiological
and behavioral parameters of human beings to answer immediate questions. (p. 26)
After the initial serendipitous identification of a phenomenon, whether from a clinical setting
or from careful review of research studies, attention grabbing is followed by attention giving.
Attention giving is a more deliberate process. It is a process that includes a careful delineation of
those situations or events that have the potential of demonstrating the phenomenon under consid-
eration. Situations or incidents selected for observation should vary to consider different aspects
of phenomena. An example may illustrate this process. A primary health care worker in Cali,
Colombia, noticed over the years that per diem maids tended to ignore all attempts to bring them
to the clinic early in their pregnancy for prenatal care. She also noticed that they tended to bring
their sick children to the emergency room with the very first sign of any mild illness. The discrep-
ancy between getting prenatal care and getting pediatric care caught her attention. The health care
worker may then choose to give this matter her attention and deliberately look into the differences
between the two clinics, the meanings attached to pregnancies and offspring, and to preventive
and curative care, or she may choose to consider the environments of both clinics or a number of
alternatives, depending on her interest, goals, and previous experiences as a theorist.
Sometimes a question—a patient’s, a colleague’s, one’s own—may call attention to some phe-
nomenon and provoke thinking. The beginning may be the absence of an expected response
experienced by the nurse with surprise, anger, disappointment, or relief. These subjective
responses may be used as clues to the nature of the phenomenon itself. (Zderad, 1978, p. 40)
It is looking at the experience with wide-open eyes, with knowledge, facts, theories held at
bay; looking at the experience with astonishment. Concentrating on the experience is
absolutely necessary. Becoming absorbed in the phenomenon without being possessed by it is
equally important. (Oiler, 1982, p. 180)
During the taking-in and attention-getting processes, a dialogue with oneself, with one’s the-
oretical journal, with others, or with all these may be helpful in delineating the phenomenon to
further pursuit. The dialogue may include the following questions:
What is it that is attracting the attention of the observer?
Where does it happen?
Is it similar to or different from happenings under different sets of circumstances?
Under what conditions does the observer sense it, see it, hear it, observe it, read it, or touch
it?
Can the observer describe it? What is the description?
Can the observer document it with model cases and prototype situations?
The objective of completing the taking-in stage with the two processes of attention grabbing
and attention giving is to delineate a phenomenon for further theoretical development.
Describing a Phenomenon
The interest in some problem, question, situation, or event—theoretical or clinical—gnaws at
the observer for some time. Our early theorists began their theoretical formulations with a nagging
problem based on experience, observation, and thinking related to the organization of nursing
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CHAPTER 15 Concept Development 383
curricula and the nature of the substantive knowledge that should be included in nursing courses.
Some specific questions that baffled them were: What is nursing? And, what is nursing’s mission?
The combination of their questions and their clinical backgrounds resulted in several theories that
have helped us distinguish the boundaries of our discipline. These theories have attempted, and
succeeded in some ways, to provide some abstract concepts and propositions that can be general-
ized to different areas of specialization in nursing.
Nursing has gone beyond the beginnings of being concerned only with the disciplinary
boundary questions that preoccupied our colleagues in theory. Members of the discipline are now
capable of focusing inquiry with the goal of developing theories on phenomena surrounding
health, transitions, interactions, nursing clients, and nursing therapeutics.
The observer should attempt to respond to the following questions in defining the phenomenon:
What is the phenomenon?
When does it occur?
What are the boundaries of the phenomenon?
What does it share with a larger class of phenomena?
Does the phenomenon vary? Under what circumstances?
Is the phenomenon isolated in reality?
Does it have a function? Are there multiple factors associated with it? Does it serve an
explanatory purpose?
Does it refer to a long-term behavior, to characteristic or habitual modes of behaving, or to
patterns of behavior detectable in repeated or similar acts?
Is the phenomenon related to time and place?
Is the phenomenon related to some theoretical framework, to one’s basic philosophy of
nursing or manner of being? In what way?
This sums up what the phenomenon is and where and when it occurs. Answers to each of
these questions will help describe a phenomenon.
The description of a phenomenon may be first articulated in question form. An interest in
sleeplessness in intensive care units may prompt one of the following questions (Landis, 1983):
Why do patients experience periods of lack of sleep in intensive care units?
What are the properties of sleeplessness or wakefulness in intensive care units?
Is sleeplessness an adaptive coping style or a maladaptive one?
Others’ interests or clinical focuses may prompt other types of questions, such as:
What processes do nurses go through to decide whether or not to provide pain medication for
patients experiencing pain?
What are the properties of effective transition into the sick or well role?
What are effective and ineffective transitions?
What are the predictors of occurrence of premenstrual stress?
What is a stressful menopausal experience?
Why do certain immigrant groups seem to be more consistently “satisfied” with health care
than others?
What types of social support do different subcultural groups need during illness?
Once the general problem area is identified, questions are then asked to determine whether
the problem of interest falls within the domain of nursing. They include:
In what way is the phenomenon related to nursing’s substantive knowledge process?
In what way would understanding the phenomenon help in explaining some aspect of nursing
care?
Can you think of some questions around that phenomenon, the answer to which would be
significant to nursing?
How is the phenomenon related to the social policy statement of what nursing is?
Are there some biases that you could identify: background of the researcher, presence of the
researcher?
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384 PART FIVE Our Theoretical Future
Did the investigator provide contrasting observations, thereby demonstrating contexts in
which phenomena are observed or not observed?
Are there repetitive patterns?
A phenomenon is not a thing in itself; it is not what exists, but rather is organized around per-
ceptions. When experience, and sensory and intuitive data become coherent as a whole, and prior
to attachment of any meaning, we have a phenomenon. A phenomenon, then, is an aspect of real-
ity colored by the perception of the viewer of that reality. A phenomenon remains merely a phe-
nomenon as long as we attach to it no cognitive, intuitive, or inferential interpretation. For
example, separate and repetitive observations of the appearance of newly immigrated groups
occurring more often in emergency rooms than in the regularly scheduled outpatient clinics is a
beginning observation that may evolve into a phenomenon. When one observes that individuals
belonging to the immigrant group tend to miss scheduled appointments and appear more often at
unscheduled times, a vague pattern begins to emerge. When the observer further hears an individ-
ual from the same or another immigrant group rejecting the pace of life in the United States and
complaining about having to plan activities and events so far in advance, then the vague pattern
begins to form into a shape. The form could be concerns about planning, disenchantment with
structured existence, or various abilities to deal with emergencies in preference to maintenance.
The observer can then ask questions, observe, read, and structure situations in which planning is
considered a norm (e.g., birthing preparation, rehabilitation, and discharge), and can therefore
ascertain whether indeed a pattern is still apparent.
Delineation of phenomena is achieved through the analysis of models, situations, or exem-
plars. Model situations are vivid examples of the phenomenon and help to describe it. A model sit-
uation depicts reality in its prototype, its ideal form, and it allows demonstration of what the
phenomenon is and where it exists (Chinn and Jacobs, 1987).
Labeling
Labeling is a stage that comes somewhere during the process of theorizing, and a label may
change several times in the process. The function of labeling is to communicate succinctly, to
relate to the written literature, to help to delineate what further observations to obtain, and to
reduce a phenomenon that is usually described in a paragraph to a concept or statement. Labeling
is more than selecting a Label X to describe Phenomenon Y. Labeling allows for semantic analysis
(Scheffler, 1958). Semantic analysis permits the theorist to consider the normative use of the term,
as well as other more esoteric uses. Labeling is associated with a kind of defining that ranges from
a dictionary definition to a more complex definition that takes the perspective of the theorist into
consideration. The label, “preference for spontaneity,” emerged from further consideration of
Middle Eastern immigrants’ health and illness behaviors to denote their lack of enthusiasm about
planning, preference for dropping in over making appointments, preference for missing appoint-
ments, and preference for showing up in the delivery room with no prenatal care (Olesen and
Meleis, 1990). A label of “positioning” allows exploration of a patient’s position in bed, ability to
breathe, outcome of decrease in edema, and/or ability to feel empowered when communicating
with others. A label and semantic analysis bring the theorist closer to concept development.
Some criteria must be considered when labeling concepts. Lundberg (1942) suggests
Eubank’s (1932) criteria, which insists on the use of precise labels that contain only one idea and
that are consistent in their meaning whenever they are employed.
Labeling a concept is a highly individualized experience involving interpretations of the phe-
nomenon. It includes hunches, opinions, and speculations. A labeled phenomenon is a concept or
a statement, but it is predefined theoretically and operationally.
Concept Development
Somewhere in this process of theorizing, and not in linear progression, a concept begins to
emerge. Concepts evolve out of a complex constellation of impressions, perceptions, and experi-
ences. Conception in Kantian terms is an organized perception. Phenomena are perceived, and
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CHAPTER 15 Concept Development 385
only when they are organized and labeled do they become concepts. Concepts are a mental image
of reality, tinted with the theorist’s perception, experience, and philosophical bent. They function
as a reservoir and an organizational entity, and they bring order to observation and perceptions.
They help to flag related ideas and perceptions without going into detailed descriptions.
Several processes are useful in concept development: defining, differentiating, delineating
antecedents and consequences, modeling, analogizing, and synthesizing. Defining depends on the
label given to the phenomenon. Therefore, the labeling stage should be carefully considered; pre-
mature labeling may prompt the theorist to review unrelated literature. Defining a concept helps to
delineate subconcepts and dimensions of the concept. During the process of defining concepts
theoretically and operationally, the theorist is smoothing rough edges, clarifying ambiguities,
enhancing precision, and relating concepts to some empirical referents.
Lundberg (1942) also suggests that:
Operational definitions, then, are merely definitions which consist as far as possible of words
clearly designating observations of events and performable and observable operations subject
to corroboration. Thus, they may consist of (1) “physical manipulations,” such as reading the
weight on a weight scale, (2) “objective verbal designations of these manipulations,” or (3)
“verbal designations of symbolical or mental operations,” such as the definition of “prefer-
ence for spontaneity.”
Operational definitions of concepts in nursing have to be referenced in practice and put into
context in reality. Otherwise, they would not be useful for nurses (Jacobs and Huether, 1978). A
human response, a unit of analysis for nursing theorists, may not always lend itself to the same
corroboration expected in the physical sciences and strived for by social scientists, nor should it.
Defining concepts could also be based on an extensive review of literature to further delineate
a concept. Covington (2003) reviewed literature related to “caring presence” and articulated a def-
inition that could be used to further develop a concept.
Differentiating is a process of sorting in and sorting out similarities in and differences
between the concept being developed and other like concepts. In developing the concept of transi-
tion as a central concept in nursing, Chick and Meleis (1986) discussed the similarities and differ-
ences between the priorities of the concepts of transition and change. Similarly, Reed and Leonard
(1989) described how they saw the differences between self-neglect, the concept under develop-
ment, and suicide and noncompliance. The importance in using the process of differentiation is in
accessing related bodies of literature and in further refining the attributes of the concept under
development.
In delineating antecedents, the theorist is attempting to define the contextual conditions
under which the concept is perceived and is expected to occur. Antecedents to transitions that are
of interest to the domain of nursing have been defined as events such as recovery, death, immigra-
tion, amputation, diagnoses of chronic illnesses, pregnancy, and admission to hospital (Chick and
Meleis, 1986). The theorist may ask, “So what?” in attempting to identify the consequences of the
concept. Consequences are those events, situations, or conditions that are related to and preceded
by the concept under development.
To delineate consequences, a theorist can practice by listing every concept or statement that,
in her opinion or as manifested in research findings, may result from the concept. It is important to
deliberately attempt to delineate positive as well as negative consequences. Consequences of tran-
sition may be disorientation, confusion, growth, changes in body image, changes in self-concept,
and role sufficiency (Meleis, 1975).
Modeling is the process of defining and identifying exemplars to illustrate some aspect of the
concept. Exemplars could be clinical referents or research referents. Several types of models are
used, each to illustrate different aspects of a concept. A like model is one that illustrates the con-
cept in its entirety. A contrary model is a situation, a group, or an incident in which a contrasting
aspect of the concept is absent or is present under a different set of contextual conditions. A popu-
lation that is not in some major transition may be compared with one that is undergoing a signifi-
cant transition, which may provide the contrary model. A like model and a contrary model help
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386 PART FIVE Our Theoretical Future
the theorist in articulating, demonstrating, and highlighting the differences between situations,
events, and clients in which the phenomena related to the concept are demonstrated and not
demonstrated, thus increasing the potential for clarifying it further. Paterson and Zderad (1988)
described a technique of explanation through negation to help in describing the phenomena. Pre-
senting another related phenomenon that does not describe the phenomenon under development
helps sharpen the clarity of that phenomenon.
A phenomenon cannot be described completely by negation but it may be clarified to some
extent by saying what it is not. For instance, empathy is not sympathy; it is not projection; it is
not identification. (p. 90)
Analogizing is a process by which a deliberate choice is made to describe the concept under
development through another concept or phenomenon that is sufficiently like the one under study,
but that has been studied more extensively, explored more systematically, and therefore is better
understood than the concept under study. If the phenomenon and the concept are alike, but represent
different domains, and we understand one more than the other, then perhaps the better-understood
phenomenon will help shed some light, raise better questions, and offer greater insight into the
lesser-understood phenomenon. An example of analogizing is the use of fables or fictional stories to
illustrate a concept. One example of analogizing that I used is of aliens from other times and planets
to illustrate the need for international collaboration in knowledge development (Meleis, 1987).
Synthesizing is a process of bringing together findings, meanings, and properties that have
been amplified by each of the processes described previously. Synthesizing includes, but is not
limited to, describing future steps in theorizing.
Statement Development
The development of a concept may be an end result for some theorists and an interim stage for
others, one leading to further development of a concept through statement development or research
implementation. However, concept development may not be possible because the situation requires
statement development. The questions that we may be facing in nursing as a human science are: Is con-
cept development the only avenue to the development of theory? Is it possible that the building blocks
for nursing theories are statements, descriptions of situations without zeroing in on specific concepts?
Statement development is a stage during which explanations related to the phenomenon are
provided. The explanations link the concepts, antecedents, consequences, and assumptions. State-
ments are developed to describe, explain, prescribe, or predict. They are developed as an end
result or to synthesize other statements for research purposes.
To develop statements, several questions may be helpful. Examples are:
In what ways can we further explicate the concept being considered?
In what ways are nursing clients’ health and environment affected by the concept?
What are some potential consequences of the concept?
What are some corollaries of the concept?
Propositions are tentative statements about reality and its nature. They describe relationships
between events, situations, or actions. Propositions could be developed to describe the properties
of the concepts; these descriptive propositions are called existence propositions (Zetterberg,
1963). They are factor-isolating propositions (Dickoff, James, and Wiedenbach, 1968), and the
end result is therefore descriptive theory, as essential to science as any other theory. Consider, for
example, descriptive theory of the atom and its significance to our knowledge of the atom.
Propositions may also be relational, describing the association between concepts or causal
relationships between concepts (Reynolds, 1971). The process of developing propositions is also a
process of identifying the central questions related to the concept. Propositions provide the central
answers that help to explain, describe, or predict nursing reality. The more refined, developed, and
advanced the relationship statements are, the more they are able to describe and predict the nature
of the relationship, the direction of the relationship, and the strength of the relationship (Chinn
and Jacobs, 1987).
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CHAPTER 15 Concept Development 387
Organizing propositions is one of the processes in the propositional stages. Proposition
organization could be accomplished through different channels. Propositions may be arranged to
represent the process of concept discovery and the process of proposition formation. In this case, a
chronological organization is achieved. A second way is to organize propositions around the cen-
tral concepts in the theory. A third method is to organize propositions in terms of significance for
testing, beginning with those whose test represents the central questions of the theory. Other ways
are to organize around independent or dependent variables. Ordering propositions enhances their
usefulness and their aestheticism (Zetterberg, 1963).
Explicating Assumptions
During every stage of the process, the observer pauses, reflects, and questions both implicit
and explicit assumptions. To regard periods of wakefulness as sleeplessness, the observer has
made an assumption that certain periods of wakefulness are disruptive and that disturbed behavior
may result in sleeplessness. Imagine that the observer is beginning from an opposite point of view
(i.e., that wakefulness promotes healing); observation will be more open to positive consequences,
and to what promotes wakefulness. Therefore, reflection on and analysis of one’s views, beliefs,
and theoretical underpinnings will help delineate assumptions of the developing theory.
Sharing and Communicating
None of these stages and processes is entirely new to nurses, whether they are clinicians, theo-
rists, or researchers. What may have made it appear new in the 1980s was the growing acceptance of
conceptualization as a significant aspect of knowledge development in nursing. This acceptance is
demonstrated in the journals devoted to conceptual development of the discipline and in the increas-
ing productivity in metatheory and theory writing. No theorization process is complete without
opportunities to share and communicate it with colleagues. Theorizing may happen in isolation, but
it does not grow in isolation. Sharing and communicating goes beyond writing and publication. It
should be defined as a daily happening in the lives of clinicians, theorists, and researchers.
Instead of staging opportunities for sharing and communicating conceptualizations, redefin-
ing existing opportunities and resources may enhance this process. Clinical conferences may be
redefined to include a theoretical journal sharing hour. Faculty meeting time may be reorganized
to permit discussion for evolving concepts or statements; students may use part of their class time
for a juice or sherry hour to freely discuss phenomena of interest.
CONCLUSION
Concepts are the building blocks of theories and the cornerstones of every discipline. The rate of
progress in the discipline of nursing can be measured by the extent to which members of the disci-
pline are able to uncover and develop concepts that reflect the phenomena related to nursing care.
These phenomena, neglected in the past because of the focus on more biomedical phenomena, are
being identified, defined, and developed by nursing scholars. Strategies used in developing con-
cepts that reflect these phenomena were initially borrowed from other disciplines. In the process
of using these strategies, nursing scholars refined and further developed them. This chapter has
described major strategies for the development of concepts, providing examples to ground each
strategy in the experience of concept development. The strategies were also compared and
contrasted.
As you select one of these strategies to use in developing a concept of your choice, remember
to use it as a guideline and not as a blueprint that must be implemented as is. The nature of the
phenomena, the creativity of the user, the experience of the clinician, and the findings of the
research should shape the nature of the concept. Do not sacrifice substance for method. The sub-
stance of nursing should continue to shape and drive the methods used. You, the reader, should
also remember that you have a vital role in further developing and refining any and all strategies
used in developing concepts.
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388 PART FIVE Our Theoretical Future
progress in developing knowledge in
your field of interest?
6. In the integrative strategy, clinical prac-
tice, research, and conceptualizing are
proposed to be used for concept develop-
ment. Provide an example from literature
in your field of interest for which you
think this strategy is used. Critically
describe how it was or was not utilized.
Then, redevelop the concept using the
integrative strategy.
7. Compare and contrast all strategies,
identifying areas of agreement and those
of disagreement.
8. Under the description of phenomena, the
author identified a number of questions
to define the phenomena of interest.
Identify five critical/essential questions
for this phase of integrated concept
development.
REFLECTIVE QUESTIONS
1. Select a phenomenon that interests you.
Use the steps outlined by Wilson to
define and develop it.
2. Compare and contrast the results in
developing the phenomenon using
Wilson to those you could achieve using
the simultaneous strategy.
3. There was an attempt in this chapter to
not present recipes for concept develop-
ment, but rather to present guidelines.
What do you consider are the strengths
and weaknesses of each of the strategies
presented in this chapter?
4. Select one published paper related to your
phenomenon or concept of interest, and
identify and critically analyze the processes
in the development of the concept.
5. In what ways did the strategies used to
define concepts support or stagnate the
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C H A P T E R 16
Theory Development
The aim of nursing science is to develop theories to describe, explain, and understand the nature
of phenomena, and anticipate the occurrence of phenomena, events, and situations related directly
or indirectly to nursing care. Theories are also developed to provide nurses with the rationale and
the guidelines for models of care to change unwanted aspects of phenomena, as well as to support
other aspects of phenomena. Theories provide frameworks for nursing prescriptions as well.
These emerging explanatory and prescriptive theories reflect abstract representations of response
patterns of human beings to health and illness, to environments, to treatments, and to health care
professionals. They also represent patterns of how and under what conditions and within what
contexts healthy and therapeutic and unhealthy and untherapeutic relationships are formed in the
health care system. In nursing, a human science, such descriptions and explanations are developed
within a context of time, history, environment (social sanctions and obligations), and human con-
ditions (including human rights). These aims for the development of theories in human science are
congruent with the aims of other human sciences that are focused on human beings and their lives
(Schensul, 1985).
The nature of nursing science and the potential in its growth require a close relationship
between theory, practice, and research. Theoreticians, clinicians, and researchers in nursing share
one ultimate goal—understanding the health care needs of clients and communities for the pur-
pose of enhancing their sense of well-being, promoting their health status, facilitating their transi-
tions, and increasing their access and options for health care that is most appropriate for their
situation.
Despite this shared goal, few would deny that, in the history of the discipline, some tension has
existed among theorists, clinicians, and researchers. This tension has been caused by myths and
confusion about each others’ intentions, methods, and goals. Some nurses, who may hold any one
of these roles, may believe some myths about other unfamiliar roles. For example, some clinicians
may believe that theorists are only “ivory tower” philosophers who dream up ideas unconnected
with practice or research. Without delving into these ideas and studying them, they may tend to dis-
miss them. Researchers, the theorists counter, focus on small research projects using empirical
approaches to the development of nursing knowledge. These research projects may confirm or
refute propositions that are disconnected and may not reflect a coherent approach to illuminating
phenomena within a coherent context. Some clinicians believe that researchers and theorists are too
far removed from clinical practice to be able to develop models of care useful for implementation,
so how could they possibly develop theories that could be helpful in understanding clinical phe-
nomena? Some clinicians even go so far as to ask how theoreticians and researchers could presume
to describe, explain, or predict outcomes of clinical practice when they have not been regularly
involved in providing nursing care to patients, families, or communities?
Truth is multidimensional and tends to be dynamic and contextual; therefore, there are some
truths in all these positions, but none represents all truths for any one position. The theorists have
provided the discipline—and continue to do so—with a coherent vision of the core of its domain:
the focus on patients as human beings; the interactional nature of clients, nurses, environment; and
the primacy of health and well-being as the crux of the discipline’s mission. The goals of self-
care, adaptation, homeostasis, expanded consciousness, balance, and harmony with environments
were articulated by theorists as the major goals of nursing care. They proposed concepts that have
become the cornerstones of the discipline and about which there has been more agreement than
was anticipated in the 1970s. Researchers, on the other hand, have developed instruments for
some central concepts, such as wound healing, levels of confusion, social support, pain intensity,
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and symptom distress. Researchers also have tested some theoretical propositions related to clini-
cal practice, such as the determinants of maternal role development, or the determinants of recov-
ery in cardiovascular patients. Clinicians have used theory as the bases for their actions, even
when they were not able to articulate which theories they use and under which circumstances.
In the 1980s, attempts were made to complete the practice–theory–research cycle. Mercer,
for example, systematically worked on identifying responses to mothering in adult women, in
adolescent women, and in women undergoing cesarean and vaginal deliveries (Mercer, 1984;
Mercer, Ferketich, May, and de Joseph, 1987; Mercer, Ferketich, May, de Joseph, and Sollid,
1987). Mercer identified clinical issues related to mothering, such as ways in which new mothers
establish mothering role cues, as well as the timing in which these cues appear. Mercer continued
to develop and refine her theoretical ideas. She relabeled and redefined mother role attainment
theory to “becoming a mother,” which is more congruent with nursing as a human science (Mercer,
2004). Benoliel’s critical analyses on psychosocial responses of patients to cancer are another
example. Benoliel is a researcher who was engaged in studying clinically relevant questions that
are embedded in a theoretical tradition, and she has developed theoretical propositions from her
clinical and investigative work. She also provided guidelines to using her findings and theoretical
guidelines in holistic care for clients who have life-threatening diseases or who are grieving from
losses related to terminal illness (Benoliel, 1977; Benoliel and De Valde, 1975; Benoliel, Torn-
berg, and McGrath, 1984). She bridged the gaps between education, research, and practice by pro-
viding guidelines for educators for curricular development related to transitions and life-threatening
diseases (Benoliel, 1982, 1983). These are only two powerful examples that illustrate the notion that
progress in the discipline of nursing is predicated on actualizing the relationship between the
research, theoretical, clinical, and educational bases.
One assumption that appears to receive approving nods from members of the discipline is
that disciplines develop through scientific discoveries, and scientific discoveries are useful when
they are organized into some coherent wholes. These wholes could be theories or theoretical state-
ments. Theories provide the frameworks that help in describing, explaining, predicting, and pre-
scribing. Therefore, theory construction and development are activities that are essential in all
disciplines. In fact, the progress of any discipline is measured by the scope and quality of its theo-
ries and the extent to which its community of scholars is engaged in theory development. Com-
pleting isolated research projects that are not cumulative or that do not lead to the development or
corroboration of theories has limited usefulness. Kuhn (1970) contends that disciplines that are in
the preparadigmatic stage demonstrate a pattern of research equated with haphazard problem
solving; the central questions of the field are not well identified. The results of the individual
research projects do not lead to theoretical formulations that may explain phenomena; may predict
events, situations, or responses; and may help in prescribing interventions.
Activities of theory development are not new to nurses, despite another myth that persisted
for many years, that nurses began their theoretical journey only in the mid-1970s and early 1980s.
Whether they were aware of it or not, clinical nurses have actively participated in conceptualizing
many aspects of the domain of nursing. These conceptualizations demonstrate different
approaches to theory development. For example, the earliest attempts at capturing nursing prac-
tice conceptually are well illustrated by Florence Nightingale, who, through the wisdom she
gained from her work in the Crimean War, linked health with environmental factors, linked care
with systematic data collection, and linked hygiene with well-being. Her efforts resulted in con-
ceptual views of patients as physical, spiritual, and intellectual beings needing warmth, nutrition,
and quiet environments (Nightingale, 1992). She conceptualized the environment as external to
the patient, comprised of air, water, drainage, light, and cleanliness. Her writings about data col-
lection, graphics and statistics, and health and illness demonstrate many theoretical propositions,
some of which have been tested by epidemiologists. Other aspects of her conceptualization, such
as the relationship between health and clean environments, have been used in the development of
other theories, such as Rogers’ theory of unitary human beings (Rogers, 1970).
Many more attempts at theory development followed Nightingale’s. Some are reported in the
literature, and many more may have gone unreported. Any time that concepts are delineated,
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CHAPTER 16 Theory Development 393
hunches are developed by linking concepts together to help describe, explain, predict, or pre-
scribe, and those hunches are communicated and used in a number of situations (the genesis of
generalization), the beginnings of a theory are formulated. The developer of those hunches has
been engaged in a process of theory development. In most instances, the process and product go
unreported; therefore, the process is not complete, and a theory does not formally develop. A the-
ory is the articulation and communication of a mental image of a certain order that exists in the
world, of the important components of that order, and of the way in which those components are
connected. The mental image is an abstract representation of order that exists in reality as per-
ceived by the theorist. It includes abstract concepts that then provide the potential of being gener-
alized to a number of categorical events or situations. Some efforts in theory development go
unrecognized, most probably because of a lack of communication and a limited potential for gen-
eralization beyond the one experienced situation. But perhaps it is also because nurses lack an
awareness of their potential to articulate aspects of the discipline theoretically or are reluctant to
accept the potential for theorizing in a practice discipline.
The 1980s were characterized by a multiplicity of strategies for theory development. For
example, Walker and Avant (1988, 1995, 2004) proposed different beginning points for theorizing
concepts, statements, or theories and different approaches for derivation, synthesis, or develop-
ment. The 1980s also were characterized by a multiplicity of research approaches that would
inevitably lead to different types of theories (Allen, Benner, and Diekelman, 1986). The develop-
ment of concepts important to nursing and central to its domain was another significant feature of
the decade. Examples of these concepts are self-neglect (Reed and Leonard, 1989), environment
(Stevens, 1989), dyspnea (Carrieri, Janson-Bjerklie, and Jacobs, 1984), cachexia (Lindsey, Piper,
and Stotts, 1982), and comfort (Neves-Arruda, Larson, and Meleis, 1992).
Subsequent to the momentum that focused on the mechanics and processes of theory devel-
opment, some rich dialogues in the literature are based on viewing nursing phenomena through
the critical lens of theoretical assumptions and philosophical principles, with a continuation
adherence to the confines of the syntaxes of concept development (Andershed and Ternestedt,
2001), derivations, development of taxonomies, and levels of theories as seen, for example, in
such titles as “Implications of Taxonomy on Middle Range Theories” (Blegen and Tripp-
Reimer, 1997, see Chapter 20). A new trend emerged toward the end of the 20th century in
advancing the theoretical discourse in the literature by using tools of analysis to develop new
less-developed phenomenon, such as the concept of “intentional action by clients” (Burks,
2001; Kulig, 2000).
In addition, the theoretical discourse of the new century was free from the boundaries
imposed by the early, more structured theories and approaches to theory construction. This
allowed a new breed of theory developer to use innovative and more contemporary approaches to
developing theoretical nursing approaches to viewing phenomena (Cutcliffe and McKenna,
2005). I am using “approaches” here intentionally to contrast it with structures or theories. For
example, Harden (2000) advances the argument that language analysis can be used as a frame-
work to better understand patients’ narratives and that understanding is enhanced by tapping into
the narratives of both the patients (as recipients of care) and the providers of care.
In reviewing the theoretical dialogues during the first decade of the 21st century, it is
apparent that there are many areas of agreements. Those who discussed theory development
have shared view of the proper domain for theoretical formulations. One such shared view is
to include in theories the evidence accumulated from research that depicts situations or events
related to responses or anticipated responses to health and illness (Smith and Liehr, 2003).
Current and future theoretical work will focus on the further development of concepts emanat-
ing from the nursing domain and its mission and from the practice and actions of nurses. Cen-
tral concepts in the nursing domain that continue to capture the attention of nurses are
relationships with environments, well-being, interaction, coping with transitions, positioning,
living with illness, presence of family, safety, quality of life, and nursing therapeutics, among
others. Theory development may also occur in the functional areas of administration, teaching,
and learning.
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394 PART FIVE Our Theoretical Future
THEORY DEVELOPMENT: EXISTING STRATEGIES
A review and analysis of the literature of theory in nursing yields four major strategies of theory
development. These are differentiated primarily by their origin of theory, practice, or research, and
by whether, in addition to their original source, other sources were used in developing the theory.
These four major strategies are: (1) theory to practice to theory; (2) practice to theory; (3) research
to theory; and (4) theory to research to theory. Each of the strategies is presented and discussed in
this chapter. Another strategy, an integrated approach to theory development, is proposed as an
ought-to-be strategy, to be used by itself or in combination with any of the others. This strategy,
which is presented in Chapter 17, is the most congruent with the discipline of nursing.
Theory to Practice to Theory Strategy
The theorist who uses this strategy begins the process of theorizing by selecting a theory to
use in practice and then uses practice to refine the theory further. This strategy is based on several
premises:
• An existing theory can help in describing and explaining nursing phenomena; however,
the theory’s assumptions are not completely congruent with the assumptions that guide
nursing.
• The theory is not entirely useful in helping nurses meet their goals in nursing practice. The
theory does not define phenomena in ways that are useful for the integrity of the nurse
practice act definitions.
• The theory does not directly help in defining actions for nurses. The focus of the theory is
different from the focus needed for nursing practice.
• The theory does not provide adequate definitions of the central concepts of nursing.
A theorist using this strategy attempts to explain and describe a clinical situation through the
selected theory and discovers the need for a modification of concepts, redevelopment of others,
and possible reconsideration of other definitions that better reflect the practice situation. She may
also consider relationships between concepts that were not proposed in the original theory or ones
that interpret these relationships from a nursing perspective. This strategy for theory development
speaks only to circumstances in which we see the world through an established theory with delin-
eated concepts. It is a particular theory then that guides actions and dictates how we see nursing
and how we act in the world.
Many examples in the nursing literature demonstrate the use of this strategy in theory devel-
opment (Table 16-1). Peplau’s (1952) theory of interpersonal relations in nursing was based on
TABLE 16-1 EXAMPLES OF THEORY TO PRACTICE TO THEORY: CLINICAL AND
PARADIGMATIC ORIGINS OF SELECTED NURSING THEORIES
Theory n Practice n Theory n
Psychoanalytic theory Psychiatry Peplau
Systems theory Pediatrics Johnson
Adaptation theory Pediatrics Roy
Existentialist Psychiatry Travelbee
Adult/Med Surg Paterson and Zderad
Biomedical systems Med Surg Orem
Henderson
Adbellah
Maslow
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CHAPTER 16 Theory Development 395
psychoanalytical theory that she used as a framework to describe psychiatric nursing practice. Her
theory of nursing reflects psychoanalytical concepts and her psychiatric nursing clinical expertise.
Johnson’s (1980) view of the client as consisting of subsystems of behavior and her theory about
assessments and diagnoses of nursing problems as occurring due to imbalance, overload, or depri-
vation are based on biomedical and systems paradigms. Her background in pediatric care, her
continuous interest in clinical nursing, and the paradigms guiding her nursing world resulted in
her theory of nursing. Johnson’s view of a client with subsystems of behavior is analogous, but
not equal to, the biomedical system. Her notion of homeostasis as a goal of nursing is parallel to
Parsons’ (1951) idea of homeostasis of social systems. The structure and function of Johnson’s
subsystems are modeled after the structure and function of Parson’s social systems. The result is a
theory of nursing that describes a nursing client, explains some of the actions of the client and the
nurse, and, perhaps, could in the future predict further action. Another example of this strategy is
Benner’s theory of novice and expert practice (1984) based on her clinical observations through
the Dreyfus and Dreyfus model of skill acquisition in aircraft pilots (1986).
Some may say these are borrowed theories. Barnum (1990) disagreed. She stated that “bor-
rowed theories remain borrowed as long as they are not adapted to the nursing milieu and the nurs-
ing image of human beings. Once such theories have been adapted to the nursing milieu, it is
logical to refer to these boundary overlaps as shared knowledge rather than as borrowed theories”
(p. 95). The strategy discussed here is based on deriving nursing theories from theories developed
in other disciplines. These derived theories reflect unique nursing knowledge and its practice field.
Dickoff and James (1968) contended that theories from biology, psychology, and sociology are
“building blocks . . . in the mansion of nursing theory” (p. 202). A new meaning is given to the
guiding theory or paradigm, a new meaning that is pertinent to nursing. Norbeck (1981), Mercer
(1981), Millor (1981), and Meleis (1975) used a theory or viewed nursing through another para-
digm to develop a conceptualization of social support, maternal role attainment, child battering,
and role supplementation, respectively, describing and explaining behaviors related to nursing
care.
Other modifications of this strategy are exemplified by Roy and Roberts (1981) and Paterson
and Zderad (1988). Roy viewed nursing from systems, adaptation, and interactionist paradigms. Her
theory combines those paradigms with nursing practice, and the result is the person as an adaptive
system or with two internal control systems, the regulator and the cognator subsystems. The activi-
ties of these subsystems are demonstrated through four adaptive modes (effectors): the physiologic
mode, the self-concept mode, the role-function mode, and the interdependence mode. The develop-
ment of the modes, particularly the self-concept, the role-function, and the interdependence modes,
is derived from an interactionist sociological paradigm as exemplified by self-concept, role, and
symbolic interactionist theories. Paterson and Zderad’s (1988) uniqueness evolved from using exis-
tentialist philosophy as the paradigm for the development of their nursing theory. There are several
common processes in the development of theories through this strategy:
• Knowledge of nonnursing theories and of a practice field
• Analysis of theory and practice area (analysis is a process by which the object of analysis
is reduced into components and each component is defined and evaluated; theories are
reduced to assumptions, concepts, and propositions; and practice is described through
exemplars and case models)
• Use of assumptions, concepts, and propositions of theory to describe the clinical area
• Redefinition of assumptions, concepts, and propositions to reflect the domain of nursing
(redefining may also include modifications of some aspects of theory)
• Construction of theories involving the development and explanation of exemplars repre-
senting the redefined assumptions, concepts, and propositions (assumptions, concepts, and
propositions reflect the original theory)
An example of these processes is provided by considering Johnson’s theory of behavioral sub-
system. Johnson (1980) used Parson’s (1951) concept of behavioral system, redefined it from a
nursing perspective as “all patterned, repetitive and purposeful ways of behaving that characterize
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each man’s life, are considered to comprise his behavioral system” (Johnson, 1980, p. 209). She
then identified seven subsystems, labeled each, and discussed the relationship between each
subsystem and the whole system. Several characteristics of a theory evolve from this strategy.
The parent theory is well described and parallels the new practice-based theory. Concepts,
attributes, properties, and descriptions are similar in both theories. The context for the evolving
theory is differentiated from the context of the parent theory. Dalton (2003) used Kim’s theory
of collaborative decision making in a dyad in practice and added concepts about caregiver coali-
tion formation and outcomes to develop a theory that could be used in research for family deci-
sion making.
Finally, it might be helpful to differentiate between the clinical theorist and the clinician who
uses theory. The clinical theorist is one whose goals include the refinement and development of
theory. The clinician who uses theory has a goal of theory application. The clinical theorist is
engaged in practice and in the development or refinement of theory. She uses such processes as
analyses, syntheses, comparisons, refinements, extensions, and reflections, as well as other mental
processes. She uses the process of theory development to understand, know, or further develop
some coherent generalizations that go beyond the present situation. The clinician who uses theory
uses mainly clinical strategies to apply theories for the purpose of understanding and knowing.
The differences and similarities are presented in Table 16-2.
Practice to Theory Strategy
Some theories are driven by clinical practice situations and are inductively developed. They
reflect experiences that evolve from practice and are based on clinical situations and on the expe-
riences of theorists in practice. This strategy is built on several premises:
1. Whatever theories that exist are not useful in describing the phenomenon of interest to
the person. Existing theories are not helpful in understanding problems a clinician is con-
fronting. We may not know, for example, what is providing comfort to nursing clients,
how comfort is defined, how it is achieved, who is expected to participate in providing it,
TABLE 16-2 THE CLINICAL THEORIST (THEORY TO PRACTICE TO THEORY) AND
THE CLINICIAN WHO USES THEORY (THEORY TO PRACTICE)
Theory to Practice to Theory Theory to Practice
Goal
Development; strategies for development Application; strategies for application
Strategies
Analyses; synthesis; comparison; refinement; Analyses; description; interpretation; application
extension; mental processes; reflection; creation
Uses
Understand; know; develop Understand; know
Evaluation
Authenticity; congruency; context for discovery; Authenticity; congruency; context for justification
context for justification; other criteria for evaluation
of theory
Person
Clinical theorist Clinician
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CHAPTER 16 Theory Development 397
what are the different ways in which it is manifested, and what is feasible and what is not
feasible in comforting patients in various stages of health–illness. Answers to these ques-
tions could be articulated conceptually by clinical experts through descriptions of models
of comforting acts derived from their practice, then by defining it and continuing to
develop it (Kolcaba, 2004).
2. The person is able to develop theories; there are resources to support the process of
developing theories. Each theory, whether developed from practice or from research, was
developed over a long span of time.
3. The phenomenon is significant enough to pursue, as developing knowledge about a phe-
nomenon is a long process. The significance of the phenomenon is established histori-
cally, and supported by present imperatives or through reflection about breaking new
future grounds.
4. There may be clinical understanding and wisdom about the phenomenon, but that under-
standing has not been articulated into a meaningful whole. Nurses may be viewing the
phenomena individually and independently.
The clinician begins the process of theory development with a nagging question that evolves
from a practice situation (Henderson, 1995; Kolcaba, 2004; Orlando, 1961). The insight is
grounded in the practice situation, and the result has the potential for understanding other similar
situations through the development of a set of propositions. This strategy depends on observing
new phenomena in a practice situation; developing sensitizing concepts; and labeling, describing,
and articulating the properties of these concepts. The properties are the subconcepts included in
them, the boundaries, the definitions, the examples, the meaning, and so forth.
The development of theory using this strategy is based heavily on the work of Glaser and Strauss
(1967). While collecting data, the researcher keeps diaries, observes, analyzes similarities and differ-
ences, compares and contrasts responses, and develops concepts and then linkages (Clarke, 2005).
The grounded theory approach is credited to sociologists Schatzman and Strauss (1973) and Glaser
and Strauss (1968), who have done a great deal to articulate the process and share its nuances, provid-
ing us with a multitude of examples to demonstrate its utility. It is a strategy not entirely foreign to
nursing; the Yale school of thought in nursing produced many examples of theoretical development
that are parallel to the work done by Glaser and Strauss (1968). Theories evolving from the Yale
approach are those related to interpersonal relations and interactions in nursing, as viewed by
Orlando, Travelbee, and Wiedenbach (see Chapter 13). These theorists developed their ideas by being
totally immersed in clinical work, either giving care themselves or observing care being given. They
used a variety of methods to collect their clinical data, such as case studies, interviews, and observa-
tions. It appears that they then isolated the central phenomenon of nursing related to the client’s inter-
action with the nurse and those phenomena related to the development of nurse–patient relationships.
Categories emerged, concepts were labeled, and beginning propositions were developed.
These were theories based on and evolving from clinical practice, with the intention of
describing and explaining extant nursing practice. One may presume that the theorists did not use
any existing paradigm or theories. This may or may not be true. An equal presumption may be that
these theorists had an interactionist background, prompting them to see nursing practice in one
particular way. This strategy is most useful for clinicians, particularly when they deliberately
begin to use the process to develop theories, then articulate and communicate them. (Backscheider
[1971] offers a useful example of this process.)
One of the most significant processes used by the pre-1980s theorists who demonstrated this
strategy is their knowledge of their clinical areas. They had the resources to identify exemplars
and to compare and contrast different exemplars. They may have used the same components
defined and discussed in this chapter under the heading “Theory to Practice to Theory Strategy.”
However, without more information published about their strategies, it is not possible to use their
work as an example of the modified practice–theory method.
Theorists using this strategy (such as Olshansky [1962] on chronic sorrow) tended to
describe the clinical situation and processes that supported and/or inspired the evolving theories.
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398 PART FIVE Our Theoretical Future
An example of the use of this strategy is that provided by theorists who were interested in describ-
ing noncompliant behaviors. Clients who do not follow and “comply” with prescribed regimens
have been labeled noncompliant or difficult. Some nursing scholars provided analyses demon-
strating that neither concept adequately described the roles of intention and environment in not
adhering to a regimen. Therefore, Reed and Leonard (1989) proposed instead the concept of self-
neglect, which is defined as intentional neglect despite available resources. The authors described
a clinical situation that prompted their conceptualization, reviewed existing theories, compared
and contrasted self-neglect with other like concepts, such as suicide and noncompliance, then pro-
vided more clinical exemplars to refine the properties and attributes of the concept. This strategy
is also exemplified by Maeve’s (1994) “carrier bag theory of nursing practice.” Her theory of
nursing practice was modeled after Fisher’s (1979) carrier bag theory of human evolution, posit-
ing that human beings evolved not through developing weapons, tools, and hunting, but through
collecting, gathering, and accumulating. Instead of viewing human evolution as based on “man
the hunter,” she proposed “women as the carriers,” and suggested that instead of viewing evolution
through the innovation of hunting, that we consider the spectacular development of containers by
women, the heroines, as the impetus for evolution and development. Maeve (1994) used this theory
to reflect the everyday practices of nurses that evolve from storytelling of lived experiences in prac-
tice situations. She proposes that theories should be the result of capturing practice through articu-
lating those ideas that represent nursing phenomena. The theory components are bedside nurses
sharing their experiences, and the process of sharing and articulating these experiences, with prac-
tice-driven theories as the outcome of the narrative. Eakes (1995, 2004) integrated different pub-
lished clinical observations on chronic sorrow into a middle-range theory, supported by research.
The processes used in developing practice-driven theoretical formulation are dynamic,
changing to reflect the participants in theory development. Keeping journals, writing notes,
reflecting in diaries, writing stories about clinical practice, talking with others, exposing our ideas
for discussion, uncovering meaning, challenging assumptions, and most importantly, using criti-
cal thinking throughout these processes are methods to develop theories (Benner, 1984; Gadow,
1988; Habermas, 1984).
Research to Theory Strategy
The research to theory strategy is the most acknowledged and accepted strategy for theory
development, both by scientists in other fields as well as by many within the discipline of nursing.
This strategy is used to develop theories that are based on research. In fact, for empiricists,
postempiricists, and postpositivists, theory development is considered exclusively a product of
research. Therefore, according to this perspective, the strategy par excellence is research to theory.
Theorists who adhere to this strategy believe that theories evolve from replicated and confirmed
research findings and a series of falsifications (Allmark, 2003). From this perspective, theories are
referred to as scientific theories, and the purpose for developing such theories as described by
Jacox (1974) is because:
[I]solated facts are of little interest to scientists, they try to put the knowledge of their respec-
tive fields together in such a way that the various events or phenomena with which they are
concerned are systematically related to one another. A biologist, for example, wants to know
not only about cells, species, and adaptation, but also how all of these are related to each other
and to other biological phenomena. Scientific knowledge is systematically organized into
“theories.” The purpose of a scientific theory is to describe, explain, and predict a part of the
empirical world. (p. 4)
Reynolds (1971) refers to this strategy in the construction of theories as the “Baconian
approach.” It is also most commonly known as the inductive method. Reynolds proposed four
steps to this strategy.
1. Select a phenomenon that occurs frequently and list all the characteristics of the phe-
nomenon.
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CHAPTER 16 Theory Development 399
2. Measure all the characteristics of the phenomenon in a variety of situations (as many as
possible).
3. Analyze the resulting data carefully to determine if there are any systematic patterns
among the data worthy of further attention.
4. Once significant patterns have been found in the data, formalization of these patterns as
theoretical statements constitutes the laws of nature (axioms, in Bacon’s terminology).
(p. 140)
The strategy presupposes two significant conditions: (1) that there is agreement in the field
on the major concepts that should concern its community of researchers and (2) that each research
concerns itself with a manageable number of variables with easily detectable patterns. Social sci-
ence research could not guarantee these conditions (Reynolds, 1971); nursing is similar in some
ways. Until the 1980s, there was very little agreement on the central questions in the field. There-
fore, isolated research projects were launched to explore questions that were either tangentially
related to the mission of nursing or the answers that were central to other disciplines.
As nurse scholars began to agree that nursing deals with human beings who are constantly
influencing and being influenced by their environment, there was more appreciation of the com-
plexities inherent in the phenomena central to the care processes. Therefore, although some theo-
ries may evolve from research findings, others may continue to capture nursing practice and still
others may be derived from other theories. In a dynamic science, all strategies for theory develop-
ment will continue to inform the discipline.
The development of theory from research will be enhanced by completing research projects that
answer questions that are central to the discipline and that are driven by common and shared concep-
tualizations. Often, we find that research findings were designed to answer questions that are either
not central to nursing or are not translatable to connect with other findings to form a coherent con-
ceptualization. This limitation in potential coherence results from lack of articulated theory to drive
the questions; the consequences may be research findings, but not theory development.
This strategy is built on the assumption that there is truth out there in real life that can be cap-
tured through the senses and that this truth can be verified or falsified. Repeated verification is an
indication of the existence of this truth, and repeated support of a hypothesis leads to the develop-
ment of scientific theories. There are numerous examples in the literature of nurse researchers
who have used this strategy in developing theories; among them are Johnson (1972), Barnard
(1973), Lindeman and Van Aernam (1973), and Johnson and Rice (1974).
Not all proponents of this method advocate sensory data as the basis of truth, and not all of
them speak of validation and falsification. The grounded theorists have proposed another
approach within this strategy, one based on the discovery of concepts and on the identification
of patterns, processes, and explanations. The research design proposed by Glaser and Strauss
(1968), and further developed by Strauss and Corbin (1994), is that of field study, in which not
only theories evolve from research but the research question also evolves from the data gath-
ered. The sole purpose of research, as proposed by this group of field researchers, is the devel-
opment of theory. Numerous theories have been developed using this second approach, the
grounded theorists’ approach (Fagerhaugh, 1974; Stern, 1981). A similar approach was used by
Smith (1981) in conceptualizing health. She identified four modalities to describe how her
research participants tended to view health. These were clinical, role–performance, adaptation,
and eudaemonistic modes of viewing and conceptualizing health. Hopkinson, Hallett, and
Luker (2005) used phenomenological philosophy to frame a qualitative study, the results of
which were articulated in a theory of how new graduates in nursing tend to cope with caring for
dying patients.
Two examples will be offered here of the steps to use in the research to theory strategy. The
first is by Lindeman (1980), who advocated the development of theory from research in her
keynote address to the Western Society for Research in 1980. Lindeman used her own research to
illustrate the research to theory process and to identify the steps to use in developing theory from
research. The second example is Dluhy’s proposal (1995) which is discussed on page 402.
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400 PART FIVE Our Theoretical Future
The Research to Theory Method: Exemplar by a Researcher, Carole A. Lindeman (1980)
The first study, designed to determine the value of preoperative teaching, led to the conclusion
that structured preoperative teaching significantly improved the adult surgical patient’s ability
to cough and deep breathe postoperatively and also significantly reduced the mean length of
hospital stay.
A second study was conducted to determine the most efficient way to implement a struc-
tured preoperative teaching program. That study, “The Effects of Group and Individual Preop-
erative Teaching,” led me to conclude that group teaching was as effective and more efficient
than individual teaching. These findings and those from the first study were consistent with
educational research and theory. However, other results from that second study could not be
explained by existing theory and continued to trouble me. Those results were:
1. Site of incision does interact in a significant way with teaching method. Subjects receiving
group instruction and having “other” incisions had a shorter length of hospital stay than the
same group receiving individual instruction. Ventilatory function scores were not different
for the two groups. Interpretation required consideration of psychosocial factors in contrast
to the physiological factors associated with the stir-up regime.
2. Age, per se, does not alter postoperative ventilatory function when preoperative teaching
and practice are provided. Mean postoperative values on ventilatory function tests were not
significantly different for subjects in the various age ranges. In fact, older subjects having
major procedures did significantly better than their younger counterparts.
3. Smoking history, per se, does not affect postoperative ventilatory function, length of hospi-
tal stay, or number of analgesics administered when preoperative teaching and practice are
provided. There were no significant differences between smokers and nonsmokers.
According to the medical literature, these were factors associated with high-risk groups.
However, when these so-called “high-risk” patients received structured preoperative teaching,
their postoperative ventilatory function measures were comparable to those of other patients.
The conceptual/theoretical framework for the research did not explain these results. I was left
with a big unanswered “Why?”
Before pursuing those unanswered questions, I conducted a third study dealing with the
effects of preoperative visits by operating room nurses. Although a large array of dependent
variables was included, the data led to the conclusions that the preoperative visit was useful to
the operating room nursing personnel for creating a safe, effective, and efficient intraoperative
experience, but it did not produce measurable health status benefits for the patient. Coming
from an educational psychology framework, I focused on the content of the teaching
encounter as a way to explain why the one intervention, structured preoperative teaching, pro-
duced measurable benefits and the second intervention, preoperative interview, did not. I con-
cluded that patients could learn and recall psychomotor behaviors taught in the preoperative
period, but material that only served a cognitive structuring process, if learned, would not be
retained.
However, I was then involved in a fourth study that refuted my interpretation and led me to
propose a different set of theoretical statements. The fourth study was a descriptive study of
significant nursing interventions in the preoperative and intraoperative periods and postopera-
tive welfare. The study used Donabedian’s structure, process, and outcome framework; how-
ever, due to observations made in our pilot study, we added patient baseline data to the overall
framework. Much to my surprise, the data showed that patient baseline and organizational data
were more strongly correlated with patient welfare than were specific nursing interventions.
I continued to mull over the conclusions from these various studies in an attempt to
bring order to the data. Although each study by itself had been useful in making decisions
about nursing practice, it seemed that they would be more useful if the results—the
expected and the unexpected—could be tied together in some meaningful way in the form
of nursing practice theory.
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CHAPTER 16 Theory Development 401
It is difficult, if not impossible, to describe one’s thought processes as data and concepts are
analyzed. Let it suffice to say that I continued to focus on three concerns:
1. A nursing intervention relating to skill development had a significant impact; a nursing
intervention involving cognitive structuring did not.
2. Interactions between the patient and the intervention were not totally predictable and, in
fact, were quite surprising.
3. Interactions between the institution and the intervention were not totally predictable.
Emerging from these data, from observations made during the research, and from my fur-
ther analysis was the conclusion that patient welfare is [affected] by three major sets of vari-
ables: organizational, content of care, and patient characteristics. It also seemed clear to me
that the critical variable is the patient, with nursing care only effective to the extent that it
facilitates the patients’ management of their own care.
Having identified the major concepts, the next step in this inductive process involves for-
mulation and validation of relational statements.
The following statements have validity in terms of the research cited earlier:
1. The recipient of health care is the single most important variable in determining actual
health status.
2. Those organizations having a potential for enhancing self-health-care management are
most likely to have a positive influence on actual health status.
3. Those interventions having a potential for enhancing self-health-care management are
most likely to have a positive influence on actual health status.
4. Characteristics of the caregiver as a person are not significant in determining actual health status.
5. The presurgical nursing interventions designed to enhance the self-health-care manage-
ment abilities of the patient will influence postoperative health status.
Within this inductive process, I am now at the point of theory construction. To complete this
step of the process I have had to reconsider the nature or definition of nursing. Without this
broader perspective, any theory would exist in limbo. Its ability to predict and its test in reality
would remain unknown. Again, for my own efforts, I have conceptualized nursing as a profes-
sion that exists because society has needs for health care. These needs generate from three
factors: environmental and social factors, disease factors, and health factors. Those health
issues or needs that arise because of the interaction of these three factors are the primary focus
of nursing. Included are such issues as child abuse, maternal attachment, teenage suicide, the
chronically ill, and so forth. Nursing may also assist other professionals by coordinating or
implementing components of their plan of care. The social workers, nutritionists, physicians,
psychologists, and others all have a role in dealing with issues generating from one or more of
these three factors. I personally believe that nursing does have a unique and independent prac-
tice role, and it is defined in terms of the point of interplay of these factors.
Now, back to theory development. My next step is to analyze already completed
research in terms of the five relational statements presented earlier. I need to consider
patients other than presurgical. I need to explore settings other than acute care. I need to
explore further interventions—those that relate to health maintenance more than disease
prevention. I need to re-examine my major construct, “self-health-care management,” in
terms of the label—does it truly and clearly communicate the nature of the variable? Is it
really the variable producing the observable effects? Only when a review of this nature is
completed will I be ready to construct a formal theory that can then be tested, modified,
and expanded by other researchers and scholars.*
*Quoted by permission from the author and publisher. Lindeman, C.A. (1980). The challenge of nursing research in the
1980s. In Communicating nursing research: Direction for the 1980s. Boulder, CO: Western Interstate Commission for
Higher Education.
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402 PART FIVE Our Theoretical Future
The Research to Theory Method: Dluhy’s Proposal
Dluhy’s (1995) proposal for a method to map pluralistic knowledge for the purpose of generat-
ing theory is another example of the research to theory strategy. She proposes to identify the core
elements, the implicit and explicit assumptions, and the relationship between variables from studies
that have been done in nursing and other disciplines. The purposes of knowledge mapping are to
answer the questions of what are the best explanations of a central question in the discipline and
what are the optimal ways by which these explanations tend to complement each other. Mapping
findings is a strategy to integrate massive amounts of knowledge by linking multiple variables and
considering these variables from within multiple contexts. Developing theory from research, partic-
ularly theory that could inform the discipline of nursing, requires knowledge of the nursing disci-
pline, knowledge of its mission and its perspective, knowledge of philosophical views of science,
and knowledge of the various theoretical perspectives that drive the kind of questions explored.
Several steps support the processes needed for integrating research knowledge into theoretical
wholes. These steps are used to develop a coherent map of findings (Blalock, 1979; Dluhy, 1995):
1. Know well the substantive area for which mapping is proposed by identifying all relevant
literature, findings, and dialogues.
2. Identify the different ontological beliefs and epistemological approaches used in this area
of research.
3. Identify major philosophical and theoretical issues that can clearly divide the findings
related to the question under review.
4. Develop a grid reflecting the ontology on one axis and epistemology on another axis.
5. Identify major concepts that evolve as core in the literature. This process may entail
counting the number of times that a concept may have been the focus of an investigation,
or it may require a qualitative analysis of the centrality of the concept. The context of the
particular question may dictate the ways by which a concept is declared central. Identify
and analyze similarities and differences between the evolving central concepts.
6. Analyze the core concepts and the findings to reflect patterns and themes by placing
them at different points on the four quarters of the grid.
7. Engage in scholarly dialogues to identify assumptions, conceptual areas, and epistemo-
logical approaches.
8. Validate axes of grid and placement of conceptual themes and areas through some estab-
lished methods of validation, such as constant comparisons, Q-sort, or use of different
validation teams.
Dluhy (1995) mapped knowledge related to chronic illness by identifying two ontological
vertical axes representing the ability to control and be controlled (determinism to free will), and
the nature of person (reductionism to idealism). She then identified the horizontal axis as the epis-
temological axis ranging from positivism to subjectivism. She placed conceptual areas in each
quadrant that resulted from a review of more than 300 research and theoretical references. Place-
ment in a particular quadrant was based on the conceptual area within the context of the related
ontology and epistemology. Examples of conceptual areas are fatigue, dyspnea, pain, defense
mechanisms, and support. A large cluster of conceptual areas in any quadrant is an indication of
their predominance within the context of a certain set of ontological assumptions and epistemo-
logical approaches.
Determining agreements on concepts, on findings related to these concepts, and on translat-
ing findings that reflect diverse contexts are steps toward developing coherent conceptualizations
that may lead to developing theory from research.
Several variations of processes for integrating knowledge have been used to develop theories.
Lenz, Suppe, Gift, Pugh, and Milligan (1995) pooled their individual work and collaborated in
developing a middle-range theory to describe “unpleasant symptoms.” The processes they used
are similar to the processes used in mapping, with the difference that this group primarily worked
on mapping their own findings. The original work on this theory was done by Pugh and Gift when
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CHAPTER 16 Theory Development 403
they combined efforts to write a chapter on dyspnea and fatigue and subsequently combined
efforts with others to develop a theory for unpleasant symptoms. Gift (2004) provides a clear tra-
jectory on how the theory was developed from research related to fatigue, dyspnea, and pain.
Theory to Research to Theory Strategy
In this strategy, theory drives the research questions and the results that answer these
research questions inform and modify the theory. The difference between this strategy and the
research to theory strategy lies in the use or nonuse of theory as a guiding framework for the research
questions. Theorists who begin the research by defining a theory and determining propositions
for testing, and then go further to modify and develop the original theories, are considered users
of this strategy. Although many researchers use processes similar to the ones that theorists may
use, some significant differences are apparent between researchers and theorists using this strat-
egy. The researcher using theories aims at testing, confirming, refuting, or replicating theories.
She uses theory as a framework for the operational definitions for variables and statements, and
she uses mental processes, problem solving, and interpretive processes to describe findings. The
theorist who uses research as a means for the development of theory ends investigation with a
refined, modified, or further-developed coherent theoretical explanation of theory. The impact on
the discipline is different, and is needed for different purposes such as translation, refinement, or
development. The theorist researcher’s findings are specific to selected phenomena and selected
findings, whereas the theorist’s impact may be through integrated theoretical statements that
explain and predict a wider range of phenomena (Table 16-3).
TABLE 16-3 DIFFERENCES BETWEEN THEORY TO RESEARCH TO THEORY
STRATEGY AND THEORY TO RESEARCH STRATEGY
Theory to Research to Theory Theory to Research
Goal
Test, refine, develop theory; openness to options for Test, accept, refute, replicate; aim to conclude
further developments
Uses
A framework for research and for modification of A framework for research; define variables and
theory; define concepts for future use; generate questions; prove/disprove
new propositions; explain, define questions
Strategies
Mental processes; creative, abstract, reflective Mental processes; problem solving; interpretation
thoughts; interpretation; synthesis; intuitive leaps
Evaluation
Theoretical thinking; conceptual definitions; other Variable definitions; validity; reliability; other
theory analyses criteria research criteria
Impact on Discipline
Through integrated theoretical statements that Through selected scientific findings that explain and
explain and predict with a wider scope predict specifics
Future
Generates more propositions; inspires Provides support for existing propositions and for
clinical actions
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404 PART FIVE Our Theoretical Future
The processes used for the theory to research to theory method are:
1. A theory that is compatible with the domain of nursing is selected to explain the phenom-
enon of interest.
2. Concepts of the theory are redefined and operationalized for the research.
3. Findings are synthesized and used to modify, refine, or develop the original theory.
4. In some instances, the result may be a new theory.
Examples of this strategy are offered by Berg and Sarvimaki (2003). Berg and Sarvimaki
used three theories to study health promotion and developed a framework of health promotion.
CONCLUSION
Knowing and experimenting with strategies for theory development enhance members of the dis-
cipline’s capacity to advance knowledge and subsequently translate it into models of care.
Another probable result of such knowledge is the integration of philosophical processes with
empirical processes, resulting in a more integrated knowledge. The rift between scientists and
philosophers that marked the era of empirical positivism is decreasing. Our early philosophers
believed that science is based totally on philosophical processes; our scientists believed that it is
based on the intellectual labor inherent in philosophical processes. This chapter demonstrated this
latter process as essential for embarking on research and for interpreting research. Both processes
are processes of theorizing. The end result may or may not be a theory; the end result may be clar-
ification of a concept or the articulation of a number of propositions that may be an extension of
another theory. Systematic research is an essential step in the process of completing the practice to
theory to research loop. Eventually, a theory will have to respond to the analytical and critical
evaluative criteria presented in Chapter 10.
REFLECTIVE QUESTIONS
1. What assumptions must be made to
engage in theory development in nurs-
ing? Identify and discuss the implicit and
explicit assumptions in this chapter.
2. Identify one theory in your field of inter-
est; indicate the rationale for which it is
considered a theory and why it is or it is
not a nursing theory.
3. Describe how the author developed this
theory and what strategies you may use
to develop it further.
4. Select a phenomenon for which a theory
may be developed. Develop a theory
using one of the strategies discussed in
this chapter. Why did you select this
strategy? How might you refine it?
5. Prepare a manuscript for publication
using one of the strategies in developing
a theory reflecting your field of interest.
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C H A P T E R 17
Middle-Range and
Situation-Specific Theories
To advance nursing knowledge, we must continue to build a robust scientific base and develop
coherent frameworks that drive the science, as well as become a reservoir for the accumulating evi-
dence that results from research. Both these categories, middle-range and situation-specific theo-
ries, are at those levels of conceptualization that could inform nursing practice and research and
thus continue the cycle of advancing foundational knowledge and enhancing quality care. The the-
ories discussed in this book have had a transformational effect on the entire discipline of nursing.
They were conceptualized to answer questions about the overall mission, goals, and nature of the
discipline of nursing and to differentiate the substance of the discipline from other disciplines. The
theories of Martha Rogers, Dorothy Johnson, and other theorists of their era in nursing helped pro-
vide the framework for the discipline, and their theories set the boundaries for the nature of ques-
tions to be explored and investigated in the process of building and advancing the discipline.
Without these fundamental theories to build on, we would not have been able to progress to the next
level: the middle-range and situation-specific theories. Both of these types of theories are defined in
this chapter, and exemplars will be provided for each one. The goal for this chapter, then, is to pro-
pose strategies and processes that could be used to develop middle-range and situation-specific theo-
ries. The strategies described in Chapter 16 will undoubtedly continue to inform the discipline; that
is, scientists will use theories to develop research projects, which in turn will modify other theories,
and clinicians will propose theories based on their clinical observations. However, patterns of scien-
tific discovery and in the progress of certain disciplines, particularly nursing, tend to demonstrate a
more integrated approach to theory development. Similarly, the tendency is to develop middle-range
and situation-specific theories, rather than grand theories. The differences between the three types
of theories—grand, middle-range, and situation-specific—are illustrated in Table 17-1 on page 408.
One equally important difference that reflects the growing level of sophistication in the progress of
the discipline is the reliance of its scholars on using a more integrated approach to developing theo-
ries. The integrated strategy to theory development is described in the following section.
THE INTEGRATIVE PROCESS FOR DEVELOPING MIDDLE-RANGE
AND SITUATION-SPECIFIC THEORIES
Theories that tend to be rich in explaining responses, illuminating situations, enhancing wisdom
about events, and providing directions for actions have evolved through an integrated approach.
Such theories may have emerged primarily from any one source; however, the complexity of situ-
ations that give rise to these theories usually compels theorists to gather clinical evidence, identify
exemplars, collect solutions, and garner support from other sources. In using an integrated strat-
egy, theorists combine in any combination experience that is based on clinical practice, evidence
from research, and knowledge that is based on theoretical formulations. This knowledge depends
on the type of evidence and support that is needed, based on the phenomenon for which they are
developing a theory.
Clinical practice has been one of the most significant sources for theory development. Subse-
quent to the group of nurse theorists discussed in this volume, some more contemporary theories
may be deemphasizing the role of practice in theory development and are favoring more the role
of research evidence in formulating theories. Theorists who use the integrated strategy, however,
recognize the significance of the relationship among practice, theory, and research and understand
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408 PART FIVE Our Theoretical Future
that each plays a role in the development of nursing theory. In addition, when using an integrative
strategy, the person, theorist, clinician, or researcher also becomes an integral part of the theoretical
formulation. Even when a deliberate attempt is made to distance the agent (the theorist or
researcher) from the subject matter, and even when such attempts are carefully guarded and imple-
mented, the infiltration of previous experiences in shaping the clinical situation and subsequently
the theoretical formulation is inevitable. These experiences are part of a nursing perspective that is
then reflected in the evolving conceptualization. All these factors become the context that shapes
what we see, how we see it, and how we analyze it. They are part of an integrative strategy.
Phenomena seen from a nursing perspective are not seen in exactly the same way as phenom-
ena seen from a sociological perspective. A nursing perspective is focused on considering the phe-
nomena holistically and dynamically and within a context. Nurses are concerned with phenomena
related to the experience of and response to health and illness, such as health, comfort, care, the
nursing process, supporting, coping, grieving, mourning, suffering, and monitoring; in other words,
phenomena that will eventually make a difference in some aspect of health care. Phenomena are
described or explained through the interaction of health–illness events, person–environment rela-
tionships, and the human-responses perspective. Different perspectives provide different lenses
through which phenomena are viewed. Each perspective identifies the limits within which
inquiries are made (Donaldson and Crowley, 1978). (See Chapter 6 for a discussion on nursing
perspective.) Another assumption for this strategy is that some kind of reality exists out there,
and that there is a pattern and order in the universe around us, as well as, paradoxically, a certain
degree of uniqueness. Because we live in an orderly, nonrandom world, this order is comprehensible
TABLE 17-1 PROPERTIES AND EXAMPLES OF GRAND, MIDDLE-RANGE, AND
SITUATION-SPECIFIC THEORIES
Middle-Range Situation-Specific
Properties Grand Theories Theories Theories
Level of Abstraction High Medium Low
Scope The nature, mission, and Specific phenomena or Specific nursing phenomena
goals of nursing concepts transcending limited to specific populations
and crossing different or to a particular field
nursing fields
Level of Context Low Medium High
Connection to Too broad to connect Limited Relationship readily apparent
nursing research (may prescribe for clinical
and practice practice)
Diversities, Ensuring universalization Crossing different nursing Respecting diversities in nursing
generalizations, and generalization, fields and reflecting a phenomena, but negating
and/or but negating diversities wide variety of nursing universalization and limiting
universalization care situations, but generalization
rarely respecting
diversities in them
Examples Theories by Peplau, Theories by Hagerty, et al. Theories by Braden, Im and
Henderson, Hall, Johnson, and Mishel Meleis, and Hall, et al.
Abdellah, King,
Wiedenbach, and Rogers
Reprinted with permission from Im, E. and Meleis, A.I. (1999). Situation-specific theories: Philosophical roots, properties, and approach.
Advances in Nursing Science, 22(2), 11–24.
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CHAPTER 17 Middle-Range and Situation-Specific Theories 409
to a certain extent and within a certain context. The concept of uniqueness, however, deserves a
closer look.
If each event or process of a phenomenon were absolutely unique or occurred randomly,
without order or pattern, then no generalizations could be made. Without some degree of general-
ization, there is no science because all sciences attempt to generalize about recurrent phenomena.
Scientists, unlike philosophers, must also assume some logical connection between perceivable
events, as well as a certain degree of predictability. In practice, nurses focus on the uniqueness of
individuals for the purpose of individualizing care. However, we must consider seriously Ellis’
(1982) everlasting admonition against using the uniqueness of man as a crutch to avoid patterning
and order, which remain the essential components of theory and science. Uniqueness reminds us
to consider patterns of diversity and individuality, which, when examined, could add to the com-
plexity and richness of theory. Therefore, uniqueness and patterning are also significant premises
on which the integrative strategy of theory development is based.
With this caveat, and with the necessity of considering a rich contextual background, it may
seem difficult to isolate a beginning point for the integrative strategy in theory development. How-
ever, like the strategies discussed in the previous chapter, some essential stages and processes may
facilitate theorizing.
An integrated approach must be grounded in clinical practice at many different stages in the-
ory development. An integrated strategy requires collaboration and dialogue. The beginning
hunches and conceptual schemes are shared and communicated with others to allow for critique
and further development. An integrated approach requires the development of a framework and a
theoretical vision, as well as opportunities to test these hunches or evolving conceptualizations
with colleagues and other participants. Other components of this integrated approach are research
(of different designs) and different methods to clarify, support, or test some of the evolving
hunches. Research documentation may be supplemented by reflective clinical diaries, descriptive
journals, and dialogues about analyses, among other sources and approaches. An example of a
theory in which the theorists used an integrated approach is the Theory of Human Relatedness
(Hagerty, Lynch-Sauer, Patusky, and Bouwsema, 1993). The authors of this theory experienced
situations in clinical practice that prompted them to think of various states of connectedness and
disconnectedness. They dialogued, observed, kept notes, conducted research in the library, and
identified the social processes inherent in relating, as well as the different states of relatedness,
including connectedness, disconnectedness, parallelism, and enmeshment. The evolving theory
explains, describes, and has the potential for clarifying situations in which nurses relate to others
(which is most of the time). The potential power of this theory in enhancing the understanding of
such situations is directly related to its integrated approach of development.
TOOLS FOR DEVELOPING MIDDLE-RANGE OR SITUATION-SPECIFIC THEORIES
Theory development includes mental processes that incorporate analysis, discovery, formulation,
and validation of uniformities. These may come as a result of sensory observation or as a conse-
quence of a logical or rational analysis of the problem or the phenomenon. They may also result
from intuitive reasoning, from an insight that occurs over an extended period of time, or from a
“click” that comes as quick as lightning. The thought processes can be spontaneous or premedi-
tated—the timing is never predictable (Sorokin, 1974)—but a conscious effort to look at the phe-
nomenon or the question is infinitely more helpful in bringing the process to closure. It does not
guarantee the “click,” but it increases its chances.
Just as the process of researching is enhanced by a knowledge of substantive content, a
knowledge of research methodology, experience, and the ability to critique research, all processes
of theory development are also supported and enhanced by the knowledge of what constitutes the-
ory, knowledge of what major issues confront theorizing, ability to critique theory, knowledge of
existing theories, and knowledge of major pitfalls in the development of theory. Knowledge of
theory’s context, such as the clinical area, is essential. Theorizing is a process that is refined
through a deliberate experience. The processes of reflecting, analyzing, questioning, relating,
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410 PART FIVE Our Theoretical Future
thinking, writing, changing, and communicating are integral parts of philosophical analysis,
essential to theory development, and a prelude to and a consequence of research. Keeping a theory
diary or journal in which observations, reflections, and relationships are systematically logged
helps the theorist to sort out thoughts, develop documentation, and synthesize empirical reasoning
with intuitive reasoning (Zderad, 1978).
Norms used to enhance science also are useful in enhancing theory development and they
drive the utilization of other tools. Merton (1968, 1979) identified a number of these norms, two
of which are pertinent here: the norms of communality and organized skepticism. Communality
encourages nurses to share developing ideas and expose beginning theories for review by peers, to
help sharpen the theory and to allow the norm of organized skepticism to prevail. This latter norm
“requires detached scrutiny of work according to empirical and logical criteria” (Meleis and May,
1981, p. 38). Dialogues with colleagues in practice, in theory, and in research promote other ways
of looking at concepts—other angles and other perspectives.
Collaboration is another significant tool for theory development. In a human science such as
nursing, theory development is increasingly a collaborative effort. Collaboration allows the con-
stant comparison and evaluation of competing ideas, provides the medium for a scholarly dia-
logue to refine concepts, and enhances the integration of seemingly diverse findings, all of which
are important processes in developing coherent theories. Theorists of the future are not individual
workers; they are team participants (Meleis, 1992). There is support for this new generation of
collaborative theorists: for example, the team that proposed the use of simultaneous concept
analysis in the development of concepts started from the assumption of collaboration (Haase,
Britt, Coward, Leidy, and Penn, 1992). Other examples of collaborative theories are the evolving
theory of unpleasant symptoms (Lenz, Suppe, Gift, Pugh, and Milligan, 1995) and the conceptual-
ization of symptom management (University of California, San Francisco, School of Nursing
Symptom Management Faculty Group, 1994).
Intuition is another essential tool that has been discussed in the nursing literature. Intuition is
defined as reaching some decision or conclusion without the conscious or apparent availability of
information (Rew, 1986; Westcott, 1968). Rew (1986) defines the attributes of intuition as:
“Knowledge of a fact or truth, as a whole; immediate possession of knowledge; and knowledge
independent of the linear reasoning process” (p. 23). Whether this tool is intuition or the expert
speaking (Benner, 1984), recent writings encourage allowing that inner voice to surface, believing
in it, and trusting it (Agan, 1987; Rew, 1986; Rew and Barrow, 1987); others argue that intuition is
grounded in cognitive science and psychology and could be tested through a combination of soft
and hard methods (Gobet and Chassy, 2008).
Closely related to intuition are introspection and reflection. Silva (1977) reminded us “to
value truths arrived at by intuition and introspection as much as those arrived at by scientific
experimentation” (p. 62). Reflection is a process of thinking that may or may not be bound by the
need for problem solving.
MIDDLE-RANGE THEORIES
The integrative processes for theory development and the tools described above are the corner-
stones for developing middle-range theories. Several books have been written to present and
describe middle-range theories. Among these analyses are those edited by Smith and Liehr (2003)
and Peterson and Bredow (2009). In the book by Smith and Liehr (2003), the middle-range theo-
ries of uncertainty in illness, self-efficacy, unpleasant symptoms, family stress and adaptation,
community empowerment, meaning, and self-transcendence are presented and discussed. Peterson
and Bredow’s (2009) intent is to apply these theories to nursing research, and they categorize the
middle-range theories in terms of their origin and emphasis. Therefore, they use the broad cate-
gories of physiological, cognitive, emotional, and social integrative to discuss the most widely
used middle-range theories. Under the physiological framework, they present and analyze two
theories of pain: a balance between analgesia and side effects, and unpleasant symptoms. Under
the cognitive framework they focus on self-efficacy, and reasoned action and planned behavior.
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CHAPTER 17 Middle-Range and Situation-Specific Theories 411
Within the emotional framework, empathy and chronic sorrow are discussed. Under the social
framework, they discuss social support and interpersonal relations. And finally, they create an inte-
grative category under which they include modeling and role modeling, comfort, health-related
quality of life, health promotion, deliberative nursing process, planned change, and resilience
(Peterson and Bredow, 2009). Although the potential exists for different classifications that could
prompt different approaches to advancing knowledge and, therefore, yield different outcomes,
there is a clear indication that our discipline has undergone a turning point toward producing more
accessible and functional theories that guide productive research programs, as well as providing
theory- and research-based evidence to nursing practice. These middle-range theories also support
the notion that the discipline of nursing’s mission, goals, and focus have been defined and that we
are ready for more specific questions about nursing care. The majority of middle-range theories
describe and provide frameworks to deal with clients’ experiences of symptoms, and they provide
the means to understand responses to health and illness situations. The language of these middle-
range theories is that used in nursing practice to deal with patient care phenomena such as pain,
unpleasant symptoms, empathy, uncertainty, comfort, change, lifestyle, health promotion, relation-
ship, and deliberative planning for care. This language reflects the early theorists’ attempts to move
the discipline away from adopting biomedical language that focuses on disease, pathology, and
malfunctioning and to focus on individuals’ responses and experiences within the context of health,
illness, and encounters with the health care system.
Definition of Middle-Range Theory
Middle-range theory is defined as the coherent articulation of a set of concepts that describe
and explain relationships that are related to a particular phenomenon. Middle-range theories are
less abstract than grand theories, are more accessible to researchers and clinicians, but reside at a
higher level of abstraction than do empirical findings, and they contain propositions that reflect
generalizations that go beyond specific clinical case studies. Middle-range theories were defined
by their inventor, the sociologist Merton, in 1968, as lying in the middle—between the hunches
developed in a practice situation and the highly abstract, all-encompassing theory. Middle-range
theories deal with more specific phenomena (Meleis, 1997); they usually have a limited number of
concepts and propositions (Fawcett, 2005), they are more operationable and amenable to testing
(Walker and Avant, 2005), they avail themselves more to empirical work (Meleis, 1997), and they
provide a limited view of reality (Smith and Liehr, 2003) (Table 17-1).
Process for Developing Middle-Range Theories
Developing theories is a dynamic process, not based on static steps or strategies. It is driven
by different sources, and although it starts at many different points, it always ends with a middle-
range theory. While it must start by selecting a particular area of knowledge, either from a spe-
cific clinical question or from a research finding, the selection process may be a deliberate one or
it may be the result of serendipity. In any case, a critical assessment of the rationale for selection
is an essential component of the development process. However, I must emphasize that the
process for developing theories is not a linear one, nor does it ever follow any one specific path.
The components should be viewed as parts of a segmented puzzle; the full picture becomes man-
ifest when all the pieces of the puzzle are put together. The different pieces of the puzzle may fit
together at a different pace and not in any systematic fashion. The theory emerges slowly, just as
a very complex puzzle takes shape in slow motion, with different shapes manifesting themselves
as several pieces come together to form a recognizable whole. At a certain point when putting a
puzzle together, several pieces fit together and a shape begins to emerge faster than expected,
then a slow period ensues. Building a theory is also a very dynamic process. Just as shapes and
images in a puzzle may project one image midway, the end image may be completely different.
The process for developing a middle-range theory is depicted in Box 17-1. The example dis-
cussed here is the development of the concept of transition into a middle-range theory (Meleis,
2010).
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412 PART FIVE Our Theoretical Future
In the same way that an emerging shape takes form in a puzzle, different team members
develop different parts of the theory at different times in its development. Although the journey, as
presented here, may make the process of development appear linear and systematic, it is not.
Questions that I asked in the 1960s led to the development of a conceptual framework–based
intervention that I called Role Supplementation. After testing the intervention empirically, I ques-
tioned whether we knew which patient responses may have necessitated such an intervention, and
with my colleagues, I began a more systematic approach to developing the experience and out-
comes of transitions. We then moved on to a full circle of theory-based intervention.
In the following sections, I reconstruct the components of the theoretical journey that led to
developing the middle-range theory of transitions (Meleis, 2010).
Clinical Observations
First, the theorist (who may or may not perceive him- or herself as a theorist) asks questions
about a particular client or a situation. For the theory of transitions, the impetus was triggered by
clinical observations. It was the experience of people and their responses to changes in their
lives—specifically, becoming new mothers—that attracted my intellectual curiosity. My interest
was triggered by how nurses facilitate individuals’ acquisition of new roles to support healthy
lifestyles and diminish the potential for becoming ill in patients facing changes in their lives. In
addition, in a world where people are in constant movement and change, and one in which indi-
viduals are constantly learning to cope with short- and long-term changes, the human experiences
and responses during transition become central to nursing interests. Assisting individuals and
communities in dealing with transitions that affect their health emerged as a challenge for nurses,
both before a change occurs, as well as during and after the change.
Developing theories is a long, laborious process. My interest in transitions dates back to the
mid-1960s, when many support groups evolved to help people deal with a variety of problems.
Support groups were initiated by nurses or lay people to help clients deal with the demands of new
parenting responsibilities, with loss of family members, or with understanding a devastating diag-
nosis of mastectomy, as well as with anything in a person’s life that was deemed out of the ordi-
nary. As Ph.D. students and new graduates, we found ourselves practicing what was preached, and
we asked questions, such as: “What are some common threads among all these groups?” We
became aware of the need to consider the presence of some universal features in creating and con-
ducting these groups and in their outcomes. I guess this awareness and the need to find some order
in seemingly unrelated events was also driven by a growing interest in theory, and in theorizing
about nursing.
This awareness was also nurtured by an interest in the phenomena that surrounded planning
pregnancies, in the processes involved in caring for spouses with long-term illness, and in the
BOX 17-1 THE PROCESS OF DEVELOPING A MIDDLE-RANGE THEORY
• Clinical observations of different groups to whom nurses were providing care, and facilitation of
developing new roles for patients and significant others.
• Identifying similarities and differences in groups and in nursing care provided.
• Developing a conceptually based nursing intervention.
• Testing the intervention clinically and through a series of research studies.
• Integrating the research findings, and finding commonalities and themes.
• Asking the next set of questions to reveal any lack of knowledge about the concept.
• A thorough review of research and clinical publications in nursing about the concept.
• An analysis of commonalities and differences in the literature, and an identification of concepts
depicting the nature of questions about theory.
• Communicating and reporting theory at different stages.
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CHAPTER 17 Middle-Range and Situation-Specific Theories 413
experiences of becoming a new parent and mastering parenting roles, which were the subjects of
my master’s and Ph.D. dissertation researches. I studied the process of decision making in family
planning and discovered the significance of spousal communication and interaction in effective or
ineffective planning of the number of children in families (Meleis, 1971). Although there were
minimal data and interest at the time in the processes of and responses to changes, my colleague
and I assumed that the knowledge needed was not about transitions, but rather about how nurses
can make a difference in helping people achieve healthy outcomes after their transitions (Meleis
and Swendsen, 1978). We focused on nurses’ actions, on developing interventions, and on defin-
ing outcomes. In doing so, we were influenced by the context of justifying nursing actions to
demonstrate that these actions make a difference in patients’ outcomes.
Preliminary Research
Therefore, my next research questions were about what happens to people who do not make
healthy transitions, and what nursing interventions nurses use to facilitate their clients’ healthy
transitions. The theoretical background of symbolic interactionism led to a focus on the symbolic
world that shapes those interactions and responses that get organized into coherent sets of roles.
We began observing people in transition with lenses that could organize and order these observa-
tions in terms of the roles enacted by both the actors and reactors. When people are not able to
understand and enact particular new roles, they experience deficiencies. Roles, from a symbolic
interactionist perspective, are defined in terms of behaviors, sentiments, and goals (Turner, 1962).
That is where our clinical observations of health-oriented groups came in. So, first, we defined
unhealthy or ineffective transitions as leading to role insufficiency, and we defined role insuffi-
ciency as any difficulty in the cognizance and/or performance of a role or of the sentiments and
goals associated with the role behavior as perceived by the self or by significant others. Role
insufficiency is characterized by behaviors and sentiments affiliated with the perception of dispar-
ity in fulfilling role obligations or expectations (Meleis, 1975).
Defining Concepts
In developing the middle-range theory of nursing intellectual capital, so that we could under-
stand the relationship between organizational members’ (in one case, nurses) knowledge, skills,
and experiences on organizational outcomes, it was necessary to define and differentiate between
the key concepts of human, social, structural, and relational capital and potential patient outcomes
(Covell, 2008). Similarly, in our work on developing transitions, we defined the goal of healthy
transitions as a mastery of the behaviors, sentiments, cues, and symbols associated with new roles
and identities and nonproblematic transitions. Although the nature of transitions and the nature of
responses to different transitions were still a mystery, this was not a mystery we felt compelled to
uncover. We believed that knowledge development in nursing should be geared toward the develop-
ment of nursing therapeutics and not toward understanding the phenomena related to responses to
health and illness situations. In retrospect, we think that it is this belief in the need for developing
nursing therapeutics and in finding out what difference nursing makes that may have been the driv-
ing force toward our development of role supplementation as a nursing therapeutic and for the
research that occupied us during all of the 1970s (Meleis, 1975, Meleis and Swendsen, 1978). The
reader should note how a particular philosophy on theory shapes how a phenomenon is defined and
the nature of questions asked.
Research Program
Subsequently, role supplementation as a nursing therapeutic was used in a number of
research projects. The major questions in each research project sought to further define the com-
ponents, processes, and strategies related to role supplementation, and to answer the question of
whether it made a difference in helping patients complete a healthy transition. At that time, I
defined health as mastery, and in different research projects mastery was tested through such
proxy outcome variables as “fewer symptoms,” “perceived well-being,” and/or “ability to assume
new roles.” Role supplementation was used to help couples assume the new role of parenting
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414 PART FIVE Our Theoretical Future
(Meleis and Swendsen, 1978) and to help postmyocardial infarction patients develop an at-risk
identity, which led to better compliance with a rehabilitation regimen (Dracup, Meleis, Baker, and
Edlefsen, 1984). It was also used to describe how the elderly maintained their sexuality (Kass and
Rousseau, 1983) and how parental caregiving roles are acquired effectively (Brackley, 1992).
Similarly, it was used to ease the caregivers’ roles for Alzheimer’s patients (Kelly and Lakin,
1988). The framework was also used to better describe women who were not successful in becom-
ing mothers and who manifested role insufficiency (Gaffney, 1992). Having a coherent framework
helped articulate new research questions and provided a reservoir for accumulating the answers
and refining the framework. The results demonstrated that nurses’ actions tended to anticipate,
facilitate, and enhance transitions and healthy outcomes. Having research programs that continue
the development of middle-range theories may require the development of new or the refinement
of existing research instruments (Räsänen, Backman, and Kyngäs, 2007). By articulating a coher-
ent theory, researchers can continue to refine it through research conducted in other countries.
Clinical Observations Post Research Findings
Once again, it was time to go back for clinical observations. The growing interest in the disci-
pline to uncover the lived experiences of people in health and illness prompted the need for more
clinical immersion. Dr. Norma Chick of Massey University, Palmerston North, New Zealand,
came to work with me during her sabbatical and agreed to collaborate with me in further developing
the phenomena of how people respond to change. We both observed people undergoing changes
due to immigration, and due to critical and intensive care. In 1985, we completed and published
the results of our findings in an article that we entitled, “Transitions: A Nursing Concern” (Chick
and Meleis, 1986). During this phase, “transition” was defined conceptually and was connected to
the discipline of nursing. I believe that the result of our analysis positioned transition as a central
concept in nursing thought. After developing a conceptualization of a phenomenon, a periodic
determination of research and theory gaps may require revisiting care situations. In fact, clinical
observations and periodic immersion in clinical situations are vital to the process of developing
theories in a human science. This periodic revisiting of caring episodes is one of the hallmarks of
an integrative strategy to developing middle-range theories. Theories identify gaps in the science
of self-management of chronic health problems through knowledge gained from concrete experi-
ences (Reed, 2006). Ryan and Sawin (2009) developed an individual and family self-management
theory to describe and predict quality of life, perceived well-being, and cost. They point out that
interventions that are both person- and family-centered must address the context of care by fostering
structural conditions or the self-management process itself by enhancing knowledge, beliefs, and
self-regulatory behaviors. The need to focus on families is driven by actually working in clinical
situations and recognizing that the management of chronic health conditions is both influenced by
family and acts to affect families. The authors identified gaps in research and previous conceptual-
izations that led to a new, more comprehensive middle-range theory.
Integrative Literature Review
Flight nurses have existed since flying became a mode of transportation. The properties of
the experiences and actions of those nurses who are involved in the safe care of people in flight are
similar in some ways and different in others from those of nurses who care for patients in hospitals
or communities. To develop a coherent understanding of these properties, actions, and responses,
Reimer and Moore (2010) conducted an extensive review of the literature spanning about five
decades. They then developed nine concepts and five propositions that formed the middle-range
theory of flight nurses’ expertise, skills, knowledge, and subsequent actions.
A vital component in the process of developing a middle-range theory is extensive, compre-
hensive, and integrative literature review to define concepts or identify the existing evidence.
Extensive literature searches should be conducted at different critical points in developing a middle-
range theory. In continuing the dynamic and integrative strategies to develop transitions, 10 years
marked a critical point to revisit the literature in a more systematic way, and to integrate and
analyze it. With Dr. Karen Schumacher, then a doctoral student at the University of California at
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CHAPTER 17 Middle-Range and Situation-Specific Theories 415
San Francisco, I wondered about the extent to which transitions were used as a concept or a
framework in nursing literature. A search of the literature yielded 310 articles that focused on
transitions. We then analyzed these articles and identified more support for transitions as a central
concept in nursing (Schumacher and Meleis, 1994).
During this part of theory development, clinical observations and findings from the literature
are integrated. Literature reviews are also used to refine, support, or refute previous formulations.
The review and analysis of the literature on transitions (Schumacher and Meleis, 1994) reaffirmed
what we previously conceptualized; however, it also provided evidence to refine earlier conceptu-
alizations. Instead of only three types of transitions: developmental, situational, and health–illness
(Chick and Meleis, 1986), a fourth type of transition emerged. This new type of transition
received much attention in the literature—we called it “organizational transition.” Organizational
transition was another type of transition explored by nurses, and it also represented an environ-
mental transition. All the results of the literature analysis and interpretation indicated that transi-
tion is an area that requires more systematic, scholarly attention in the discipline of nursing.
Reviewing literature should not be confined to nursing literature. In developing and explicat-
ing transition, certain authors emerged as important to our continuous development of the theory
of transitions. Bridges (1980, 1991), the guru of transitions and author of two significant books
(Making Sense of Life’s Changes: Transitions, and Managing Transitions: Making the Most of
Changes), described three phases of going through transitions. These are an ending phase, charac-
terized by disenchantment; a neutral phase, characterized by disintegration and disequilibrium;
and a beginning phase, characterized by anticipations and taking on new roles. Each one of these
phases requires different coping strategies and congruent nursing therapeutics. His work affirmed
the significance and universality of transitional experiences and responses, and provided the impe-
tus to continue in our journey to further clarify and develop transition, conceptually as well as
empirically.
We then asked the question, “What happens to people during transitions?” We began answer-
ing this question through clinical observations, literature reviews, and research findings. Coping
with transitions is a dynamic process that includes different processes, some of which are cre-
atively constructed, such as those attached to caregivers’ role acquisitions (Schumacher, 1995).
Critical Reviews Through Dialogues
Having established the significance of transitions to nursing, and having demonstrated the
extent to which nurses participate in patients’ transitions, we were led to extensive dialogues
with many colleagues. This is another important component in the process of developing theo-
ries. The question presented in these dialogues was: “What nursing therapeutics could be used to
enhance healthy outcomes in individuals who are experiencing a transition?” Most of the care
that nurses provide happens during individuals’ transitions, and the goal of nursing care is to
enhance healthy outcomes. Therefore, we defined the mission of nursing within a framework of
transition. Developing the concept of transition and supporting its significance through review
and analysis of literature related to transition led us to define nursing as the art and science of
facilitating the transition of a population’s health and well-being. Nursing is also defined as
“being concerned with the processes and the experiences of human beings undergoing transitions
where health and perceived well-being is the outcome” (Meleis and Trangenstein, 1994, p. 257).
Within this definition, areas for knowledge development that have some universality and that
could support a more systematic effort in knowledge development were identified. Examples are
knowledge related to the processes and experiences of human beings undergoing transitions, the
nature of emerging life patterns that result from transitions, the nature of environments that sup-
port or constrain healthy transitions, and the nature of nursing therapeutics that could be used to
prevent unhealthy transitions, to augment healthy transitions, or to promote wellness during tran-
sitions (Meleis, 1993).
The cycle of theory development is informed by practice, the literature, and research, and it
subsequently leads to further identification of more integrated and coherent areas of investigation.
Strategies used during the cycle for theory development are clinical observations, literature
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416 PART FIVE Our Theoretical Future
reviews, critical thinking, analytical dialogue, questioning, empirical testing, describing, searching
for and articulating exemplars, and communicating the results. In the following section, I provide
research exemplars for utilizing transitions. These exemplars led to further development of transi-
tions as a middle-range theory.
Researching Again
Once again, it is time to ask specific research questions. The transitions framework, as con-
ceptualized in the analyses I have provided thus far, was then used as a conceptual framework in a
number of studies. It has been used as a framework for transition in the elderly (Schumacher,
Jones, and Meleis, 2010), and to describe immigrants’ transitions (Meleis, Dallafar, and Lipson,
1998), the experience of women living with rheumatoid arthritis (Shaul, 1995), the process of
recovery from cardiac surgery (Shih, 1995), the process of developing family caregiving roles for
patients in chemotherapy (Schumacher, 1995), the experience of early memory loss for patients in
Sweden (Robinson, Ekman, Meleis, Wahlund, and Winbald, 1997), and the experience of African
American women’s transitions to motherhood (Sawyer, 1999).
I asked some of the authors of these studies to describe in their own words how they used
transitions as a framework. Here is how Karen Schumacher described her interest in transitions
and how transitions shaped her work:
As a doctoral student, I conceptualized the process of taking on the caregiving role as a transi-
tion, specifically as a transition that involved the acquisition of a new role. Using the nursing
and social psychology literature on transitions, I developed a model of caregiver role acquisi-
tion. In this model, caregiver role acquisition is conceptualized as a role transition that
involves creative role-making through interaction with the role partner (the care receiver)
within a particular social structural context. The model emphasizes the interactional processes
that occur in taking on the family caregiving role. The model was published in Scholarly
Inquiry for Nursing Practice in an article entitled “Family Caregiver Role Acquisition: Role-
Making Through Situated Interaction.”
In the dissertation, I also identified critical periods in the cancer experience in which care-
givers and patients had difficulty in managing cancer-related care. These critical periods were
times of disruption and disconnectedness, in which both emotional stress and uncertainty
about what to do occurred. Four critical periods were identified: the diagnostic period, the
side-effect intensive period in the chemotherapy cycle, the junctures between treatment
modalities, and the end of treatment. An interesting finding was that access to nurses was lim-
ited or nonexistent during these critical periods. The support and continuity of care that are
nursing ideals do not appear to be made available to patients and caregivers at critical periods
in the cancer experience. The findings raise questions about what nursing care organized from
a transitions perspective, rather than in relation to medical treatment, might be like.
During my postdoctoral fellowship at Oregon Health Sciences University, I turned to skill
development as one aspect of the transition into the caregiving role. Family caregiving skill
has not been systematically conceptualized, although assisting caregivers to develop skill in
taking care of an ill person is a routine part of home care nursing. Nine caregiving processes
were identified (monitoring, interpreting, making decisions, taking action, making adjust-
ments, providing hands-on care, accessing resources, working together with the ill and family
members, and working with health care providers). For each of these processes, indicators of
the caregiver’s level of skill were identified. These indicators will be used as the basis for an
instrument that nurses will be able to use for assessment with family caregivers. The instru-
ment will enable nurses to develop a profile of caregiving skill with their clients, which then
could be used to target interventions. A long-term goal is to develop an instrument with which
to measure family caregiving skill in research. Such an instrument would make it possible to
measure changes in family caregiving skills during transitions in the caregiving experience.
It could also be used to measure the effect of nursing interventions. (Schumacher, personal
communication, 10/18/96)
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CHAPTER 17 Middle-Range and Situation-Specific Theories 417
Petra Robinson is another graduate student who worked with me on the analysis of data from
patients with early memory loss. It became apparent to us that realizing and coming to grips with
memory loss is a long process that includes stages, in-between stages, and periods of spillover and
overlap. The major experience could be captured in the category of “suffering in silence.” While
they suffer in silence, people losing their memory go through stages for which they develop different
strategies. These we called “forgetfulness,” “something is wrong,” and “in search of meaning.”
These stages occur before patients receive care congruent with their needs. During the stage of
forgetfulness, individuals try their best to normalize their experience, gloss over it, and not take it
seriously, but they suffer from it nevertheless. They watch and analyze as soon as they become
aware that something is wrong. Finally, they use the strategy of avoidance and vigilance as they
search for a meaning. Their experience is characterized by solitary suffering, and we believed that,
by uncovering that suffering, we could support the strategies they use, share in their suffering, and
enhance their resources until a definite diagnosis is made (Robinson, Ekman, Meleis, Wahlund,
and Winbald, 1997).
The process of developing mothering in African American women was described by Sawyer as
getting diagnosed with pregnancy, getting ready, dealing with reality, settling in, dreaming, and end-
ing up becoming an engaged mother (Sawyer, 1996). She defined engaged mothering as “an active,
involved, and mutual process in which a woman is preparing to be a mother, caring for herself and
her infant, and dreaming about and planning for the future” (Sawyer, 1996, p. 73). Sawyer found that
the identity women develop of being a mother was reflected by being engaged on many levels:
[E]ngaged with baby, partner, parent, family, friends, coworkers, and the general community;
engaged with their care during pregnancy; engaged in sorting through information and advice
and choosing a role model; engaged in dealing with the daily hassles they faced in society;
engaged in handling problems during the pregnancy and after the baby was born; engaged in
figuring out the baby and adapting to changes in their lives; and engaged in planning for and
dreaming about a ‘good life’ for their child and family. Motherhood is incorporated into the
women’s sense of self and is a synthesis of motherhood into the woman’s identity rather than
merely the attainment or addition of a role. Engaged mothering is dynamic and interactive and
embedded within the context of the woman’s family, history, life experiences and dreams.
(Sawyer, 1996, pp. 73–74).
Understanding women’s roles and how they mother their babies, which is part of nursing’s
mission, cannot be understood without understanding the process that women go through to
develop this mothering identity. Nursing actions to support the process are more effective when
they are matched to the different stages and critical points in the process.
Here, Linda Sawyer (personal communication, 1996) describes how she used transition to
guide her study and interpretations:
In this study on African American women, transitions theory provided a framework which
allowed motherhood to be studied as a complex, longitudinal, and multidimensional process,
focused on patterns of response over time. Common themes in the definition of transitions are
disruption, disconnectedness, and emotional upheaval—certainly themes common to expec-
tant and new mothers. Compared to all transitions, which are of interest to nursing, the transi-
tion to motherhood has received the most attention in the nursing literature. Maternal role
attainment (MRA) is the construct used in nursing to describe the transition to motherhood.
MRA has focused on the dyad of mother and child, on motherhood as a role, has not
described the meaning of motherhood, has been studied through quantitative methods using
multiple tools, and has not been tested cross culturally. Since the construct of MRA has not
been studied cross culturally, this theory cannot be generalized to all mothers, and the cultural
equivalence of this construct needs testing.
This grounded theory study described the transition to motherhood for a group of African
American women as a longitudinal process which spanned the time period between the
woman’s decision to get pregnant or to continue a pregnancy and the time when mothering
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418 PART FIVE Our Theoretical Future
was incorporated into her identity. For some women, the transition was planned and hoped
for, and for others it occurred earlier than planned but was still welcome. In this study, women
exhibited success in the transition through their active involvement in preparing, caring, and
dreaming. Women developed a sense of comfort in caring for their child, sought out sources
of support and connection within their families and the community, and planned for and
actively pursued their dreams and vision for a good future for themselves and their child.
Conditions for transitions usually include meanings, expectations, level of knowledge and
skill, the environment, level of planning, and emotional and physical well-being. Women
described their meaning of becoming a mother, which evolved out of their experiences and
dreams. Expectations were formed from hearing other women talk about their experiences
and observing other mothers, reading or watching videos, and by fantasy. The level of knowl-
edge was high among this group of women because of their active involvement in preparing
during pregnancy through classes, written materials, role models, questioning, obtaining
advice, and seeking formal prenatal care. Mothering skills were developed through figuring
out the baby, “maternal instinct,” and for some women, through previous experience in caring
for children. The environment for this group of women increased their stress during preg-
nancy. Women were faced with and dealt with incidents of racism, stereotyping, and negativ-
ity frequently in their daily lives. The environment mediated the transition through both
providing support and increasing stress. The level of planning, illustrated by the condition of
intentionality of the pregnancy, affected the transition, since women who were actively trying
to get pregnant proceed through the transition easier. A second condition of prior miscarriage
or history of health problems of the mother diminished the woman’s sense of both emotional
and physical well-being and was an inhibitor of the transition.
Several critical points in this transition may require nursing intervention. Early in the prena-
tal period, an assessment needs to occur regarding the woman’s history of prior miscarriage or
health problems and the intentionality of the pregnancy. Worries will need to be solicited and
appropriate reassurance and support provided. Nursing interventions may not be successful if
offered before the woman has passed the critical point—i.e., after the time the previous mis-
carriage occurred. Additional options to prepare for motherhood may need to be utilized for
women with a history of previous problems, since this group of women was less likely to
attend traditional classes. Special care or additional support may also need to be provided for
the women with prior problems. Nurses need to ensure that care is provided in a culturally
congruent manner and be sure that African American women receive information about the
progress of the pregnancy and the size and condition of the baby at each visit. Labor and
delivery is a particularly stressful time, and nurses need to intervene to ensure that mothers
receive support and that their birth plans are respected as much as possible. After the baby
was born, women had many questions and a need for reassurance. This is a time when nursing
interventions are welcome and heeded. Nursing support from a consistent person with whom
the woman is comfortable is important to assist new mothers in settling-in until they gain con-
fidence in making decisions regarding the care of the baby, usually at four months postpartum.
Shaul (1995) found in her doctoral dissertation research that women with rheumatoid arthritis
(RA) went through three stages before settling into the business of caring for themselves. The first
stage is becoming aware, when the symptoms are nagging but are still ignored. The second stage
is learning to live with RA. During this stage, women felt alienated from their environment while
trying to cope with the many symptoms they experience, such as fatigue, stiffness, depression, and
swelling. During stage three, they master the new knowledge and know that the condition has its
ups and downs, but they have a sense of control that comes from knowing about the disease and
knowing how to manage their own daily care.
Integrative Findings
The next step in our journey toward developing a middle-range theory for transition was to
analyze the research findings related to transition experiences and responses. Similarities and
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CHAPTER 17 Middle-Range and Situation-Specific Theories 419
differences in utilizing transitions as a framework and in the findings were then compared, con-
trasted, and integrated. Extensive reading, reviewing, and dialoguing about each research study and
finding led to the final stage of developing transition as a middle-range theory, complete with com-
ponents, conditions, responses, outcomes, and nursing therapeutics. One of the nursing therapeutics
thus identified is role supplementation, which was the very early impetus for finding a coherent way
to facilitate clients’ transitions and enhance their mastery of their roles and health in a new situation.
The middle-range theory was then articulated and published (Meleis, Sawyer, Im, Schumacher, and
Messias, 2000). By communicating the theory in literature and exposing it for critique and utiliza-
tion, other researchers and clinicians can complete the cycle of theory development.
Summary of Process
The process we used to develop transition as a middle-range theory is depicted in Box 17-1.
The impetus for this process was triggered by clinical observations. Generalizations about these
observations were articulated in a more coherent whole within a conceptual framework. The concep-
tual framework evolved from a “lens” that was colored by symbolic interactionism as a philosophy
and role theory as a theoretical framework. Empirical research, as well as clinical observations,
drove the development of a more modified conceptual framework. Extensive review of the literature
helped build on previous conceptualization by refining, extending, modifying, and developing a
more nuanced framework. Clinical exemplars illustrated the rationale for the changes. Several
empirical research studies used the most recent conceptualizations. Critical analyses of the findings,
dialogue about the researchers’ experiences with the framework, and reframing of the findings in
comparison to other findings led to a more refined middle-range theory. Concepts then were defined
using the most recent findings, with exemplars provided from the completed research. Box 17-1
summarizes this process, which ends with communication and reporting of the middle-range theory.
SITUATION-SPECIFIC THEORIES
The discipline of nursing is at a level of maturity that allows theorists to develop theories that are
more congruent with the nature of nursing, the diversity of nursing clients, the complexity of expe-
riences, the responses of human beings in the face of illness situations or calamities, and the
dynamic nature of environments. These theories answer more specific questions and provide
frameworks that are more accessible to researchers and clinicians. The future of the discipline lies
in situation-specific theories. Therefore, the next level in developing theories is developing concep-
tualizations that are closer to the clinical realities of caring for clients, as well as reflective of varia-
tions in the contexts and situations of populations. A number of concepts were attached to lower
abstract theories. Merton may have called them single-domain theories or microtheories if he chose
to write about theories that are at a lower level of abstraction than middle-range theories (Merton,
1968). In nursing, these are called practice theories (Jacox, 1974). The practice theory’s point of
departure is practice, and the goal of a practice theory is to affect practice. Situation-specific theo-
ries are theories that may be developed from other theories, from research findings, and/or from
practice (Meleis, 1997). They are differentiated from grand and middle-range theories by level of
abstraction, degree of specificity, scope of context, level of accessibility to clinical practice and
research findings, extent of reflection of population diversity, and by the extent to which they limit
or claim generalizability (Table 17-1). Im and Meleis (1999a) provided a useful comparison
between the grand theories of Peplau, Henderson, Hall, Johnson, Abdellah, King, and Wiedenbach,
the middle-range theories of Hagerty et al., and situation-specific theories of Braden, Im, and
Meleis, and Hall, et al. (Meleis and Im, 2000; Im and Meleis, 1999b). Im (2006) continued to
develop the integrated strategy and to use in it developing several situation-specific theories.
Definition of Situation-Specific Theories
Situation-specific theories are coherent representations and descriptions of a set of concepts,
an explanation of the relations between those concepts, and a prediction of outcomes related to
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420 PART FIVE Our Theoretical Future
these relationships. The representation is grounded in clinical, teaching, policy, or administrative
situations. It is focused on a specific set of phenomena, more subscribed situations, and has a lim-
ited set of conditions. Situation-specific theories are less abstract than middle-range theories and
are limited in the number of concepts described, in the range of explanations offered, in the scope
of research propositions they drive, and in the outcomes claimed. These limitations are not a
reflection of the significance of the potential contributions to the science that may be generated,
but rather are a reflection of the depth of explanation that such theories offer the user for a partic-
ular, specific area or field of concern. Depth and richness also emanate from the consideration of
such significant contextual conditions that are thought to be vital for the explanatory power of a
situation-specific theory, and that may otherwise be perceived as noise and deviation in a middle-
range theory. A consideration of the marginalization of clients due to racism is required when
developing a situation-specific theory on pain experience and management, but is less vital in a
middle-range theory about pain experience and management. Situation-specific theories are more
tolerant of multiple truths and more congruent of an increasingly integrative theory of truth, as
presented in Chapter 8.
Sources and Properties of Situation-Specific Theories
The sources of situation-specific theories are multiple. Whether the impetus is research, prac-
tice, or theory, the integration of all sources is the hallmark of these theories. The context and the
population tend to be the criteria for the development of such theories; generalizations tend to be
limited, and a specific time in history may be integral to developing situation-specific theories. Im
(2005) goes even further in suggesting that the integrated approach to theory development pro-
posed by Meleis (1997) is the strategy of choice when developing situation-specific theory. In the
21st century, the integrated approach described in this chapter is the strategy of choice for both
middle-range and situation-specific situations. However, it is imperative to include the history of
the clinical situation, the involvement and engagement of the theorist, a clear nursing perspective,
a holistic dynamic, the changing framework, and the phenomenon (described and explained
through the interaction of health–illness events, personal environment, relationships, and human
response), as well as the context in a situation-specific circumstance. As described in this chapter,
the integrative strategy also includes research findings and other data from clinical experiences or
other theories. This integrated strategy contrasts with practice-to-theory strategy, research-to-the-
ory strategy, and theory-to-theory strategy. It combines the best of all in an integrative way. Im
(2005) is explicit in including the criteria of “multiple truths” as an essential assumption for using
the integrated approach to developing situation-specific theories.
Process for Developing Situation-Specific Theories
Grounding in Nursing Domain and Perspectives
In developing a situation-specific theory that could enhance nursing science, the theorist
must be grounded in the discipline of nursing, scope of practice, and the discipline’s domain and
perspective, as discussed in Chapter 6 (Im and Meleis, 1999a). Identifying the phenomenon and
the problematics that need to be explicated, as well as the population for which the theory will be
developed, are important aspects to be considered in theory development. Being cognizant of and
driven by the goals and the mission of nursing will require immersion and understanding of the
clinical situation and the conditions for which the theory is developed. In developing a situation-
specific theory on breastfeeding, Nelson (2006) was inspired by clinical observations of the
maternal effort to breastfeed and the limited support these mothers received from their providers.
She became aware that existing theories did not help in achieving the desired outcomes.
Another example is elderly transitions. Although the starting point for this situation-specific
theory was the transition model (Schumacher and Meleis, 1994; Johnson, Morton, and Knox,
1992), the clinical experiences of the authors and their research findings in the literature helped
them develop a more specific model in which healthy and unhealthy processes in elderly transi-
tions were articulated, reflecting the aging situation and the experiences of gains and losses that
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CHAPTER 17 Middle-Range and Situation-Specific Theories 421
occur through the biological, social, and psychological aging processes. The literature reviews,
combined with clinical experiences of working with the elderly experiencing transitions, were
integrated to produce seven healthy processes that could be the triggers for healthy outcomes.
This situation’s specific theory proposes that those elderly who are aware of the transition,
experiences, and responses, and who positively and realistically redefine the meaning of their
transition, modify their expectations of themselves and others, and engage and modify the daily
routines of their lives to become more congruent with new demands in their lives. Similarly, those
who are not only willing, but who actually develop new skills and competencies that are based on
knowledge of the situation, and who maintain some continuity in their lives, go on to also create
new choices, find opportunities for growth, and tend to have a healthier transition outcome. It does
not matter whether the transitions they are experiencing are developmental, situational, or one of
health and illness. The outcome of a healthy transition is the experience of minimal symptoms; these
people tend to have optimal functional status, and they tend to feel connected and to experience a
sense of empowerment and integrity. These outcomes are mediated by the patterns of transition
and are a function of whether the events that triggered the transition are single or multiple occur-
rences, and whether the transitional events are sequential, simultaneously related, or simultane-
ously unrelated. Unhealthy transition processes, in their extremes, are apposite from the healthy
processes, and the process indicators will include compromised functional status and feelings of
disempowerment, in addition to a tendency to experience a variety of symptoms (Schumacher,
Jones, and Meleis, 2010). A coherent approach to elderly care and scholarship was suggested by
utilizing the transitions framework, and immersion in clinical observations shaped this situation-
specific theory.
Selection of a Theory
Study and analysis of middle-range theory is the usual starting point for developing a situation-
specific theory. During such review, it may be determined that the theory does not quite allow a
comprehensive and inclusive explanation of clinical situations for scientists or clinicians. Riegel
and Dickson (2008, 2010) found that no integrated and coherent set of explanations of self-care
existed for patients with heart failure. They identified several concepts that specifically reflect this
population of patients and several propositions that were tested and offered preliminary support for
the theory. Their starting point was self-care theory; they pointed out the existing confusion between
the various self-care concepts, and they opted to further clarify self-care from a number of other
concepts. Several related situation-specific theory examples that emerged from other theories exist
in the literature: Im (2005) describes Falk-Rafael’s (2001) empowered caring, LaCoursiere’s (2001)
online social support, and Poss’ (2001) synthesis of health belief model and theory of reasoned
action as examples of situation-specific theories based on other theories.
Situation-specific theories are usually developed after a middle-range theory is reported in
the literature. By using the middle-range theory of transitions in research studies and practice situ-
ations, it was apparent that more specificity was needed to describe and explain how certain popu-
lations (Korean American women experiencing menopause, and the elderly experience of
transition) experience transition within the context of immigration or within the context of other
types of change (Im and Meleis, 2010; Schumacher, Jones, and Meleis, 2010; Im, 2006). These
contexts shape people’s experiences and their responses to them, and thus require more specific
theories. Dialogue, analysis, critique, identifying exemplars, affirming and/or modifying assump-
tions, defining and redefining concepts, and explaining relationships are processes used in devel-
oping situation-specific theories. Providing a narrower scope for power of explanation by defining
more conditions and contexts limits the utility of the theory for other types of populations, as well
as for other repertoire conditions. Therefore, defining and specifying the population are essential
to the process of developing situation-specific theory.
Specifying Populations Within a Context
Developing a coherent situation-specific theory that drives science and practice requires
detailed specificity about the populations for which the theory is developed. Furthermore, it
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422 PART FIVE Our Theoretical Future
requires attention to, and incorporation of, the sociocultural and historical context to explain the
clinical situation, as well as the conditions that affect care. Additionally, it requires attention to a
particular set of genetic markers that may characterize this population. Many examples illustrate
this population focus.
A situation-specific theory of breastfeeding included a broad contextual history surrounding
breastfeeding and the sociocultural norms that influenced whether women breast- or bottle-feed.
Few would deny the influence of the media, society, and the bottle-feeding industry in influencing
the decisions of women and their families. Therefore, a review of these conditions, as well as
other factors, is vital in developing a theory about women’s choices, options, decisions, and
actions (Nelson, 2006). Another example is the menopausal transition of Korean immigrant
women (Im and Meleis, 2010, pg. 121). Unlike women who are not recent immigrants, Korean
immigrant women tended to pay less attention to menopause and tended not to attribute changes
in their lives to menopause, but rather more to work and the immigration transition. Menopause
was a silent experience for them, either normalized or ignored. In a research study exploring how
new Korean immigrants tended to experience and respond to menopause, the findings indicated a
need for developing a more contextual and specific conceptualization of the menopausal transi-
tion. The research findings by Im (1997) then led to developing a more specific conceptualization
of transition, one that embraced menopause as a transition, the immigration experience, and the
centrality of gender, context, and socioeconomic status, as well as the ability to manage symptoms
(Im and Meleis, 1999b). These concepts then helped to modify the middle-range theory of transi-
tions and made it more specific for the purpose of illuminating the situation and experience of
immigrant women. Such specificity leads to more focused future research questions, as well as to
a different level of understanding (for example, Korean immigrant women’s experiences in the
health care system as they manifest resistance and reluctance to discuss what may be symptoms of
menopause). A diagram depicting the situation-specific theory is presented in Figure 17-1, with
asterisks indicating how specificity to the Korean immigrant women uncovered by research led to
modifications or extensions of the Schumacher and Meleis (1994) model. Within the immigration
transition framework, Clingerman (2007) further modified the transition middle-range theory by
adding the context for migrant farm workers. She sharpened the propositions by considering
immigration documentation, citizenship status, and personal U.S. identity; this led her to consider
a sense of peace as a more congruent outcome for this population.
Using population characteristics as a starting point for the development of situation-specific
theories is another productive approach. Im used her cumulative wisdom from research evidence
about vulnerable women and their health to develop several situation-specific theories to explain
different phenomena and generate propositions for further research. Among them are situation-
specific theories about the cancer pain experience (Im, 2008) and women’s attitudes toward phys-
ical activity (Im, Stuifbergen, and Walker, 2010).
Review of Literature
An integrative review of literature that encompasses the theory, research, and practice
research will illuminate the emerging situation-specific theory throughout the process of develop-
ment. Although Sakraida (2005) did not call her conceptualization of the divorce transition of
midlife women a situation-specific theory, the results of her research program could eventually
lead to a coherent situation-specific theory. She offers an example of an extensive review of
divorce transition literature, the transition for midlife women, and the determinants of outcomes
based on initiators and noninitiators of the divorce.
Developing Situation-Specific Theory
Grounding the theory in a particular population’s responses; completing an analytical, inte-
grative, and well-synthesized review at different points in theory development; and conducting
preliminary studies could lead to the development of a situation-specific theory. (Review the
beginning of this chapter.) This process is well described and applied in the transition of siblings
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CHAPTER 17 Middle-Range and Situation-Specific Theories 423
of children with cancer (Wilkins and Woodgate, 2006), as well as in the transition of Taiwanese
nurse practitioners (Chang, Mu, and Tsay, 2006).
Summary of Process for Developing Situation-Specific Theories
The starting point may be clinical practice or research, but a situation-specific theory must
have another theory as a reference point. That theory most probably is a middle-range theory. As
summarized in Box 17-2 on page 424, specifying the phenomena and the characteristics of the
population are essential in situation-specific theory. Another vital component of this process is
considering the population within the psychological, social, cultural, and political context and
within a historical context. Similarly, the phenomena and the relationships it encompasses must be
described and explained within a context. Assumptions, concepts, relationships, outcomes, and
consequences are driven by these properties and their place in history, community, society, and
culture. Dialogues and critiques inform the process and outcomes of situation-specific theories.
CONCLUSION
The integrative process for theory development and the tools used are described and discussed in
this chapter. The future for advancing nursing knowledge depends on the extent to which we are
Meaning
Expectations
Level of knowledge/skill
Environment
Level of planning
Emotional & physical well-being
Socioeconomic planning
Gender
Context
Attitudes toward health &
illness
Interrelationships among
transition conditions
Transition Conditions
Nursing Therapeutics
Process
Direction
Change in identity
Roles
Relationships
Abilities
Patterns of behavior
Structure
Function
Dynamics
Universal Properties
Developmental
Situational
Health–Illness
Organizational
Types of Transitions
Number,
Seriousness, and
Priorities of
Transitions*
Subjective well-being
Mastery
Well-being of relationships
Effective management of
symptoms*
Indicators of Healthy
Transition
*
*
*
*
*
*Additions to the model of Schumacher and Meleis (1994).
FIGURE 17-1 ◆ Model of a situation-specific theory: The menopausal transition experience
of Korean immigrant women. Reprinted with permission from Im, E.O. and Meleis,
A.I. (1999). Situation-specific theory of Korean immigrant women’s menopausal transition.
Image: Journal of Nursing Scholarship, 31(4), 333–338.
LWBK821_c17_p407-426 07/01/11 6:16 PM Page 423
424 PART FIVE Our Theoretical Future
willing to commit to developing coherent frameworks to drive future research programs and
practice models. The future theoretical development in nursing is in presenting our science in
middle-range and situation-specific theories. I strongly believe that the nature of nursing as a
human science focused on the experiences and responses to health and illness lends itself far bet-
ter to the development and use of situation-specific theories (American Nurses Association,
2003). The use of middle-range theories is a step in the right direction in the journey and moves
our discipline toward a trajectory of more focused situation-specific theories. In this chapter, I
provide the process used to develop theories and give many examples of each component of the
process. In particular, the integrative approach to theory development was used to describe the
journey toward the development of middle-range and situation-specific theories of transition, as
well as in developing other theories.
BOX 17-2 THE PROCESS OF DEVELOPING SITUATION-SPECIFIC THEORIES
• Study middle-range theory.
• Use middle-range theory in research.
• Use middle-range theory in practice.
• Specify the characteristics of a population and the conditions of their experiences.
• Provide and describe a limited scope of experiences for that population.
• Ground assumptions to reflect the population’s experiences and responses.
• Review research and practice literature, redefine assumptions, and redefine concepts.
• Develop a framework with assumptions, concepts, antecedents, outcomes, and propositions.
• Provide clinical and research exemplars.
• Critique the emerging theory through dialogue.
• Communicate the emerging theory through different media.
REFLECTIVE QUESTIONS
1. What are the relationships between
grand theories, middle-range theories,
and situation-specific theories?
2. Should middle-range theories be devel-
oped and tested before developing
situation-specific theories? Why?
3. Compare and contrast a middle-range
and a situation-specific theory. What are
the similarities and differences in the
processes of development, the sources,
and the testing?
4. Select a middle-range theory in your
field and develop a situation-specific the-
ory using the guidelines outlined in this
chapter. How would you refine these
guidelines?
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C H A P T E R 18
Measuring Progress in a Discipline
As scholars continue to advance nursing science, develop knowledge, refine models of care,
answer critical disciplinary questions, and articulate theories, the question becomes: What are
the best ways to measure progress in the discipline? What are the quantitative and qualitative
indicators and metrics to allow members of the discipline to argue that progress has been made?
How do we determine trends or outcomes of growth and advancement in a discipline? How do we
recognize that a knowledge base is growing and that a discipline is progressing? These questions
become more complex as epistemic diversity grows in the discipline, and with the increasing
acceptance of multiple theories of truth and interdisciplinarity. How does this diversity translate
into ways by which to determine progress in a discipline? Within the halls of academia in the west-
ern and northern hemispheres, progress in research is measured by the level of funding that a pro-
gram receives through a competitive process of application. Funding for research programs or
projects in knowledge development have become the standard for determining the level of progress
in a particular area of science and in a specific area of research. In many parts of the world,
progress is measured by the number of accepted publications a particular researcher has amassed
in leading journals (Hofmeyer, Newton, and Scott, 2007). Publications in leading journals denote
the ability to disseminate knowledge, translate research findings, and competitively communicate
advancement in knowledge in the literature. In addition to determining progress through publica-
tions, there has been a growing practice to measure progress through citations of publications and
the level of impact of journals. In most of these gold standards for determining progress, theoreti-
cal progress has been somewhat ignored or minimized. The quest for evidence-based practice also
presumed the dominance of empirics and positivism over many other philosophies and patterns of
knowing. Among those patterns of knowing that may be eclipsed by these gold standards are the
person (knowing through the individual self), esthetic (the art of nursing), and ethics (moral
knowledge), which are essential for understanding and providing quality, comprehensive, person-
based contextual care (Porter, 2010). Others have also argued that another way of knowing is
through reciprocal interdependence, which incorporates different worldviews into a more coher-
ent and comprehensive whole (Pitre and Myrick, 2007). These different ways of knowing call for
different approaches to measuring progress. However, the dominance of empirics would make it
imperative to judge the discipline’s progress through only those gold standards that are driven by
and emanate from the empirics view.
More importantly, knowledge has been deconstructed to reflect research findings, rather than
all aspects of knowledge, which reflect more acceptance of epistemic diversity and that include
interpretation, understanding, and critical questioning of the status quo in quality of care. How is a
discipline’s progress measured within a context that reflects theoretical development and attention to
the inclusion of constituents’ views of such progress and epistemic diversity? Several philosophers
and scientists have studied scientific growth and have advanced many theories to describe patterns of
scientific progress based on retrospective analysis of physical and social science progress. The ques-
tion of how sciences develop, which has occupied philosophers of science, has also become one of
nursing’s significant questions. What processes did nursing go through to achieve its current stage
of development? To answer these questions, nurses have resorted to patterns that have been previ-
ously identified by other disciplines. However, describing growth using patterns that are more
congruent with scientific progress in the physical sciences may not be congruent with patterns that
manifest in a human discipline such as nursing. Using such patterns, then, may become a con-
straint in making progress and may impede further theoretical growth. Tentative answers to these
questions are proposed in this chapter. Three theories are used to describe growth in the discipline.
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428 PART FIVE Our Theoretical Future
Each is presented with exemplars, and each could be used to analyze progress in areas of practice.
The strengths and weaknesses of each theory are presented. I have used these theories to discuss
progress as achieved through the turn of the 21st century. As we go forward, these same theories
could be used to determine progress in dynamic reviews. Let me say at the outset that questions
about advancement, growth and progress in a discipline beg many thoughtful and critical dia-
logues that transcend contemporary and more mainstream views about knowledge development,
acquisition of new knowledge, and cutting-edge discoveries. Dialogues about progress must be made
within the context of patterns of knowing and theories of truth, as discussed in Chapter 8. To help in
this discussion, I tentatively offer thoughts about how to review progress through these three theories.
A THEORY OF REVOLUTION
Thomas S. Kuhn (1970, 1971), a prolific American writer and speaker and a physicist by training,
gave credence to the philosophy of science as a field worthy of exploration and investigation. He
is credited with developing the revolutionary theory of scientific development. Revolution is
defined in Webster’s Third New International Dictionary as “a sudden, radical or complete
change” characterized by “overthrowing” fundamental changes. Kuhn’s theory is congruent with
these sentiments. Sciences, to Kuhn, develop by leaps and bounds only through periods of crisis.
During these crises, theories compete, anomalies are identified, and inadequacies are highlighted.
This period of scientific unrest is followed by a tranquil period that Kuhn calls “normal science,”
in which members of the field unify and accept one theory as a common paradigm.
Kuhn’s central ideas regarding paradigms are as follows:
1. A paradigm is defined as an entire repertoire of beliefs, values, laws, principles, theory
methodologies, ways of application, and instrumentation.
2. A paradigm encompasses substantive theoretical assumptions about the subject matter
of the discipline and methodological strategies, as well as a degree of consensus about
theory methods and techniques.
3. A paradigm includes the questionable areas in the field and some puzzle solutions that
could act as examples to help members of that scientific community solve remaining
normal science problems in the discipline.
4. A discipline matures when it has such a paradigm. Before its paradigmatic stage, how-
ever, fact-finding is haphazard and variable in the processes the discipline uses to answer
questions. This period is characterized as the preparadigmatic stage of the discipline.
The transition from crisis to normal science marks a scientific revolution. Kuhn asserts that
scientific revolutions are inevitable for the development of a science, and these revolutions occur
when earlier paradigms no longer work. This revolutionary process is characterized by sudden
changes, and its cornerstone is competition. Development is not possible without competition, the
result of which is the predominance of one paradigm and the rejection of all others. Members of a
discipline may discard one paradigm and replace it with another competing paradigm because
they find the model of the new paradigm more successful or agree more strongly with it.
Kuhn also believes that scientific development is noncumulative, meaning that a useful
aspect of one theory is not added to another competing theory to render it more useful. Thus, com-
petition between paradigms does not evolve into collaborative paradigms; rather, only one para-
digm prevails. In other words, old paradigms, regardless of their usefulness, are incompatible with
newly conceived paradigms (Kuhn, 1970).
Once a paradigm dominates and a discipline enters “normal science,” competition is halted.
Collaboration, then, replaces competition, and the scientific community prevents any alternative
paradigms from emerging during this period. Even when theoretical or methodological issues
evolve, the scientific community avoids and ignores them, permitting the continuing dominance
of the prevailing paradigm.
Kuhn’s ideas led to a belief that disciplines develop by convergence. Converging on one par-
adigm is then accepted as the goal of disciplines leading to progress. A convergent process is a
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CHAPTER 18 Measuring Progress in a Discipline 429
closed rather than an open process. One may question the notion of a closed converging process to
define science, a process antithetical to the nature of science, which is characterized as being open
to new developments and tolerant of competition.
In his later writing, Kuhn replaced the term paradigm with disciplinary matrix, denoting
the same definition of paradigm but with the addition of shared exemplars (Kuhn, 1970,
pp. 181–210). Because the content boundaries of paradigms are not entirely explicit, but rather
implicit, exemplars are provided to identify problems and solutions in the discipline. They are
models for problems and solutions that scientists accept during the period of normal science
(Table 18-1).
Challenges to Using Kuhn’s Theory to Define Progress
Kuhn’s ideas have been both revered and criticized. Many writers have taken issue with his
admonitions and questioned the capability of his theory to describe and predict the developmental
TABLE 18-1 COMPARISON AMONG THREE PROCESSES OF PROGRESS IN THE
DISCIPLINE: REVOLUTION, EVOLUTION, AND INTEGRATION
Analytical Unit Revolution Evolution Integration
Sentiment Aggression: crises Adaptation Change
Interaction Competition Cumulation Collaboration
Goals Conquering Building Progressing
Overthrowing Developing Understanding
Process Substitution Lower to higher Openness
Elimination Selection Flexibility
Discontinuity Simple to complex Contemporary and traditional
Continuity Innovation
Pattern of development Convergence Mutation Diversion
Slow, long range
Reasoning Adversarial Logical Dialectical
Mode Rejection Acceptance Understanding
Evaluation Criticize to destroy Analyze to construct Dialogue to develop
Environment Critical Restrictive Supportive
Challenge
Options No option during Limited options Open/unlimited options
normal science
Units of analysis Paradigms Merits History
Changes Competitions Pattern
Demands Development of members
Successes Number of unique phenomena
identified
Quality of questions answered
Actualizing relationships
between research, theory, and
practice
Nursing Preparadigmatic Would-be discipline Discipline
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430 PART FIVE Our Theoretical Future
process in the progress of science. More specifically, Kuhn’s notion of the development of scientific
disciplines through crises and scientific revolutions has fostered numerous debates in the field of
philosophy of science. Some have pointed to historical inconsistencies between Kuhn’s analysis
of several of the established scientific disciplines and his generalization about such developments;
these inconsistencies point to the harmonious coexistence between numerous competing para-
digms in disciplines that have progressed despite the multiplicity and competitiveness of para-
digms. This existing truth negates his theory of revolution.
In view of those who have pointed out such inconsistencies, coexistence between competing
paradigms leads to appropriate debates within a given field. Critics point out disciplines that were
established despite having no single guiding framework. Why, Dudley Shapere (1981, p. 58) asks,
should we only have the extremes, the absolute differences in competing paradigms (thus a crisis),
or the absolute identity within one paradigm (thus a revolution) followed by normal science? Is it
not possible to have, at any one point in time, both similarities and differences, both competition
and collaboration?
Larry Laudan also challenged Kuhn’s assertion, proposing that competition is continuous
and that scientific disciplines include a variety of coexisting research traditions (Laudan, 1981,
p. 153). Laudan identified five major flaws in Kuhn’s philosophical view of the development of
scientific discipline (Kuhn, 1977, pp. 74–76). These have implications for nursing.
1. “Kuhn’s failure to see the role of conceptual problems in scientific debates and in para-
digmatic evaluation.” Kuhn appears to be using only a positivistic view of science by
comparing the number of facts a theory can address and the congruence between these
facts in theory and in real life. An empirical view addresses elements in verification and
falsification of theories, but no conceptual coherence, logic, social congruence, or other
significant components of usefulness.
2. “Kuhn never really resolves the crucial question of the relationship between a paradigm
and its constituent theories.” Does a paradigm encompass all theories? Do theories
explain and describe the paradigm, or vice versa? Which gives evidence to the other?
3. The notion of a prevailing paradigm does not allow for the changes and discoveries that
characterize our present science, in which misconceptions are corrected, parts of theories
are justified, and other parts are changed. Scientific discovery is a continuous process;
present tools allow for a fast pace. Kuhn’s theory of scientific development appears to
provide a rigid structure that limits the continuous development of theories and the con-
tinuous correction of the paradigm’s weaknesses, which may become apparent only with
time.
4. Kuhn does not advocate the explicit articulation of paradigms or disciplinary matrices.
Therefore, such implicitness does not account for nursing’s attempt to make the bound-
aries of the discipline explicit or its assumptions debatable. Nor does such implicitness
promote the many controversies that Kuhn considers essential to the development of
science. Scientists can debate explicit matrices but can avoid implicit ones.
5. “Because paradigms are so implicit and can be identified only by pointing to their exem-
plars (basically an archetypal application of a mathematical formulation to an experimen-
tal problem), it follows that whenever two scientists use the same exemplars they are, for
Kuhn, ipso facto committed to the same paradigm” (Laudan, 1981, p. 85). If more scien-
tists work in this way, we come closer to a revolution. In nursing, some nurses have used
the same exemplars even though they held divergent views about the most basic concep-
tual and methodological questions. Helping people cope with transitions is an area pro-
viding exemplars in health–illness transitions, developmental transitions, or situational
transitions. These exemplars have been treated effectively by those who adhere to psy-
choanalytical views, and just as effectively by those adhering to sociocultural views in
nursing. Therefore, the exemplars themselves would not mean commitment to some
paradigm. Commitment to one paradigm over another is apparent only by making
paradigms explicit and not by maintaining implicitness.
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CHAPTER 18 Measuring Progress in a Discipline 431
Finally, Toulmin (1972) identified a sixth flaw apparent in Kuhn’s philosophy:
6. How the transitions from competing paradigms to revolution, to normal science occur is
not clear in Kuhn’s writing. Does a community of scholars hold a mass meeting to
denounce one competing paradigm and adopt another? Considering that, according to
Kuhn, followers of each paradigm are supposedly entrenched in the paradigm they use
and do not always seem to communicate, nor do they always share a common language
or worldview, how could they agree on one rather than another paradigm? Contrary to
Kuhn’s ideas regarding the lack of communication during the crisis period, Toulmin
offers many historical examples of careful communication, debate, discussion, or pro-
posed modification in physics before any minute change was made or any modification
was incorporated into the established body of the discipline (Toulmin, 1972, p. 10).
Revolutionary Theory of Progress and the Discipline of Nursing
Some nursing scholars seem to have accepted Kuhn’s theory of progress and have adhered to
the position that nursing is following the same patterns of revolutionary development as the other
physical sciences analyzed by Kuhn. Nursing progress has thus been measured against the canons
proposed by him (Hardy, 1978). The result has been a negatively critical assessment of nursing
progress and anticipation of a scientific revolution in nursing, in which one paradigm prevails and
is accepted by the nursing community. According to these scholars, nursing is in its preparadig-
matic stage. It is possible that the scientific revolution in nursing may never come, not because
nursing is not progressing, but because there may never be periods of normal science. Other natu-
ral and behavioral science disciplines continue to progress and have competing paradigms to
describe and predict the phenomena of their disciplines. In addition, the notion of having only one
paradigm is not acceptable to sciences, particularly to nursing, which deals with human beings
and complex health–illness situations.
Some nurses have presented a view of nursing as something that has arrived at the beginnings
of a paradigm (Fawcett, 2005; Munhall, 1982; Newman, 1983), or is undergoing a paradigm shift.
The processes depicted, however, do not demonstrate competition, rejection, and dominance as
much as an evolutionary process. Therefore, the appropriateness of using the revolutionary theory
to describe progress and the development of nursing knowledge should continue to be debated,
other theories should be discussed, and analyses of consequences should be carefully considered
(Table 18-1).
A THEORY OF EVOLUTION
A second approach to critically assessing progress in knowledge development is by using an evo-
lutionary lens. Evolution denotes change in a certain direction, unfolding from lower to higher,
from simpler to more complex, and in the direction of greater coherence. It gives the impressions
of continuity and long-term cumulative changes. An evolutionary view of a scientific discipline
combines instances of intellectual innovation complemented by a continuing process of critical
assessment and selection. It acknowledges competition but accepts the inevitability of cumulation
in knowledge development. An evolutionary stance also acknowledges the significance of the
genealogy of ideas in the progress of knowledge.
Toulmin (1972) used Darwin’s evolutionary theory as the basis for a framework to explain
the process of knowledge development. He identified four basic principles for Darwinian theory,
each of which has a counterpart in the evolution of scientific disciplines.
1. Each discipline contains its own body of concepts, areas of concern, methodologies, and
goals, all of which can change drastically but slowly through a mutable process. Never-
theless, a definite continuity can be detected in the major ideas of the discipline. Concep-
tual thoughts in each of the disciplines, while having coherence and continuity, also
manifest slow, long-term changes, with each new conceptual thought based on previous
ideas, and with the more developed concepts superseding older ones.
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432 PART FIVE Our Theoretical Future
2. All ideas, concepts, and methodologies are given a chance to compete, to be discussed,
and to be weeded out. Only those discoveries and innovations that fit will flourish and
survive from one generation to the next. This process of the retention of some conceptual
thoughts, mutation of others, and rejection of still others explains the stability of intellec-
tual thought in disciplines and accounts for transformations into new theories.
3. Marked substantive changes in the field are possible when several conditions exist. One
important condition is qualified people in the discipline who are capable of inventing new
ideas, exploring new problems, and developing new theories. An evolutionary position
presupposes an arena for debate, critique, and competition. Another necessary condition
is sufficient openness in the discipline to allow for new ideas to develop and survive long
enough to prove their suitability or to be refuted.
4. The selection of the more useful ideas, concepts, and theories is based on how well they
meet the demands of the local intellectual environment within the discipline. The selec-
tion process is also based on congruence of the demands, issues, current problem areas,
and innovative ideas that are being offered (Toulmin, 1972, pp. 139–143). Other compet-
ing ideas continue to be adhered to, refined, and further developed.
An evolutionary process of knowledge development contains such units of analysis as merits,
competitions, demands, and successes. When contrasting Darwinian biological evolutionary process
with the Toulmin intellectual evolutionary process, one finds a pattern of development based on sur-
vival of the fittest, innovation, comparison of ideas, and systematic patterns of selection of the best
among competing paradigms. One theory, one set of ideas that may have more explanatory power to
resolve some significant conceptual problem, is generally selected over another theory, however well
established it may have been. The newly adopted theory may incorporate parts of the previous theory
and reject other parts. Therefore, progress in the physical sciences is not revolutionary, according to
Toulmin, but evolutionary. It has taken on a cumulative pattern.
The evolutionary theory of knowledge presupposes agreement within a discipline about the
problem areas of the field and the criteria for truth and explanation. In addition, certain conditions
should exist as indicators that a discipline has developed cumulatively. Freese (1972) identified
the first four conditions, and I have added an additional one:
1. Modification of truth value: Generalizations are cumulative when one generalization
modifies a previous generalization; that is, one generalization causes change to occur to
or from truth, falsity, or indetermination. An empirical confirmation of the second gener-
alization modifies the truth inherent in the first.
2. Modification of antecedent value: Generalizations are cumulative if the empirical verifi-
cation or falsification of a second subsequent generalization modifies the antecedent in
the first generalization. Change of one to the other of the following would fulfill this con-
dition: necessary but not sufficient, sufficient but not necessary, necessary and sufficient,
sufficient with necessity indeterminate, and necessary with sufficiency indeterminate.
3. Premise or derivation in a deductive chain: This applies to cases in which a confirmed
proposition in one theory becomes a premise preceding another proposition in another
theory. Theory is cumulative when the propositions of one theory are based on or help
modify the premises of another theory.
4. Space–time independence: Theories are cumulative when their propositions transcend
geography and time.
5. Practice–research–practice–dependent link: This link presupposes modification of prac-
tice based on theory or research, or vice versa. Accumulation stems from a direct ripple
effect between practice and research.
If we accept these premises for cumulative knowledge, then the physical sciences (using rev-
olutionary criteria) are based on paradigms and (using the evolutionary process) are established
disciplines. The social and behavioral sciences, on the other hand, are classified as being in a
preparadigmatic stage or are, in Toulmin’s terms, “would-be disciplines.” One can readily detect
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CHAPTER 18 Measuring Progress in a Discipline 433
conditions of cumulation in the physical sciences, very little of which exists in the social and
behavioral sciences or, indeed, in nursing (Table 18-1).
Propositions emanating from theoretical nursing do not fit in a deductively tight, logically
interrelated cumulative model. Systematic cumulative development that begins from a common
point and expands upward to become another canon cannot be detected in nursing knowledge. If
cumulation is the unit of analysis for the evolution of disciplines, then nursing scientific develop-
ment is not closely congruent with either a revolutionary or an evolutionary concept. Rather, it has
followed a course that may be considered unsystematic, haphazard, and lacking direction—if we
impose on it the two theories that we have just discussed.
A THEORY OF INTEGRATION
Progress in nursing charted its own path, which could be better described through a theory of inte-
gration. As a discipline and a profession, nursing has many unique features of development and
progress that do not lend themselves to capture through either a revolutionary or an evolutionary
theory of progress. Hence, a theory of integration is proposed here to describe progress in the dis-
cipline of nursing. The rationale is also provided to support the effectiveness of this theory.
It is possible that the development of the discipline of nursing did not follow a strictly revolu-
tionary or evolutionary path. The revolutionary path would deny nursing’s scientific status,
whereas the evolutionary path would presume systematic development, with research based on
theory and theory evolving from research. Several patterns of development characterize the disci-
pline of nursing as it evolved through peaks, valleys, detours, circular paths, retracing of steps, and
series of crises, as well as through an evolutionary process. Therefore, these patterns may support a
more integrative approach to describe its development.
One unique feature of nursing is its theory development. The development of nursing theory
was not based on the research of the discipline, nor did every research project contribute to the
development of theory (Batey, 1977; Fawcett, 1978). Another unique feature of the discipline is
that its competing ideas exist simultaneously and have existed for decades (different research
methodologies; conceptual approaches to care, comfort, and pain). In fact, competing theories are
used even within the same institutions. To be sure, areas of agreement exist: significance of envi-
ronment, focus on health and coping, interest in transitions, and fascination with human responses
to health and illness. Although each of these concepts may be viewed from a different theoretical
background, agreement is growing that these concepts are central to the discipline.
One may argue that the discipline has been in continuous crisis over the origins of its knowl-
edge base for many years (practice, teaching, or administration) and that the agreement now is that
knowledge develops, for the most part, from clinical practice. There also is agreement, however,
that the discipline of nursing incorporates professional practice, research, education, and teaching.
There are also areas of disagreement, such as the nature of the nursing client and methodologies
that are most congruent with the subject matter of nursing and its philosophical stand.
In a discipline that deals with human beings, it is perhaps not feasible for only one theory to
explain, describe, predict, and change all the discipline’s phenomena. For example, medicine uses
the biomedical model, based on the structure and function of biologic systems. It also incorporates
various means for auscultation, palpation, and laboratory tests, all of which are accompanied by
different competing but coexisting theories (Frank, 1957, pp. 356–358).
A case for paradigmatic pluralism has to be made in nursing because there is a need for theo-
ries about people, interactions, illness, health, and nursing interventions. In fact, many different
current theories, although seen by some as competing with each other, address different relation-
ships and focus on different phenomena, thereby actually complementing each other. These theo-
ries evolved from many paradigms (adaptation, system, and interactionist, among others). Nursing
deals with human behavior, and human behavior could not be explained through a single, com-
pletely general and comprehensive theory. In fact, the desire for a single, all-embracing “scientific
psychology” may itself prove to be a “will-o’-the-wisp.” Certainly, a similar will-o’-the-wisp had
to be disregarded before modern physics could become the discipline it now is; the reasons why
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434 PART FIVE Our Theoretical Future
this was so throws some light on the contemporary state of behavioral science (Toulmin, 1972,
p. 386).
Another feature of nursing that supports its uniqueness is that, as a profession, it exists in an
open system, and it must be influenced by and be responsive to society’s needs at all times, and
through collaboration with many constituents (Andrew and Wilkie, 2007). Therefore, nursing can-
not afford to converge on one paradigm to the exclusion of others. Nurses’ and clients’ actions
continue to be shaped by each other and by their social environments. This is where the analogy
between nursing and sociology appears (Urry, 1973); both disciplines must be dynamic and
changing, and both develop through integration, rather than revolutions or evolutions. Nursing has
many communities, but no one community can act as a unit to support one competing theory over
another, just as there are no unified communities in any of the other disciplines. Engagement in
the different communities is also an indication of progress (Burrage, Shattell, and Habermann,
2005). If we decide to wait for total agreement, we may not be able to work diligently on much-
needed conceptual clarity and the further development of existing competing thoughts.
Another pattern of knowledge development in nursing is the compromise between old and
new concepts. Researchers focus on the family and on individuals, on parts of the individuals, and
on individuals as wholes. They use quantitative and qualitative techniques and explore administra-
tive and clinical questions. In instances in which changes occur, old paradigms are redefined
rather than totally rejected. For example, even as Nightingale’s concept of environment is revived,
new paradigms, such as Rogers’, are redefining her ideas.
It is the presence of competing theories, competing schools of thought, and debatable ideas
that makes a discipline scholarly. The right to question, critique, and challenge has characterized
all advanced disciplines (Toulmin, 1972, p. 110). If nursing were to adopt a revolutionary philoso-
phy for its growth, it could put an end to this significant property of scholarliness (Laudan, 1977,
pp. 73–76). Competition, creativity, and innovation are the hallmarks of scientific growth.
The discussion thus far has attempted to address the unique features of nursing that may
make revolutionary or evolutionary development unsuitable for describing nursing development
(at best) and that may distort such developments (at worst) (Table 18-1). The thesis of this discus-
sion is that nursing progress seems to have charted its own path; ideas that were rejected in one
stage of development have been accepted at a different stage. Examples of this are the early rejec-
tion of nursing theories, the revival of Nightingale’s focus on health and environment, and on spir-
ituality (Macrae, 1995), the preoccupation with quantitative research methodology in the 1960s,
the more recent revival of meaning of experience, the greater acceptance of alternate designs for
research such as phenomenology, and the arguments for reclaiming our traditions (Bradshaw,
1995). Ideas have been cumulative at times and unrelated to previous stages at others. Toulmin
(1972), despite his interest in cumulation, observed that:
[T]he leading ideas current at any stage in the development of the 20th century social science
have tended to resemble those current two or three generations before, more than they have
resembled those of the immediately previous generation (p. 385).
The discipline of nursing, with its perspective, domain, theories, and research, is increasingly
used as the organizing framework and as substantive content for education, clinical practice, and
research. There is less need for advocacy of nursing and a preoccupation with the rationale for
nursing theories. Nursing programs discuss and use nursing theories in addition to theories from
other disciplines. Graduates of programs that use nursing theories are aware of the strengths and
limitations in utility of nursing theory, and the strengths and limitations of theories that were
developed to answer questions that are more central and more relevant to other disciplines.
The syntactical debates (theory versus conceptual framework; nursing theory versus bor-
rowed theory; and qualitative versus quantitative methods) are fading, giving way to substantive
debates (different views of health, environment, client, and communities). Indications of theory
refinement and extension began in the early 1980s, and gained momentum at the turn of the 21st
century. Relationships between domain concepts were being explored using existing nursing theo-
ries and other pertinent theories, such as interpersonal relations and the delivery of nursing care
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CHAPTER 18 Measuring Progress in a Discipline 435
(nursing therapeutics), resulting in theoretical exemplars that could guide nursing research
(Kasch, 1984).
Because our scholarly work centers around and emanates from a nursing domain, special-interest
groups emerged as (what Merton calls) a “community of scholars” who, in turn, helped in the refine-
ment and extension process (Merton, 1973). These communities of scholars are organized and active
locally and globally, focused on different theories. In the future, they may be organized around sub-
stantive nursing areas such as mobility, rest, nursing interventions, quality of care, symptom man-
agement, women’s health, nursing theories, and nursing diagnosis, among others. It is also proposed
that criteria for measuring progress be based on the scholarship of engagement in the various com-
munities (Burrage, Shattell, and Habermann, 2005; Duke and Moss, 2009). Another example of
engagement in a defined community of scholars is manifested in the development of research centers
in some of the leading schools of nursing. For example, at the University of Pennsylvania, faculty
belong to research centers as they focus on different sets of phenomena and concepts such as transi-
tions, history, and outcomes, among others. These communities of scholars, organized around phe-
nomenon and particular areas of investigation, drive organized and coherent scientific productivity
that goes beyond a single study or one person’s program of research.
We have achieved, as members of the discipline, an incredible level of wisdom about our dis-
cipline. What Johnson referred to as “practical wisdom” (1959, p. 294) characterizes nursing at
the end of the first decade of the 21st century. Practical wisdom is manifested in actions that are
theoretically sound and are designed to make a difference in the lives of people and provide some
good for them. It includes a deliberate action that is subjected to reflection and analysis. Lauder
(1994) differentiated between theoretical knowledge and practical wisdom, with the former end-
ing up with an intellectual conclusion and the latter with action that is morally good for human
beings. The age of wisdom encompasses all the properties of the stages that the discipline of nurs-
ing has experienced, not in a cumulative way but rather synthetically and developmentally, with
experience and practice as its hallmark. Acceptance grows for the complexity and fluidity of nurs-
ing concepts and the significance of the temporal dimension in our research and theory develop-
ment. Natural turns and detours are made with more ease and comfort, just as Newton made a
natural turn to astronomy because, at that time, finding one’s way at sea had been a preoccupation
of the time, or just as Kepler turned to astrology and used it during the Thirty Years’ War.
Using theories and developing new theories has benefited from temporal experiences. From such
use and further development came wisdom. Although we must not forget Bacon’s reasoning for
empirical testing or Kant’s insistence on a priori conceptual schemata independent of experience, a
practice discipline such as nursing cannot exist if it forgets Kaplan’s advice that the pursuit of wisdom
expresses a deep concern with the good that can be achieved in human life. Those benefits resulting
from nursing practice have to be conveyed to the public, to whom nursing is ultimately accountable.
Public awareness and accountability are the main pillars on which the discipline of nursing will rest.
Popular theories of knowledge development call for a pattern of progress that is not mani-
fested in its entirety in nursing. Therefore, nursing progress has been minimized, and its delays
and limitations have been highlighted. An integrative process of development allows for an expla-
nation of competitions and collaborations, acceptances and rejections, cumulations and innova-
tions, peaks and valleys, reconsideration and development, evolution and convolution (complex,
twisting, winding form, or design) (Webster’s Third New International Dictionary, 1986).
Integration is neither a nonpattern nor a negative pattern; rather, it allows for pendulum swings
and is explained as a pattern in progress. It is not a pattern that follows the conventional idea of
progress, toward a paradigm. Rather, it is a pattern of progress that depicts nursing’s accomplish-
ments and its solid theoretical present through accommodation, refinement, and collaboration
among thoughts, ideas, and individuals, and through its impact on health care (Gottlieb, 2007). This
pattern of progress does not underestimate the further need for progress that is inherent in all scien-
tific disciplines. It allows for careful critique of what has been and what is yet to be accomplished.
Table 18-1 illustrates the differences and similarities among the three processes of knowledge
progress discussed here. When the progress of nursing is analyzed through each of these three philo-
sophical views, different conclusions can be drawn. To a revolutionist, nursing is in a preparadigmatic
LWBK821_c18_p427-438 07/01/11 6:16 PM Page 435
436 PART FIVE Our Theoretical Future
stage; to an evolutionist, nursing is a would-be discipline; to an integrationist, nursing has achieved
a disciplinary status. A careful assessment of patterns of growth and development, milestones,
stages, and phenomena identified in nursing demonstrate the quality and significance of questions
asked and answers provided. These units of analyses represent a synthesis of research, theory, and
practice. When nursing is analyzed in these terms, it has achieved a disciplinary status.
At any particular time, a recognized domain will include many phenomena that are not
entirely clear or apparently consequential, and these might create genuine and inquisitive stances.
This does not reflect lack of maturity in a discipline, but rather indicates its continuing growth
(Chinn, 2008). The bond between scientific endeavors and reflection is becoming stronger; adapta-
tion and demand are becoming key forces of progress, instead of structure and inflexibility. It is
accepted that limitations in the nursing discipline stem from limitations of time, not from some per-
ceived shortcoming. To paraphrase McBride (1986), the future should not be viewed with apolo-
gies nor should we highlight and focus on our inadequacies; rather, we should develop and nurture
a sense that theoretical nursing has contributed a great deal to the present maturity of the discipline.
CONCLUSION
Reviewing progress in the discipline demonstrates that a considerable level of wisdom has been
achieved. Wisdom is the “capacity to take account of all important factors in a problem and to attach
to each its due weight” and to know which ends to pursue (Russell, 1957, p. 29). It combines knowl-
edge, feelings, morals, and practice. Wisdom is a sense of proportion. Knowledge can give us nurs-
ing therapeutics to enhance self-care, increase mother–infant attachment, increase social support or
networks, ease the effects of transition, or maintain the integrity of the individual. Only wisdom and
understanding can ensure their appropriate use for our clients without imposing our own values.
Wisdom is a total perspective, seeing an object, event, or idea in all its pertinent relationships. Spin-
oza defined wisdom as seeing things “sub specie aeternitatis,” in view of eternity (Copleston, 1963,
p. 253); Durant (1957) suggested defining wisdom as seeing things “sub specie totuis,” in view of
the whole. Considering the stages of knowledge development in nursing and considering nursing as
a whole leads to the proposition that nursing is currently encountering a scholarly evolution.
Emerson once said, “To the philosopher, all things are friendly and sacred, all events profitable,
all days whole, all men (or women) divine.” To nursing, all stages were essential to bring us to the
stage of scholarliness, and from all stages will emerge the age of wisdom. “Knowledge is power, but
only wisdom is liberty” (Durant, 1957, p. 9). Once there was a there. Now “there” is here. Let us
acknowledge and enjoy our accomplishments, but also remember that there is no end to what lies
ahead because it is the process that is the future.
REFLECTIVE QUESTIONS
1. Articulate an area or field of interest
using two of the theories of progress to
describe advancement in that field. Com-
pare and contrast your conclusions about
progress in that field. Why did you arrive
at this conclusion?
2. Discuss the wisdom, or lack of it, in
using integration theory as a theory to
determine the level of progress and
development in the discipline.
3. Extrapolating from theories of progress
discussed in this chapter, discuss what
indicators of progress you would use in
evaluating the developmental stages of
the scholars/scientists in the field of
nursing. Use similar analysis to develop
criteria and benchmarks for academi-
cians and clinicians.
4. What are the major conclusions that you
would draw from reviewing this book?
Compare and contrast these conclusions
with the author’s conclusions. Provide
the rationale for your conclusions and
support from contemporary literature in
nursing theory.
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CHAPTER 18 Measuring Progress in a Discipline 437
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Our Historical Literature
LITERATURE in nursing is rich with writings in theory, of theory, and on theory. Some
of the writings provided significant milestones in the shaping of the theoretical
progress in nursing. Chapters 19 and 20 of this book are organized around these writ-
ings. They provide an analytical review of the central literature in metatheory and
theory up to the beginning of the 1980s, as well as a comprehensive bibliography up
to the beginning of the 1990s. Chapter 20 provides a categorized listing of litera-
ture related to theory through 2010.
These chapters are offered for students, faculty, clinicians, and researchers. The
serious theory student needs analytical familiarity with the significant writing that
shaped progress in the discipline of nursing. The cursory theory student can find
these chapters helpful as an overview of writing related to nursing theory. All con-
cerned with the discipline of nursing will find that the literature relates, in some way,
to their specific area of expertise. This literature is a significant component of our
heritage, without which our practice, teaching, and research are limited.
P A R T S I X
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C H A P T E R 19
Historical Writings in Theory
To develop, analyze, or critique theories, a theory student, user, or developer needs a background
that includes all the significant writings related to theoretical nursing. This chapter provides the
reader with a critical assessment of the central writing contained in the nursing literature of the
1980s. With the publication of Advances in Nursing Science, as well as of other theoretically ori-
ented journals and books, theory literature has developed and proliferated exponentially, and it is
therefore no longer possible to include a comprehensive critical assessment of writings in theory.
As many as possible of those writings on theory up to the early 1980s that are considered classic
are included in this chapter.
The chapter is divided into two sections. Section I includes analysis and critique of the
metatheory literature. Section II includes analysis and critique of the literature on nursing the-
ory, written by nurse theorists or by others who have used nursing theory in research, practice,
education, and administration. All analytical abstracts are listed alphabetically within the sec-
tions.
A reader can use this chapter in many ways: first, the reader can use it in conjunction with the
contents of various chapters in the book; second, when studying a particular theorist’s work, the
reader can identify citations related to the theorist and can pull out those that have been abstracted
for review; third, Section I could be read in its entirety as a way to prepare for a general overview
of nursing theory; fourth, the reader can divide the writings in Section II into those relating to a
particular theory or read the abstracts related to each theorist separately; and fifth, readers inter-
ested in the development of theoretical nursing may wish to have a temporal perspective by read-
ing abstracts according to year of citation.
The intent of the abstracts is to challenge readers to different interpretations, not to critique the
writing. Readers are encouraged to read original writings and to use these analytical abstracts
only to provide them with one perspective of the writings. Finally, the reader should remember that
the analyses here include the interpretation of the authors who abstracted them, which may or may
not agree with others’ interpretations.
SECTION I
Abstracts of Writings in Metatheory, 1960–1984
Ellen Mahoney and Afaf Meleis
Abdellah, F.G. (1969). The nature of nursing science. Nursing Research, 18(5), 390–393.
This article seeks to move toward the “identification of a nursing science.” History is
reviewed, and nursing scientists are exhorted to build on the work of nurse pioneers who were
mainly theorists. Nursing science is defined as a body of cumulative scientific knowledge (drawn
from the physical, biologic, and behavioral sciences) that is uniquely nursing. Emphasis is on an
evolving science. The more that nursing research is directed by scientific theory, the more likely
its results will contribute to the development of a nursing science. There are too few nursing scien-
tists (should be 1%), but the numbers are growing. “It is the inescapable role of the nurse–scientist
to point the way for change in nursing.”
This is a short overview article, but it contains details of nursing history and random observa-
tions of interest.
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Andreoli, K.G. and Thompson, C.E. (1977). The nature of science in nursing. Image, 9(2), 32–37.
The theoretical basis of practice is the science of nursing, and it defines nursing’s uniqueness.
Science is defined as a system of knowledge based on scientific principles. Its ultimate goal is the
discovery of new knowledge, the expansion of existing knowledge, and the reaffirmation of previ-
ously held knowledge. Nursing is defined by abstracting the major elements from the conceptions of
several nursing theorists. Science in nursing (the body of verified knowledge found within the disci-
pline of nursing) is distinguished from the science of nursing (that body of verifiable knowledge that
will be derived from nursing practice, the unique way in which nursing uses borrowed knowledge).
Nursing will attain the status of a science once it has clearly identified a verifiable knowledge base
that can be contested and corroborated. This knowledge base will come from practice. Specific
attention is given to the scientific methodologies of nursing research, conceptual models in nursing,
the nursing process, and nursing diagnosis as a means of developing a knowledge base.
The fact that the article offers more than the others in the category is an interesting argument
for the integration of basic and applied science and the sections on scientific methodologies in
nursing that stress the theory–practice–research link. One might argue that the “unique” elements
of nursing presented are really not so unique. The definition of “science” comes from the diction-
ary; the conceptions of nursing science presented (especially by Johnson and Rogers) should be
read in the original.
Batey, M.V. (1972). Values relative to research and to science in nursing as influenced by a sociological perspective.
Nursing Research, 21(6), 504–508.
Central to the development of a science of nursing is the continuing issue of the function of val-
ues in research and in science. This article is a response to the question: How does preparation in one
of the disciplines related to nursing bear on the identification and conceptualization of nursing
research problems and approaches used to design and carry through an investigation? Batey’s
response is organized in three topics: (1) an overview of her conceptual and methodological orienta-
tion in sociology; (2) illustrations of the research in her work; and (3) contrasting perspectives of sci-
ence with thought geared toward nursing science. It is to the third topic that the abstract is addressed.
Research is a tool of science; the goal of science is the continuing advancement of an objec-
tive body of knowledge. Batey contrasts two perspectives of science: (1) as a social system with
values (expressed) as the desired goal toward which science strives (i.e., an advancing and objec-
tively verified body of knowledge), norms (expected standards of behavior, including disinterest,
organized skepticism, and communality), and parteined relations (the expectation of a competent
response to one’s creative effort); versus (2) as a means (knowledge for use). An investigator’s
perspective will influence types of research problems identified, as well as the selection of knowl-
edge brought to bear for their conceptualization and research methodologies. In nursing, where
knowledge is valued for its use (perspective 2), it is hypothesized that a greater emphasis is placed
on descriptive studies than on the subsequent stages of the discovery process toward an objec-
tively verified body of knowledge. Until we alter our normative system in nursing relative to sci-
ence, we can expect little movement toward nursing science.
Whereas a major thrust of the article focuses on the dilemma of conflicting values for nurses
educated in other fields, the section “Perspectives of Science” (pp. 507–508) is provocative and
well worth reading, particularly after exposure to explications of nursing science and arguments
for practice theory. Does the reader agree with Batey’s hypothesis that a discipline emphasizing
knowledge for use will emphasize descriptive research?
Batey, M.V. (1977). Conceptualization: Knowledge and logic guiding empirical research. Nursing Research,
26(5), 324–329.
This is an excellent article analyzing functions and processes of research conceptualization.
Analyzing a systematic sample of articles published in Nursing Research, Batey identified “limiting
CHAPTER 19 Historical Writings in Theory 441
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442 PART SIX Our Historical Literature
features” representing problems of: (1) the conceptual phase (“fallacies of reasoning, specification
of meaning, and use of knowledge in conveying the problem, conceptual framework, and/or pur-
pose”); (2) the empirical phase (“technical processes related to the methods and procedures of
data production and reduction”); and (3) the interpretative phase (“analytical processes related to
deriving meanings of findings”). Batey judged that the vast majority of problems are due to limita-
tions of the conceptual phase, particularly the lack of clear definition and inadequate development
or utilization of a conceptual framework. Factors contributing to conceptual limitations are identi-
fied, as are their consequences.
The remainder of the paper is an explication of the conceptual phase of research to achieve a
reduction of the limitations noted. Components of the conceptual phase are: (1) The problem deter-
mines the context of the study by setting the major parameters of the phenomenon of concern; it
includes what, how, why, or under what conditions phenomena occur, and a normative statement; (2)
the conceptual framework involves background knowledge that delineates the present knowledge
state about the problem and that yields the theoretical statement through which the investigator
attempts to construct an accurate image of the phenomenon of study; it includes background (review
of literature) and rationale (theoretical framework); and (3) the purpose is derived from the rationale;
the research purpose is the hypothesis to be tested.
The article also includes brief but helpful sections on purposes and methods for literature
review, scientific versus common-sense meanings of concepts, tips on critical reading, and guide-
lines for the interpretative phase and its dynamic relation to conceptualization.
There is some overlap and lack of clarity in defining the three components of the conceptual
phase, and it would have been appropriate to explicate more on the theoretical background of a
study. This article should be read in the context of other articles that address conceptualization and
conceptual frameworks. Besides tying these phases together, this article provides useful criteria
for the design and evaluation of research.
Becker, C.H. (1983). A conceptualization of concept. Nursing papers: Perspectives in Nursing, 15(2), 51–58.
The first part of this article is a series of lists. The first list has to do with characteristics of
concepts: ambiguity, conventional meaning, dependent on context, neither false nor true, and
either significant or nonsignificant. The author inserts an observation: “Concepts arise in the mind
of an individual as a result of attempts to make order out of what is observed.”
The next list describes modes of concept analysis (from Edel, 1979): Socratic (general and
essential), element analysis, genetic (how evolved), functional, systems, pragmatic, logical, oper-
ational, and phenomenological. A summary list gives the requirements for an appropriate use of
concepts in theory development: “(1) concepts have intention; (2) concepts are seen as models of
some aspect of reality; (3) the concepts selected are significant; (4) the mode of concept analysis
dictates the method of investigation of the concept; (5) the value bias and semantic overtones are
inherently present in the concepts selected for study; and (6) concepts are subject to continual
analysis and refinement.”
Then, micro-concepts are endorsed: “micro-concepts rather than general macro-concepts may
have the potential to contribute more to the structuring of nursing knowledge.” An example is
given: self-esteem (micro) versus personality (macro). The author presents the following reasoning:
“Macro-concepts, because of their generalness, have a loose flexibility of meaning. Micro-concepts
would not allow this looseness.” There are also fewer variables in micro-level concepts: (1) the
intention of the author is easily understood; (2) meaning is not so easily distorted; (3) the most
appropriate mode of analysis is easily identified; and (4) there is no polarity.
Beckstrand, J. (1978). The notion of a practice theory and the relationship of scientific and ethical knowledge to
practice. Research in Nursing and Health, 1(3), 131–136.
Beckstrand critiques several authors who have supported a “practice theory” (Dickoff and
James, Jacox, etc.). For such notions to be meaningful, practice knowledge must be shown to be dif-
ferent from scientific knowledge or ethical knowledge, or else “no need for a separate practice
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CHAPTER 19 Historical Writings in Theory 443
theory would exist.” Two primary aspects of practice knowledge, the knowledge of how to make
changes and the knowledge of what is “good” are examined. First science, “the knowledge of law-
like empirical relationships,” is studied to determine if it includes the knowledge used to control
phenomena in practice. Beckstrand provides an extended summary discussion of the nature of sci-
entific knowledge, relating it to the notion of “control.” “The potential for controlling a phenome-
non is synonymous with lawlike relationships and the potential for prediction that they provide. . . .
Science seeks to establish the knowledge that allows for this kind of control.” To make changes
one must have some control. Although practice often seeks this control through invalid argument,
“functional argument,” and empirical generalization, these are “based on the knowledge of scien-
tific laws and lawlike relationships.” The controls possible in scientific experimentation are impossi-
ble in the practice situation, but despite uncertainty of outcome, practice methodology nonetheless
proceeds by valid deduction from scientific laws.
Next is a review of the field of ethics. Ethics is concerned with the knowledge of what is
right, good, or obligatory. Both normative ethics and metaethics have relevance to practice. But
theories of the moral obligations of practitioners “are identical in form” to other theories of moral
obligation; theories of moral value in practice do not represent unique forms of theory. The goals
defined in practice are not moral values that may be determined by the methods of ethical philos-
ophy and no others. In short, “it would appear that there is no need for a practice theory distinct
from a scientific or ethical theory.”
The bulk of the article is Beckstrand’s reading in the philosophy of science and ethical theory.
Her more abbreviated attempts to apply these readings to Dickoff and colleagues are dependent on
crucial unargued and unevidenced assertions. For example, (1) the relation of “practice knowledge,”
(Beckstrand’s term) to “practice theory,” which is the focus of the authors she surveys, after all, to
have a theory of teaching is not to have the knowledge to teach a course in Russian history; (2) the
assertion that practice knowledge can be broken down into two generalizations—”how to make
changes” and “what is good”—without oversimplification or distortion; and (3) the assertion that
unscientific reasoning and procedures are “based” on scientific reasoning and procedures. Although
Beckstrand argues that the knowledge on which practice is based is science-knowledge, she admits
outright that the reasoning process in practice is often unscientific, and she ignores experience, tradi-
tion, or even nonscientific logic as bases.
Beckstrand emphasizes what might be called “content” with regard to science and practice
theory (i.e., concern only for the knowledge in science and practice and not the reasoning
processes, and concern only for just what information, basically, is used in it and not for the
descriptive shape of the activity, its form, nor its outline definition). Beckstrand reverses herself
when discussing ethics, saying that although there may be specific ethical obligations or directives
especially and uniquely applicable to a practice, the form of the theory is that of an ethical theory.
Might one not ask her then, why a theory of practice (although the information used in it may well
be the same as ethics and science) cannot remain unique because its shape and its form is that of a
practice theory?
Beckstrand, J. (1978). The need for a practice theory as indicated by the knowledge used in the conduct of prac-
tice. Research in Nursing and Health, 1(4), 175–179.
Beckstrand’s aim is to extend her previous argument. Her first article said that “much of the
knowledge required for practice is the knowledge of science and ethics.” Here, she “examines”
practice to see if “the theoretical knowledge used in practice is completely defined by science,
ethics, and logic.” To determine this, she turns to the definition of the purpose of practice: “Prac-
tice attempts to change an entity or phenomenon in such a way that a greater good is realized.”
Accomplishing change in practice necessitates the knowledge of both change and action. This
knowledge can be reduced to limited categorization, but Beckstrand broadens the base of neces-
sary knowledge here to include “the domain of logic in general.”
Following this is the logical analysis of the conduct of practice. First, she discusses condi-
tions. She asserts that “[t]o say that an interaction is meaningful is to say that the interaction has
logical implications in relation to existing scientific or ethical knowledge.” She argues that
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although the combination of conditions in each situation can draw on infinite numbers for infinite
variance, and that because the “human potential” to perceive or the “personal knowledge” of the
practitioner are limited, only a finite number of conditions are attended to or identified, and they
are identified in a way “most dependent on the practitioner’s scientific and ethical knowledge.”
Next, under the rubric of “description” of the conduct of practice, Beckstrand discusses val-
ues and goals. She restates that the goal of practice is change toward the greater good. Determina-
tion of this greater good depends on the values of the practice discipline, values that “reflect
normative ethical theories.” A practitioner sometimes accepts a hierarchy of values “implicitly
and uncritically, but these hierarchies and their implementation represent ethical decisions.” She
concludes that the knowledge of practice “depends not on some special aspects of practice, but on
science and ethics alone.”
Immediately in her introduction, Beckstrand, without calling attention to it, puts forward two
new factors missing from her first article: “theoretical knowledge” presumably now will bridge
her pass from “theory” to “knowledge” (whereas this formulation does not appear at all in her first
essay, it is seen three times in this introduction to her second), and “logic” is added (again, without
comment) to science and ethics, to subsume practice theory. One might hypothesize that these
additions reflect a reaction to criticism (her own or that of others) of the first piece, and therefore
that these problems are to be addressed. The body of the article never again mentions “theoretical
knowledge” but instead substitutes “knowledge” alone, as in the first essay. What is more, because
she freely interchanges “theoretical knowledge used in practice” with “knowledge used in prac-
tice,” one may deduce a confusion in the use of the concept “theoretical.” What of the goal to
maintain health against changes?
In addition, it would have been helpful if Beckstrand had considered, even as an error to be
refuted, that a theory of nursing might be as relevant to “nursing ethics” as a theory of ethics.
Finally, her conclusion forgets her introduction and its specificities of “theoretical” and “logic.”
“Thus, the knowledge of practice depends not on some special aspects of practice, but on science
and ethics alone.” Both articles are thought-provoking and central readings in metatheory.
Beckstrand, J. (1980). A critique of several conceptions of practice theory in nursing. Research in Nursing and
Health, 3, 69–79.
Although the title and summary suggest a survey of ideas about “practice theory,” half of this
article (roughly five pages) is devoted to what Beckstrand characterizes as the “set-of-rules” con-
ception of practice theory, which she attributes to Ada Jacox. Other writers, most notably Dickoff,
James, and Wiedenbach, who provide the opening focus of the essay, are given remarkably short
shrift. The initial section, “The notion of Dickoff et al.,” attempts to explain their notion, mixing
restatement of their formulations with a series of asserted exemplifications of what they mean:
“the articulation of the conceptual frameworks . . . practitioners actually use”; “in changing a flat
tire a practice theory is being employed”; an identity between their notions and “technology” (i.e.,
“the totality of a plan of action used to bring about a goal that is presumed desirable”).
The big interest for Beckstrand is Jacox (1974). Jacox’s is presented as an incorrect interpreta-
tion of Dickoff and colleagues—incorrect because Beckstrand appears to interpret Dickoff and
James’ position in terms of each practitioner having her own practice theory formula. Jacox,
according to Beckstrand, suggests a rigid, compulsion-carrying deck of directives, which one shuf-
fles on each occasion to find the right rules of procedure. Nurses are “compelled to conform . . . to
a set of rules imposed by an external authority.” Under this conception, “prescriptive practice the-
ory becomes a set of universally prescribed rules for practice.”
Following this is the longest section of the essay (by far)—an attack on the Jacox position so
characterized. Beckstrand produces a discussion of ethics intended to demonstrate that one cannot
prescribe a goal without making an unjustifiable value judgment. Then she makes a series of “prac-
tical arguments.” Prescriptions cannot take into account all the variables in a given situation. Some-
times, two prescriptions will conflict. The practitioner will be forced to make an “arbitrary”
decision between them. She takes time to “demonstrate” that you could not have a prescription spe-
cific to every situation. She responds to objections by saying that, even under such a theory, scientific
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CHAPTER 19 Historical Writings in Theory 445
and ethical judgment would still be required. Granted this, Beckstrand asserts that the change
would be nil. She argues that such a theory will not be valuable in the education of practitioners
because she has already shown it is not valuable in practice. Nursing education does not involve
prescriptions of this kind because those in education “are not imperatives carrying sanctions for
their adoption or violation.” Sets of rules for practice are no aid in research because “as prescrip-
tions, they imply no deductively derivable empirically true or false consequences (predictions).”
Other notions of practice theory are briefly examined. Conceptual frameworks of nursing,
such as Roy’s or Jones’ “are not scientific theories but ideologies” because they are “legitimately
alterable on the sole basis of personal or public discretion.” Beckstrand also differs with those (like
Peterson) who wish to try to delineate the bounds of nursing inquiry. In theory development and in
research, one does not know a priori what is relevant, rather, one lets the characterizations and cat-
egorizations emerge and evolve from the situation.
In this article, Beckstrand provides a unique interpretation of Dickoff and colleagues and of
Jacox. Although the problem with Dickoff and colleagues inevitably represents some difficulties with
their exposition, most attempts like this at reduction can be problematic (as they dismiss and refute
such approaches in their 1975 article) simply because they fail to include all the elements Dickoff,
James, and Wiedenbach insist on (i.e., a conceptual framework with built-in goal orientation, pre-
scriptions, and a survey list). The set-of-rules theory attributed to Jacox also has some flaws. We
would assume that Jacox would argue that her proposed system is not intended to be a straightjacket
and that provisions for “breaking” rules are made. Beckstrand’s arguments against Jacox would seem
to apply to any attempts to teach practice, or to any potential contributions from research. She sees the
possibility of this objection: “one might argue that if a prescriptive practice theory of the set-of-rules
type cannot be justified, then no decision can be made about what to do in practice.”
As to her paragraph on metatheory, first, under Carnap’s definition, all theories of nursing are
metatheories. Second, after all these attempts to discredit practice theory, she says that, if one will
call it metatheory, it is okay, and Dickoff and colleagues’ may be considered a beginning (and
worthy) metatheory of nursing practice. Beckstrand notes that because Dickoff and colleagues
“did not fully explicate or formalize their theory,” they have only offered “undeveloped ideas.”
Dickoff and colleagues, of course, do not have a theory. (That is to say, they do not have a “prac-
tice theory.”) These appear to be unfortunate mix-ups. Despite our analytical arguments, we con-
sider Beckstrand’s writing stimulating, challenging, and an absolute must for a theory student.
Benoliel, J.Q. (1977). The interaction between theory and research. Nursing Outlook, 25(2), 108–113.
This essay explores relationships between theory and research as reciprocal elements in an
ongoing process through which scientific knowledge relevant to nursing is created, expanded,
tested, and refined. Practice can serve as a stimulus to research and can therefore form part of the
cyclical process. There is also a brief section on sources of knowledge in nursing.
This is a simple account of the “constantly flowing interchange between the realities of practice,
theory development, and scientific investigation.” The inductive/deductive cycle is demonstrated, as is
an example of building a body of knowledge by the “application of different philosophical approaches
to the study of a particular human phenomenon.” Better “sources of knowledge” include Rogers,
Carper, and Beckstrand.
Berthold, J.S. (1968). Prologue: Symposium on theory development in nursing. Nursing Research, 17(3),
196–197.
According to the author, no substantive definition of “theory” can be applied with any gener-
ality due to the ambiguity and complexity of the concept “theory.” Differential use of terms neces-
sitates clear understanding of their use to avoid semantic confusion and to allow for attention to
the substance of various positions.
In this introduction to the symposium, Berthold states: “The questions . . . involve a discus-
sion of various positions about and approaches to developing a conceptual structure of knowledge
useful and necessary to attain the goals established by nurses.” In elaborating on this statement,
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446 PART SIX Our Historical Literature
the author stresses thought processes that result in theoretical constructs, ordered in a systematic
way; knowledge that is verified; theory that is useful in stimulating new observations and insights
and in generating propositions concerning relevant events; and goals that are established and con-
trolled by nurses for nursing.
This is a brief overview that succinctly captures the major issues, questions, and debates
about nursing theory development addressed in the symposium. (See articles by Schrag, Crowley,
Folta, and Brown, as well as Panel Discussion.)
Brown, M.I. (1964). Research on the development of nursing theory: The importance of a theoretical framework
in nursing research. Nursing Research, 13(2), 109–112.
Two major questions are addressed: (1) How far have we progressed through research
toward the development of an integrated body of nursing theory? And (2), how can we determine
if a research project has a theoretical framework that will make possible a contribution to scien-
tific knowledge? Sections of the paper include the need for nursing theory, concept validation
through research, and assessment of the theoretical framework of a research project. A research
project that contributes to nursing theory can be identified by certain characteristics, such as an
aim to pursue knowledge for its own sake, the statement of the relationship of the problem to
research and nursing literature, the use of established meaningful terms, the association of find-
ings to the work of others, and the logical but creative exposition of implications and further
hypotheses for testing.
This early, easy-to-read article is a brief reminder of the theory–research symbiosis. The arti-
cle emphasizes rationale rather than criteria for selecting theoretical frameworks. Would Brown’s
conclusions be different if this article were written in the 1980s?
Brown, M.I. (1968). Theory development in nursing: Social theory in geriatric nursing research. Nursing
Research, 17(3), 213–217.
This is an exemplification of Brown’s theme—the nature of nursing research and its relation
to theory formation. The article is a descriptive account of the use of the concept of socialization
in a gerontologic research project.
Although Brown asks how theories of the basic and other applied sciences relate to nursing
research, her response stresses problems intrinsic to the theories. Other authors (see especially
Klein, Crawford, and Johnson et al.) emphasize the implications of “borrowing” theories formu-
lated in other disciplines. The article is part of the 1968 Symposium on Theory Development in
Nursing.
Brown, M.L. (1983). Research questions and answers: The use of theory and conceptual frameworks in nursing
research and practice. Oncology Nursing Forum, 10(2), 111–112.
The author presents an initial distinction: “A theory explains the nature of phenomena and a
conceptual framework identifies what variables are important.” Both are important to “identify,
categorize, and expand nursing knowledge in an organized and thoughtful way. A catalog of
notions of theory is then offered. The author summarizes: “Theory, then, helps identify the
research problem, defines . . . appropriate evidence . . . and determines methods to obtain, organ-
ize, and integrate information.”
In dealing with conceptual frameworks, on the other hand, the author simply presents a defi-
nition: “A conceptual framework is an organized grouping of ideas or concepts that assists in pro-
viding overall structure to the research project and the nursing process.”
The author follows Derdiarian’s delineation of the need for order and systematization in
nursing research, education, and practice. Finally, she cites Marino’s conceptual framework for
cancer nursing.
This article is actually a columnist’s response to a question by readers about the terms “the-
ory” and “conceptual framework.” More elaborate and somewhat different presentations are avail-
able elsewhere in the literature.
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CHAPTER 19 Historical Writings in Theory 447
Burgess, G. (1978). The personal development of the nursing student as a conceptual framework. Nursing Forum,
17(1), 96–102.
Burgess proposes “personal development” of the student nurse as a conceptual framework in
professional nursing education. Rationales are presented (enhanced potential for professional
effectiveness, improved quality of care, criteria for retention of students), as well as means of
operationalizing personal development (ability to articulate goals and philosophy and to evaluate
accomplishments and needs, change in attitudes, increased sensitivity to others).
A conceptual framework is defined, by analogy, as a unifying central theme that provides the
mechanism for articulating and relating all parts of the curriculum. Course objectives are the
means of providing attachment to the central theme, and the courses themselves (content plus
learning experiences) are “free to respond to currents of movement and creative expression,”
while maintaining their attachment to the central theme.
The proposed conceptual framework provides a provocative, if controversial, alternative to
more common subject- or process-oriented curricula. The major value of this article however, is
its simple, yet creative and helpful explanation of the characteristics and purposes of the concep-
tual framework and its emphasis on the need to operationalize concepts.
Bush, H.A. (1979). Models for nursing. Advances in Nursing Science. 1(2), 13–21.
This article examines types of models, the relationship between models and theories, and the
use of models in nursing research, education, and practice.
Models provide a means for ordering, clarifying, and analyzing concepts and their relation-
ships; they provide analogs to reality and stimulate the scientific process by identifying new possi-
bilities. A model primarily expresses structure, whereas a theory provides substance. Models used
in nursing must represent the ordered reality of focus on human beings, their environment, their
health, and nursing itself (i.e., isomorphic). Models are used: (1) in research, to conceptualize the
research process itself and to facilitate thinking about concepts and their relationships; (2) in edu-
cation, to guide curricula planning; and (3) in practice, to guide assessment, intervention, and
evaluation.
This article provides a good summary of types of models and their purposes in nursing. More
pragmatic information on the development of models may be found in Jacox and McKay.
Carper, B.A. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1(1), 13–23.
A classification of the patterns of knowledge in nursing is presented here. The article
addresses the question: “What kinds of knowledge are most valuable to the discipline of nursing?”
Answers are meant to provide (1) perspective and significance to the discipline, (2) awareness of
the complexity and diversity of nursing knowledge, and (3) an operational definition of nursing.
Four patterns of knowing are identified:
1. Empirical (the science of nursing). The science of nursing is in a healthy but embryonic
stage; theoretical models are presenting new perspectives.
2. Aesthetics (the art of nursing). Aesthetics is achieved by empathy, “dynamic integration”
of parts into the whole, and the recognition of particulars versus universals.
3. Personal knowledge. Personal knowledge is concerned with the quality of interpersonal
contacts, promoting therapeutic relationships, and individualized care.
4. Ethics (the moral component) “what ought to be done.” Each individual pattern of know-
ing is necessary, but not sufficient, for achieving the goals of nursing. It is their interrela-
tionship that defines the whole. These patterns provide structure and boundaries, dictate
subject matter for nursing education, and, together, represent a complete approach to the
problems and questions of the discipline of nursing.
The reader of this article should consider several points. The “Aesthetics of Nursing” section
appears to confuse knowledge with action (“a science teaches us to know, and an art to do”) and blurs
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448 PART SIX Our Historical Literature
distinctions between intuition, perception, instinct, and what we more ordinarily call knowledge. Per-
haps most important, the identification of aesthetic with empathy loses any sense of clear distinction
between this and her third category, described as “acceptance.” In this case, Carper is rejecting an
approach to the client as an “object,” and is rejecting establishing “authentic personal relationships.”
In addition, the “Ethics of Nursing” obscures a major oversight of this paper (something
emphasized by Donaldson and Crowley)—that nursing involves history and philosophy, as well as
science and art. The delineation of goals, principles, and values and of the hierarchies among
these that are specific to nursing are the continuing products of nursing experience and of thought
in nursing that is broadly theoretical. The value of this article lies in its provision of a broader per-
spective of nursing knowledge than has been previously presented in the literature.
Chapman, C.M. (1976). The use of sociological theories and models in nursing. Journal of Advanced Nursing, 1,
111–127.
Theory development has not kept pace with expanding roles in nursing and does not support
nursing actions. Nursing and sociology are similarly defined as interactive processes between
individuals, and the author therefore suggests the potential contribution of sociological theories
and models to the development of nursing theory.
Social exchange theory is proposed to explain how patients and nurses satisfy their own
needs and goals, and organizational theories are considered in the context of their effect on goal
achievement, communication, and compliance. Concluding remarks stress that (1) borrowed theo-
ries must be validated in the new situation, and (2) theories in the behavioral sciences can describe
and explain more accurately than they can predict due to the variability in human behavior.
The bulk of this article focuses on the effects of organizational structure on nurse roles and
behaviors in the United Kingdom. The reader might question comparisons between nursing and
sociology and assumptions about nurses and patients. The article emphasizes theories related to the
delivery of care and the development of nursing theory that would support clinical practice. Whereas
the ideas presented in the conclusions are important, their development is somewhat limited.
Chinn, P.L. and Jacobs, M.K. (1978). A model of theory development in nursing. Advances in Nursing Science,
1(1), 1–11.
The process of theory development is a means of facilitating the evolution of nursing science
and is the most critical task facing the nursing profession. Theory is defined as “an internally con-
sistent body of relational statements about phenomena which is useful for prediction and control.”
Conceptual frameworks are presented as less developed theoretical statements allowing descrip-
tion and explanation.
The model of theory development contains four separate but interrelated components: (1)
examination and analysis of concepts, (2) formulation and testing of relational statements, (3) the-
ory construction, and (4) practical application of theory. These components may be differentiated
by the nature of the operations involved: cognitive (1 and 3); empirical (2 and 4); and by their
functions: description and explanation (1 and 2); prediction and control (3 and 4). As a whole, the
model demonstrates, “how different types of research yield varying types of products, each con-
tributing to the total development of the science.” Also included in the model are boundaries that
delimit areas of nursing concern, while allowing free exchange of content and processes among
sciences, and a central core denoting the influence of history on theory development in nursing.
The importance of the theory–practice linkage and the dynamic and contextual nature of the
process of theory development are emphasized.
Two major arguments are developed: (1) “The process of theory development has greater
value for nursing than the product,” and (2) the emphasis in theory development should be predic-
tion and control. These positions should be contrasted with authors who emphasize the prelimi-
nary importance of descriptive and explanatory theories, the importance of the “product” for
building a science of nursing, and the guiding influence of a clear conception of nursing.
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CHAPTER 19 Historical Writings in Theory 449
Clark, J. (1982). Development of models and theories on the concept of nursing. Journal of Advanced Nursing,
7(2), 129–134.
This article aims to show that models and theories in nursing have “practical value for the
ordinary clinical nurse.” One must relate theoretical work to what nurses actually do, built around
concepts that can be operationalized. The failure to do this explains “the relative lack of impact on
nursing practice . . . of the work in theory development undertaken in recent years.”
Clark presents a “simple model of nursing.” The model is a “gross simplification,” but delib-
erately so, as more elaborate models are less universal. Often, models do not easily fit all fields of
nursing.
How can such a model help the ordinary practicing nurse? (1) It purports explicitly that there
is something called “nursing” that has an identity of its own (“versus those who still see nursing
merely as a collection of tasks undertaken on the initiative of . . . doctors”); (2) it stresses the reci-
procity of the nurse–patient relationship and the significance of environment; and (3) it stresses
cause and effect relationships; “considerably more attention must be paid than in the past to out-
comes of nursing care.”
The remainder of the article is an application to her own situation. Clark demonstrates by
considering her own nursing care in light of the model.
More popularizing than theory or scholarship, the article provides a role model of informal,
thoughtful, and conscious practice, and does a good job of presenting serious ideas in attractive
and readily understandable ways. It is a well-written example of what it argues—relating scholar-
ship in nursing to practice, making it available to “consumers.” It is a soft-sell for theory-based
practice and is effective.
Cleland, V.S. (1967). The use of existing theories. Nursing Research, 16(2), 118–121.
Theory serves two major functions: as a tool, it gives direction to empirical investigation; as a
goal, it tends to abstract, summarize, and order research findings. The goal function of theory,
which is the basis for progression of science, has been less adequately used in nursing. The func-
tional method of research, which begins with a significant problem or question and then searches
for relevant theoretical formulations, enables the nurse researcher to take advantage of advances
made in other disciplines, while ensuring nursing relevance. It permits the researcher to work
inductively from existing empirical data and deductively from other theoretical formulations. An
example of this is given to illustrate the inherent limitation of research that has no theoretical
framework (and, of course, the superiority of one that does).
This rationale for conceptual frameworks is similar to others on the subject, and may be con-
trasted with the “grounded” approach (see Quint). Although the authors in this group of articles
agree on the values of a framework, consider the integral relationship of this section and the one on
theory critique.
Collaizzi, J. (1975). The proper object of nursing science. International Journal of Nursing Studies, 12(4),
197–200.
The beginning of a science should be a philosophical inquiry into its appropriate domain. In
initiating a science of nursing, considerable theoretical ambiguity has resulted from the assump-
tion that nursing science is synthetic. Although we have amassed a body of scientific findings (that
can be properly called health technology), what we have failed to do is circumscribe that which is
uniquely nursing. Although nursing takes place within both technical and existential dimensions,
the proper object of nursing science is the human experience of health and illness. Therefore, the
research methods of human science, rather than those of natural science, must be used to investi-
gate the questions that arise within this (existential) dimension.
This article offers an intelligent support of prevalent and influential conceptions of nursing
science that emerged in the 1980s.
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450 PART SIX Our Historical Literature
Collins, R.J. and Fielder, J.H. (1981). Beckstrand’s concept of practice theory: A critique. Research in Nursing
and Health, 4(3), 317–321.
The authors find two major flaws in Beckstrand’s analysis. First, they attack her claim that “the
knowledge nurses need to effect changes is scientific knowledge.” Specifically, they follow Toulmin’s
suggestion that there is a “plurality of different types of medical knowledge,” and they quickly col-
lapse it into two “modes.” Beckstrand has overlooked or ignored the subjective, the knowledge of
the particular, “knowing the client as a particular human being.” Several of the authors’ statements
on this issue are memorable: “The role of the nurse and the biographer are similar; both must turn
their attention to knowing individuals in all of the uniqueness and particularity. . . . The nurse’s role
is perhaps closer to that of the priest, intimate friend, or therapist—seeking not only knowledge of
the individual but also the person’s well-being. Understanding is not the primary goal, but a way of
becoming an effective adviser and advocate for the person’s interest.”
Second, there are moral issues in nursing that will not be resolved by appeal to ethics but are
specific to nursing. The authors point to activities or goals that are not obligatory but that are
praiseworthy; these are characterized as, “[M]oral ideal. . . . The questions of which, if any, moral
ideals an individual pursues is not answered by an ethical theory. The theory may be used to jus-
tify an ideal as a moral ideal, but the choice of which ones to pursue must flow from an individ-
ual’s concept of what kind of life the person wishes to lead. . . . The profession of nursing has
only recently emerged from the role of being the physician’s handmaiden and is now in the
process of defining itself as a profession in its own right, embodying certain moral ideals. Just
what those ideals should be is one of the major elements of a practice theory.”
This is an interesting, analytical article. It nicely adjusts and fills out Beckstrand’s work,
without any excessive negativity. It is a good example of the sense of a shared enterprise: Beck-
strand is a colleague whose work is to be built on.
Crawford, G., Dufault, S.K., and Rudy, E. (1979). Evolving issues in theory development. Nursing Outlook, 27(5),
346–351.
This review of nursing theory literature addresses issues in historical perspective: Is nursing
theory borrowed or unique? Is nursing a basic or applied science? Should there be theories of
nursing or for practice? What are the approaches to theory development? The purpose of the arti-
cle is to redefine these issues in light of Donaldson and Crowley’s article.
A strong bias for unique, practice-oriented, “situation-producing” theories is presented.
Problems of borrowing are presented (e.g., lack of isomorphism). Authors agree with Johnson
that the nature of knowledge required for nursing will foster theory development that is unique
to nursing.
As defined in the 1968 nursing science conference, basic science supports knowledge for its
own sake, whereas applied science demonstrates knowledge with practical aims and applications.
Donaldson and Crowley present the need to increase understanding of phenomena (basic), demon-
strate applicability of basic knowledge in real situations (applied), and explain how to use knowl-
edge to achieve goals in practice (prescriptive theory). Together, these comprise nursing science.
Regarding the issue of theory of nursing (delineation of definition and scope of or about nurs-
ing and the nursing process) versus for practice (conceptualizations guiding nursing action to
achieve desired goals), these authors address the question of unified versus diverse theories, sup-
porting Jacox’s “middle-range theories.” It is possible that they confuse “unified theory” with the
values of a theoretical framework. The complexities of the arguments for and against unified and
diverse theories are not addressed.
This approach to theory development lends support to inductive, deductive, historical, and
philosophical methods. Theories should be developed to generate new knowledge and to organize
knowledge about the discipline of nursing (supporting Donaldson and Crowley). The author states
McKay’s questions about which methods are most appropriate and what are criteria for accept-
ance of findings. She also supports Stevens’ advice to ask the significant questions and only then
to seek appropriate research methodologies.
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CHAPTER 19 Historical Writings in Theory 451
This article provides a good overview of critical issues in nursing theory development from a
historical perspective. Although one is attempting to resolve these issues, the complexities of the
arguments and contrasting positions are not always fully addressed, precluding comprehensive,
definitive resolution. Nevertheless, this article is a good synthesis of supporting positions and con-
tains an excellent bibliography on theory development in nursing.
Dickoff, J. and James, P. (1968). Researching research’s role in theory development. Nursing Research, 17(3),
204–205.
Research is for the sake of theory and theory is for practice. However, research alone will not
produce theory, and theory produced without research has little hope of viability. Research is a
tool to be used in conjunction with adequate conceptualization and with a level of precision that,
although scientifically sound, does not preclude practical usefulness. The purpose of research
(creating or testing theory) should determine the methodology used.
This excellent, humorous, and atypically brief article by Dickoff and James is one of the best
articles on the research–theory–practice link available in the literature.
Dickoff, J. and James, P. (1968). A theory of theories: A position paper. Nursing Research, 17(3), 197–203.
Dickoff and James begin by defining theory as a conceptual system or framework invented for
some purpose. (There are other kinds of theory besides “predictive theory.”) Because a profession
shapes reality, nursing theory must provide conceptualizations to guide the shaping of reality to
nursing’s professional purpose. Therefore, nursing theory is at the fourth or highest level—situation-
producing theory—because the nursing aim is practice. Nursing has an advantage to offsetting the
difficulty of producing so complex a theory, namely, “the privileged and habitual intercourse with
empirical reality carried on in a practice discipline,” together with the practical wisdom passed on in
apprenticeship. (There follows a summary of “Theory in a Practice Discipline”—see abstract of that
article for this information.) Natural and social science theories will be offered by contributors, but
one should realize that conceptualization at a sophisticated level constitutes the integration of these
into nursing theory. The authors’ summary indicates that definition and types of theory delineated
are the crucial points made. They suggest that valuation of their theory or theories rests on “whether
or not the proposed position constitutes a fruitful view of theory.”
This is a stimulating introduction to the ideas of Dickoff and James and contains some know-
ing asides (e.g., the authors encourage nurses to persist in theory building despite “the smoother
sailing and quicker payoff in status and funds to be found in repetition or imitation of inquiry” in
other disciplines). Nevertheless, the article is simply an overview and depends on more elaborate
articulations (“Theory in a Practice Discipline,” etc.) for substantive support.
Dickoff, J., James, P., and Wiedenbach, E. (1968a). Theory in a practice discipline: Part I—Practice oriented
theory. Nursing Research, 17(5), 415–435.
This is the first of two articles on the nature and development of theory in a practice discipline. A
major thesis is made explicit at the outset: theory is relevant to practice, practice to theory, and both
are relevant to research. The movement is delineated from felt discomfort/criticism to articulation of a
problem, and then to speculative and eventual practical resolution. This “epitomizes that theory is
born in practice and must return to practice.” What is theory? Theory is a “conceptual framework to
some purpose.” There is some discussion of the nature of theory and misconceptions about theory.
The four levels of theory are: (1) factor-isolating theories; (2) factor-relating theories
(descriptive); (3) situation-relating theories (predictive, etc.); and (4) situation-producing theories
(prescriptive). Each of these is then described: (1) involves naming, classifying; (2) is depicting or
“natural-history-stage” theory; (3) extends from predictive theory into “promoting and inhibiting”
theories; (4) is the primary subject of the article, situation-producing theory. The three essential
ingredients of a situation-producing theory are: (1) goal content specified as an aim for activity;
(2) prescriptions for activity; and (3) a survey list to serve as a supplement.
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Each of these ingredients is discussed, the first two briefly, the survey list at some length. As
to the first, “No more feeling of reverence to some shadowy high ideal can substitute in theory for
the conception of goal as goal.” As to prescriptions, they are commands giving a directive, aimed
at a specified end, and directed toward some specified agent. The survey list accounts for the
agent’s judgment, experience, and practical insight. It bridges the gap between particular activity
and the goal content and prescriptions. Such activity has six salient aspects: agency, patiency,
framework, terminus, procedure, and dynamics.
What is nursing theory? It must be a theory at the most sophisticated level, a situation-produc-
ing theory. This article suggests what might be expected in a nursing theory. Again, the discussion
is structured on the tripartite division—goal, prescription, and survey-list ingredients. The discus-
sion of goal content identifies the goals as “beforehand specifications of situations the theorist
deems worthy to produce,” as well as “explicit conceptualizations subject to revision.” The treat-
ment of the prescription ingredient merely expands on the original statement, using examples of
what has been said already. Furthermore, “appropriate specificity of goal content and prescription
is an important consideration in any practice theory.”
The survey list ingredients are explained and illustrated at some length. Under agency, the
question is asked, “Who might be agents of activity that realizes the nursing goal?” The conclu-
sion is that there is no theoretical reason that all nursing agents must be nurses or even persons.
Patiency, similarly, is mainly the extension of that term to cover “[a]ny person or thing that
receives the activity of a registered nurse.” Framework asks: What in the context of activity, prac-
tically speaking, is relevant? Terminus is activity in terms of outcomes. This and procedure are
fairly obvious discussions of viewing activity in terms of means and ends. Dynamics introduces
interesting questions about the motivations of nurses and how these may be influenced. The ques-
tion is of the “power sources” for successful nursing activity.
The article closes with a brief look at existing nursing theory. Actually, this is mainly a look
at nursing literature. Beginning with the observation that there is no existing nursing theory to
meet their paradigm, the authors argue nonetheless that extant nursing literature constitutes a con-
tribution to, or preparation for, such a theory. They discuss the difficulties of “would-be” nursing
theorists, they observe that there may be more than one good nursing theory, and then they pro-
pose to consider types of nursing literature (other than research studies): the “inspirational” litera-
ture of nursing, treatises and textbooks, and procedure and policy books. These constitute “a rich
mine, if we know how to exploit the veins.” The existence of something concrete to be examined
critically—written materials and existing practice—is a necessary stepping stone. “In other
words, even now, practice is guided in some incipient way by embryonic theory.”
Dickoff and colleagues have much to offer: “As Einstein’s theory of relativity is . . . so is our
theory of theories.” In fact, it is this very insistence that they are introducing a new kind of theory,
substantively different, that provides the major ground for doubt or dispute. Whereas some parts
of this article are dense and full of ideas, whole sections seem diffuse, rambling, simplistic, and
often unnecessary. There is no bibliography. However, their pretensions to metatheory are the
main objectionable elements (except for an occasional condescension to nurses and “would-be”
nurse theorists). This is the major substantive article by these authors, and it is a “must read”
because of the contagion and impact of their ideas. Critical reading of this article should be fol-
lowed by reading of the article by Jacox and the series by Beckstrand.
Dickoff, J., James, P., and Wiedenbach, E. (1968b). Theory in a practice discipline: Part II—Practice oriented
research. Nursing Research, 17(6), 545–554.
To have a nursing theory, three sources must be tapped: awareness of practice theory, interest
in developing it, and “openness to relevant empirical reality.” The authors see the first two of these
as covered in Part I of this article, which is briefly reviewed. Research and practice are the con-
stituents of the required “openness.” The essential aspect of practice, as opposed to “mere”
research, lies in the accomplishment of something in the here-and-now. Research has as its goal
“[i]nput to knowledge beyond the immediate particular.” Possible research objectives are to stim-
ulate conception and to validate a conception already formed. “We can say that research has two
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CHAPTER 19 Historical Writings in Theory 453
objectives or that research has theory as its immediate objective but in two different ways.” Sim-
ply put, though, research tests theory or stimulates theory.
There are two ways to stimulate theory: the researcher “encounters again and again, and with
as many variations as possible, empirical reality.” This is called planned “staring.” A second way
is to test theory at the just-preceding level. As for testing, only fourth-level theory testing is consid-
ered; it is “fairly well-accepted” that the others can be tested. The purpose of situation-producing
theory is threefold: (1) to achieve its goal; (2) that these results be desirable when achieved; and (3)
that guiding action by the theory is feasible in terms of cost, etc. Testing means testing all three
dimensions: the theory’s coherency must be tested; its palatability must be assessed; and the feasi-
bility claim must be evaluated. Research methodology is not absolute and can be expected to vary
with the level of theory tested, and with its being strictly “test” or stimulation. The conditional nature
of methodology is stressed to approach creatively the kind of research needed or to stimulate prac-
tice theory for nursing. Summary and conclusions follow. Noteworthy among these observations are:
“Research is for theory, theory for practice, so that practice fittingly has first place and theory
has the mediating role.”
“There is a thorough-going, mutual interdependence as among the three activities of practice,
theorizing, and research.”
“In short, to supply nursing image is to venture a nursing theory.”
The authors are mostly to be commended for certain emphases, certain stressed elements,
especially concerning the place and importance of theory in nursing. As with their other produc-
tions, this article fails to provide any bibliography. This article is not so controversial and seems
not so valuable as their other contributions.
Donaldson, S.K. and Crowley, D. (1978). The discipline of nursing. Nursing Outlook, 26(2), 113–120.
This article poses a series of significant questions. It begins by noting the question of the
nature of nursing, but addresses this through a subquestion: What are the recurrent themes in nurs-
ing inquiry? These could suggest “boundaries” for a systematic study of the discipline of nursing.
There follows a long discussion of the nature of classification of disciplines. Nursing is seen as a
“professional” discipline. It is noted as a discipline different from nursing science (doctoral train-
ing for nursing historians, as well as for nursing scientists, is endorsed) and different from nursing
practice (the discipline should be governing practice instead of vice versa). Finally, the structure
of the discipline of nursing is considered, a generalization is offered (“nursing studies the whole-
ness or health of humans”), and some “major conceptualizations in nursing” are presented.
The article is poorly organized. The opening ideas are not developed and are unrelated to
what follows (except for the assertion, not discussed, that they provide “boundaries”). On the sec-
ond page, the authors state that what is truly important is to define the discipline of nursing. Hav-
ing discussed the nature and relations of disciplines, one expected the next section to be entitled
“The Discipline of Nursing.” Instead, the authors launch into a discussion of nursing-as-practice
versus the discipline of nursing. The structure (as opposed to the nature or definition?) and nurs-
ing’s “perspective” are not clearly delineated or related. Definition is never mentioned, and what
is given is somewhat vague, broad, and unspecific to nursing, such as “Major conceptualizations
in nursing: 1. Distinctions between human and nonhuman beings; 2. Distinctions between living
and non-living. . . . 7. Human characteristics . . . such as consciousness, abstraction . . . aging,
dying, reproducing.”
Nevertheless, this seminal work is challenging, and it has had a wide and significant impact
on the theory development literature because of the importance of the topic and its timeliness. It
makes the point successfully that nursing is a discipline and gives support to its focus.
Ellis, R. (1968). Characteristics of significant theories. Nursing Research, 17(3), 217–222.
Significant theories for nursing are those that (1) improve practice by addressing the goal of
nursing (represented by Henderson’s definition) and (2) include the patient as a component. The
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454 PART SIX Our Historical Literature
purposes of theory development are (1) to distinguish fact from pseudofact, (2) to structure and
synthesize facts from other fields, (3) to give direction to practice, and (4) to provide a framework
for retrieval and use of generated and stored knowledge.
Seven characteristics of significant theories are enumerated: (1) Scope (the number of con-
cepts related). Scope provides framework for ordering observations about a variety of phenomena,
and it must include psychological and biologic variables; the broader the scope, the greater the
significance. (2) Complexity (the notion that theory should treat multiple variables or relationships
of a single variable in its full complexity). The strength of this argument is Ellis’ admonition that
“incomplete conceptualizations lead to hazards of illusory comprehension.” (3) Testability
(focuses chiefly on the importance of recognizing theories as hypothetical constructs, amenable to
change). (4) Usefulness (the ultimate criterion is that theories help develop and guide clinical
practice). (5) Implicit value must be recognized and made explicit. (6) Capability of generating
new information, new ideas, and practices must be there. (7) Terminology can be used meaning-
fully with, or applied to, phenomena observed in nursing.
These “characteristics of significant theories” speak directly or indirectly to evaluative
methodologies and criteria for internal and external validity presented elsewhere, providing a
succinct presentation of major considerations. Ellis’ positions on scope and complexity
should be compared with those of Jacox, Hardy, Stevens, Duffey and Muhlenkamp, and
Hage. The major area of disagreement between Ellis and other authors is related to the char-
acteristic of testability, which, she states, can be sacrificed in favor of scope, complexity, and
clinical usefulness. Ellis argues that “elegance and complexity of structure are to be preferred
to precision in the meaning of concepts in the present state of knowledge.” This view should
be contrasted with the more prevalent argument for testability as the ultimate determinant of
significance.
Fawcett, J. (1980). A framework for analysis and evaluation of conceptual models of nursing. Nurse Educator,
5(6), 10–14.
The purpose of this article is to provide a clear definition of conceptual models, to delineate
the confused distinction between conceptual models and theories, and to develop a framework for
analysis and evaluation of conceptual models.
A conceptual model is defined as a set of abstract concepts and the assumptions that integrate
them into a meaningful configuration. By identifying relevant phenomena (person, environment,
health, and nursing), a conceptual model provides a perspective for scientists; by describing these
phenomena and their interrelationships in general and abstract terms, the model represents the
first step in developing the theoretical formulations needed for scientific activities.
A theory is a set of interrelated concepts, definitions, and propositions that present a system-
atic view of phenomena by specifying relations among variables (Kerlinger). It postulates specific
relations among concepts and takes the form of a description, explanation, prediction, or prescrip-
tion for action. Any theory presupposes a more general abstract conceptual system. The crucial
distinction between a conceptual model and a theory is the level of abstraction; a theory is both
more precise and more limited in scope than its parent conceptual scheme.
Based on this distinction between conceptual models and theories, different frameworks are
required for analysis and evaluation. The remainder of the article is devoted to the presentation of
a framework for analysis (philosophical base, context, scope) and evaluation (internal validity,
etc.) of conceptual models of nursing.
This is an excellent, substantive article that is of value both in its articulation of differences
between conceptual models and theories and its eclectic framework.
Gebbie, K. and Lavin, M.A. (1974). Classifying nursing diagnoses. American Journal of Nursing, 74(2), 250–253.
As the Report of the First National Conference on the Classification of Nursing Diagnoses,
this article describes the process of developing a classification system and a list of tentative nurs-
ing diagnoses.
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CHAPTER 19 Historical Writings in Theory 455
It is an example of what Dickoff and James call a factor-isolating theory. The relationship of
nursing diagnoses to theory development, while observed in the article, is made explicit and
developed in detail by Kritek (1978).
Gortner, S.R. (1983). The history and philosophy of nursing science and research. Advances in Nursing Science,
5(2), 1–8.
Only in the past few years have philosophy of science issues attracted serious attention in
nursing research, as the research tradition moves into a new phase of development. Questions
regarding method, discovery (as opposed to justification or proof), ethics, politics, and so forth are
now prompting comment. This article presents an overview of this philosophical component of
emerging nursing science and research and does so in part through a historical perspective.
In the early years, practice was the source of knowledge. Efforts to generate a knowledge
base for nursing through research have been much more prominent in the past two decades. Early
research approaches included development of critical resources, surveys, conferences, studies of
procedure, case analyses, and alliance with other disciplines. More recent times have seen the
enlargement of critical resources (especially in doctoral education) and public support and new
development of colleagueship, communication, and research designs and methods.
On this last subject, Gortner addresses a major point of discussion: “To assume that the
choice of research methods used in nursing was influenced by a particular philosophy of science
(e.g., logical positivism) is to attribute too much deliberation or rationality to what was the result
of social, political, and economic events.” With doctoral training in fields other than nursing, nurs-
ing scientists brought with them methods that had served them well. They also had to face the
pragmatics of funding. “Granting agencies prefer controlled studies in which variables are well-
specified and instrumentation is precise.” Finally, generalizability has become a critical element
because “the capacity to affect practice depends heavily on this factor.”
Consensus has emerged about the definition and subject matter of nursing and the research
paradigms of its science. However, the philosophical orientation of the science remains chiefly
empirical and naturalistic. Attempts to incorporate theoretical propositions are now being made,
and the search is on to discover relationships. “Science (empirics), art (esthetics), morality
(ethics), and intuition (personal or subjective) all represent sources of knowledge. . . . The profes-
sion surely can accommodate multiple paradigms (analytic, humanistic) and modes of inquiry
(naturalistic, experimental, historical).” In the formation of research questions and the choice of
areas of inquiry, it can be expected that inquiry will be of a more fundamental nature in the future
than was true in the past. Examples of phenomena that have relevance for nursing include self-
care, social support, family functioning, and stress. Two other important areas are clinical thera-
peutics and investigation of environments.
Gortner concludes that “nursing science will make a major contribution, as science, in the
interface of the biological and social sciences concerned with illness and health.”
This article is significant because of its comprehensiveness and currency; it points to the
shape of nursing’s future.
Green, J.A. (1979). Science, nursing and nursing science: A conceptual analysis. Advances in Nursing Science,
2(1), 57–64.
This article examines the term “science” historically, linguistically, and contextually. The sci-
entific method is considered (“science includes both methodology and knowledge”), and the func-
tions of science are indicated. Various definitions are cited (Conant, Nagel, Fischer), and a
synthetic definition is offered. The usefulness of this definition of science for nursing is said to be
its potential for evaluating the status of nursing science: “It provides a standard to determine
whether or not a designated body of knowledge constitutes a science.” A distinction is established
between science and technology.
A series of definitions of nursing are considered, with attention given to chronological devel-
opment of the nurse’s role (Henderson, Wiedenbach, Yura and Walsh, King, Travelbee). Following
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456 PART SIX Our Historical Literature
Travelbee, an analytical course is set. Nursing is seen as involving content and process. A compari-
son of nursing and medicine is made. Knowledge drawn from natural, behavioral, social, and med-
ical sciences constitutes the science in nursing. This is then transformed through application in
clinical practice. So, a definition of nursing becomes “a service discipline that provides care, con-
cern, and comfort to recipients experiencing a broad range of health–illness phenomena through
the synergetic combination of its art and science.” This definition precludes the separate classifica-
tion of technical and professional nursing.
The main value of this article is that it collects and presents good basic materials on the ques-
tions “What is science?” and “What is nursing?” Green’s only argument for “nursing science” is a
reference to Gortner and colleagues, who, she says, document its existence. Also, her synthetic
definitions seem to be inferior to her citations from other sources.
Hall, B.A. (1981). The change paradigm in nursing: Growth versus persistence. Advances in Nursing Science,
3(4), 1–6.
Questions of emerging and competing paradigms in nursing theory development are
addressed as they relate to shaping the values of the professional. The “change paradigm,” which
postulates continuous flux, has been pervasive in nursing theory (e.g., adaptation, development).
It is argued that: (1) a paradigm based on change may not be the most productive departure for the
study of humans and health; (2) a focus on change leads to the illusion that things are changing
when they are actually staying the same; and (3) nursing’s attention may have been drawn to the
phenomena of change at the expense of increasing our understanding of the capacity for stability
and persistence.
Hall’s attention to the heuristic value of a paradigm is an interesting example of the sociology
of science, and her admonitions about the acceptance of unverified assumptions underlying theory
are provocative and important. Several interesting questions are raised, based on Kuhn’s work,
and have generalizability beyond the specific example: What is the process by which a paradigm
is accepted? Why and when does a paradigm’s shift occur? What is the relationship between the-
ory and value? Can competing paradigms exist simultaneously, and with what implications?
The presentation of change and stability as competing theoretical notions may be somewhat
oversimplified. Although Hall explicitly refrains from dropping models of change, her presenta-
tion is strongly biased in the direction of stability (albeit perhaps for the sake of balance). Perhaps
change and stability are better viewed as which/when versus either/or phenomena. Kuhn’s para-
digm, espoused by Hall, would seem to preempt the possibility of dialectical theory development.
This article should be read by the student with some background in theory development.
Hardy, M.E. (1978). Perspectives on nursing theory. Advances in Nursing Science, 1(1), 37–48.
Nursing theory development and evaluation are viewed within the context of stages of scien-
tific development. Applying Kuhn’s thesis on the development of scientific knowledge, Hardy
argues that nursing is in a “preparadigmatic” stage of theory development, “characterized by diver-
gent schools of thought which, although addressing the same range of phenomena, usually describe
and interpret these phenomena in different ways.” Nursing needs to struggle through and beyond
the preparadigmatic stage of scientific development because confusion, wasted energy, and poorly
focused, systematic research result from this lack of a well-defined perspective.
A “metaparadigm,” or prevailing paradigm, on the other hand, presents a general orientation
that holds the commitment and consensus of the scientists of a particular discipline. It determines
the general parameters of the field, provides focus to scientific endeavor, and may subsume sev-
eral “exemplar” paradigms, which are more concrete and specific in directing the activities of sci-
entists. The existence of a prevailing paradigm facilitates the “normal work of science.” Research
is purposeful, orderly, and raises few unanswerable questions. Whereas the adoption of a meta-
paradigm cannot be decreed but rather will be based on its scientific credence and its potential for
advancing scientific knowledge, nursing scientists can facilitate this process by being well
informed in a substantive area and participating actively in theory construction and research.
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CHAPTER 19 Historical Writings in Theory 457
Subsequent sections of this article address the nature of theory, the relationship between the-
ory and practice, criteria for “borrowing” theory from other disciplines, types (levels) of theory,
and criteria for theory evaluation, including logical adequacy, empirical adequacy, usefulness, and
significance. Each of these criteria is clearly elaborated.
Whereas Hardy’s “perspectives” are not clearly interrelated, they are well worth reading.
Before reflecting on the implications of nursing’s “preparadigmatic” stage of theory development,
consider: (1) the applicability of Kuhn’s thesis to nursing and (2) evidence for other conclusions
on the status of nursing science. The sections on development and evaluation of theory are excel-
lent. Hardy’s criteria should be compared with other taxonomies.
Jacobs, M.K. and Huether, S.E. (1978). Nursing science: The theory-practice linkage. Advances in Nursing
Science, 1(1), 63–73.
Nursing science is defined as both process and product: “the process of nursing science
requires that concepts be defined, operationalized, linked into relationships, and verified. From
verified conceptual linkages accrue the product, which is theory; and the theory explains and pre-
dicts nursing phenomena.” The goal of nursing science is to define goals and guide practice; it is
prerequisite to professional autonomy and impact.
The complementary and mutually dependent interrelationship of theory and practice are
emphasized and demonstrated. Concepts, the building blocks of theory, must be empirically
derived and operationalized in a clear and useful manner. They are then linked in theoretical for-
mulations that are subject to empirical verification. Theory without practice is vacuous; practice
without theory is intuitive rather than scientific. The contributions of both researchers and practi-
tioners are crucial.
These authors present nursing as an evolving science. The current status of nursing science is
illuminated by historical perspective; education and “cohesiveness will facilitate the advancement
of nursing science.” The article includes brief sections on the nature of science, the structure and
function of science, and the process of concept selection and definition. The theory–practice link-
age is clearly articulated and appropriately emphasized.
Jacox, A. (1974). Theory construction in nursing: An overview. Nursing Research, 23(1), 4–13.
Three levels or stages of theory development are discussed: (1) a period of specifying, defin-
ing, and classifying the concepts used in describing the phenomena of the field; (2) developing
statements or propositions that propose how two or more concepts are related; and (3) specifying
how all the propositions are related to each other in a systematic way.
Concepts are abstract representations of reality that indicate the subject matter of a theory.
They may vary both in complexity (concepts, “higher-level” concepts, constructs), and in the
degree to which they are observable versus symbolic (empirical–theoretical continuum). Precise
operational definitions are emphasized.
Propositions are statements of constant relationships between two or more concepts or facts.
All scientific propositions are based on empirical generalizations that may be proved false in the
future. Types of relational statements include laws, axioms, theorems, hypotheses, and principles—
all differentiated on the basis of degree of tentativeness. Although nursing has made wide use of
principles on which to base nursing action, Jacox observes little attempt to relate these principles to
one another systematically.
Scientific theory is defined as “a systematically related set of statements, including some
law-like generalizations, that is empirically testable.” The purpose of theory “to describe, explain,
and predict a selected aspect of empirical reality” requires the use of both inductive and deductive
reasoning and a close relationship among theory, practice, and research.
Jacox espouses nursing practice theory as that which guides the nurse’s actions in attaining nurs-
ing goals in patient care. While presupposing and building on theory that explains, describes, and pre-
dicts, nursing practice theory must allow the investigator to go beyond these levels to prescribe and
control. She describes nursing as a discipline “in which the major concern is use of knowledge.”
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Other topics discussed in this article include: (1) definition and use of models to guide
research, (2) arguments for “middle-range theories” in nursing (versus “grand theory” or
“abstracted empiricism”), and (3) a discussion of the nature and source of knowledge and theory
in (of, for) nursing and the proper use of nursing resources in theory development.
This article is a good overview of theory construction, emphasizing the relationships between
various elements of theories and emphasizing as well issues in the development of nursing theory.
Jacox’s nursing practice theory should be compared with Dickoff and James and the contrasting
position of Beckstrand. Comparisons should also be made with Hardy, Donaldson and Crowley,
and Green. Reflection on Jacox’s description of the “state of the art” of theory construction in
nursing is recommended.
Johnson, D.E. (1959). The nature of a science of nursing. Nursing Outlook, 7(5), 291–294.
The basis for the concepts set forth in this article is found in the earlier article by this author
on the philosophy of nursing. Here, the focus is on exploring the nature of nursing as a science and
as a discipline. Johnson identifies professional disciplines as representing applied sciences. One
might be interested in comparing her thoughts on this with a more recent article by Donaldson and
Crowley, noting that Johnson and Crowley were colleagues at the University of California, Los
Angeles in the mid-1960s and that Crowley was influenced by Johnson (1978).
Johnson believes that the goals of nursing must be established in precise terms to give direc-
tion to the search for a body of knowledge. Although nursing shares the ultimate goal held by all
health workers, its specific and unique goal is not as clearly understood or as widely accepted as
that of medicine’s. It is through a discussion of nursing’s professional goal that Johnson elaborates
on her conceptions as a way of illustrating how the development of science can be given direction.
Her conception of nursing care is borrowed from general systems theory, and the primary purpose
of nursing care is expressed in terms such as tension, equilibrium, and dynamic state.
For nursing to achieve its goals, it is hypothesized that two kinds of knowledge are needed: the
knowledge of people, which is shared knowledge common to all health workers, and knowledge of
the science of nursing. Furthermore, it is this author’s thesis that “the science of nursing is developed
through the reformulation of concepts drawn from the basic sciences to yield a body of knowledge
fundamental to the development of theories of nursing diagnosis and nursing intervention.”
Borrowing theory is a controversial approach to the development of nursing knowledge but is
nonetheless a useful one, as demonstrated by a number of other nursing theorists, as well as
Johnson. Here, Johnson develops a rationale for that approach. We will later see how she does this
using systems theory as a prototype to develop her behavioral systems model.
This article makes an important contribution to the early thinking about a science of nursing,
in addition to showing us Johnson’s early thinking about the behavioral systems model. The writ-
ing is clear, and the presentation is logically developed and expressed. This article should be read
by those who are interested in Johnson’s model, especially by those who wish to see how the
model unfolded, and by all who are interested in the development and organization of nursing
knowledge. Responses and patterns, part of the lexicon in nursing in the 1980s, were introduced
as early as 1959, as is evident in this publication.
Johnson, D.E. (1968). Theory in nursing: Borrowed and unique. Nursing Research, 17(3), 206–209.
Differentiation of “borrowed” and “unique” theory in nursing may help clarify nursing’s
appropriate place and focus in theory development. Borrowed theory is defined as that knowledge
developed in the main by other disciplines and drawn on by nurses. Unique theory is defined as
that knowledge derived from the observation of phenomena and the asking of questions unlike
those that characterize other disciplines.
The question of borrowed and unique is analyzed first in respect to the nature of knowledge
required for nursing practice and the availability of the knowledge. This knowledge may be
divided into: (1) knowledge of order, that which describes and explains the “normal” state of peo-
ple and the “normal” scheme of things (this kind of knowledge is the focus of the basic sciences);
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CHAPTER 19 Historical Writings in Theory 459
(2) knowledge of disorder, that which helps us understand events that pose a threat to the well-
being or survival of the individual or society; and (3) knowledge of control, that which allows the
prescription of a course of action that, when executed, changes the sequence of events in desired
ways predicated on the knowledge of disorder and geared toward specified outcomes. Although
all these types of knowledge are basic to nursing practice, it is in the area of disorder that efforts at
nursing theory development should be concentrated.
A second perspective for analysis of the borrowed/unique issue considers the problem of
nursing’s objects in scientific investigation. Nursing is ill-defined as a field of practice and as a
field of inquiry. The lack of definition constitutes a serious obstacle to professional and scientific
development. If there is an area for study and theory development unique to nursing, it will evolve
only through the study of phenomena and through asking questions in a way that uncharacteristic
of any other discipline. Behavioral system disorders represent such a focus.
Part of the 1968 Symposium on Theory Development in Nursing. This article is a “must
read” because: (1) it is a cogent and effective analysis of one of the major issues in theory devel-
opment; (2) Johnson’s framework of order, disorder, and control is one of the major typologies in
the literature; and (3) it serves as an introduction and rationale for Johnson’s Behavioral Systems
Model.
Johnson, D.E. (1978). Development of theory: A requisite for nursing as a primary health profession. In Chaska,
N. (Ed.), The nursing profession: Views through the mist. New York: McGraw-Hill.
The development of a theoretical body of nursing knowledge is a means of acquiring profes-
sional status. Impediments to the development of nursing science are surveyed, and two questions
are presented as means of providing direction: For what purpose is a theoretical body of knowl-
edge intended? And, what phenomena must be studied and what kinds of questions must be asked
to develop the needed knowledge?
In response to these questions, Johnson discusses the evaluation of scientific disciplines and
the professions as sciences. Sciences become differentiated on the basis of the distinctive per-
spective for observation and interpretation of selected phenomena. The focus of any profession’s
scientific concern is interdependent with its service (social function). Johnson discusses the
implication of different conceptual models and alternative routes to theory development and
presents three social criteria for evaluating models: congruence (Do nursing decisions and
actions that are based on the model fulfill social expectations?); significance (Do nursing deci-
sions and actions based on the model lead to outcomes for patients that make an important differ-
ence in their lives or well-being?); and utility (Is the conceptual system on which the model is
based sufficiently well-developed to provide clear direction for nursing practice, education, and
research?).
This is a good theoretical treatise on problems in nursing theory development and the evalua-
tion of solutions to these problems. Direct responses to Johnson’s guiding questions, however,
must be supplemented from other sources (see sections on philosophy, practice, research, guide-
lines). Johnson’s theory evaluation criteria, based on factors extrinsic to the substance of the
model, represent an often-neglected yet important dimension.
Kramer, S. (1969). Behavioral science and human biology in medicine. The New Physician, 18(11), 965–978.
The question is raised whether information in the biologic, behavioral, and medical sciences
can be used to develop a comprehensive theory of the human organism. Kramer presents the thesis
that “in human development, the social environment, through its influence on genetically deter-
mined patterns of behavior together with the normal process of growth, is capable of modifying
the development of every individual in characteristic ways.” Examples of the interrelated nature
of biopsychosocial variables are given, using growth and development as a frame of reference.
One major concept—“character structure”—is developed to define the psychic, somatic, and
social unity of the individual to explain the empirical finding that alterations of behavior in one
realm are capable of influencing all other realms (as in stress reactions).
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The proposed “medical–ecological model” of the human organism represents an attempt to
develop an eclectic “grand theory.” The rationale is presented intelligently, and recognition is
given to some major obstacles; for example, the fact that individual disciplines use words in dif-
ferent ways and use different units of analysis, ranging from the molecular (physiology) to the
molar (behavioral sciences). Implications for conceptualization or viable theory development are
left to the reader.
Kritek, P.B. (1978). The generation and classification of nursing diagnosis: Toward a theory of nursing. Image,
10(2), 33–40.
In building nursing theory, we have skipped the first stage of specifying, defining, and classi-
fying our concepts, and this has led to problems. To the degree that first-level theory (descriptive)
is dissonant with or unclear when related to “what is” in nursing, the eventual level-four theory
(prescriptive) will be dissonant or unclear. Returning to the level-one theory, building and doing
first things first, may be a worthwhile place to redirect our energies. This is being done through
the generation and classification of nursing diagnoses (see Gebbie and Lavin, 1974). This level-
one theory is evaluated in terms of Ellis’ criteria of a significant theory.
Read this article after Dickoff, James, and Wiedenbach (1968a, 1968b), Ellis (1968), and
Gebbie and Lavin (1974). It is most insightful in the application and implications of Dickoff,
James, and Wiedenbach’s framework. Would you call nursing diagnoses theory?
Leininger, M.M. (1969). Introduction: Nature of science in nursing. Nursing Research, 18(5), 388–389.
This is a statement of conference goals to explore approaches and methods that will support
a scientific discipline and a body of nursing knowledge. A core of nurses is eager to develop both
a scientific and a humanistic discipline of nursing within institutions of higher education.
Although “a theory” of nursing is spoken of, it is healthy and desirable that there be multiple the-
ories, models, and conceptual frameworks. An attitude of constructive skepticism and collegial
critique is urged.
In addition to induction and deduction, an ethnoscientific approach is suggested: a systematic
and descriptive documentary study of phenomena through the eyes of people in their situations.
Nursing lacks systematic ethnological studies of concrete nurse–patient–other situations.
We must be tolerant of one another’s failures and frustrations. Finally, change must be
accommodated. Students should be encouraged to explore problems and test ideas that seem
“exotic, highly radical, or out-of-this-world.” This is a brief overview of concerns facing the
conference.
McCarthy, R.T. (1972). A practice theory of nursing care. Nursing Research, 21(5), 406–410.
Can this format (of Dickoff, James, and Wiedenbach), applied to a real-life situation, produce
useful theories of nursing (practice)?
The purpose of this article is to illustrate how a practice theory can be developed on four levels.
McCarthy presents data from her survey of postoperative patterns of voiding in patients with spinal
anesthesia to demonstrate the four levels of theory as described by Dickoff and colleagues (1968a).
Under first-level theory (factor-isolating), she categorizes patients according to type of surgery. Sec-
ond-level theory (factor-relating) involves analyzing the relationships between need for catheteriza-
tion, duration of surgery, fluid intake, and so on. So far, so good. When we get to the third level, we
find that “a statement that ‘patients who have not voided within 14 hours may have to be catheter-
ized’ could be said to constitute predictive theory.” The highest level of theory—situation-producing
or prescriptive—is a nursing care plan (e.g., “note time of last voiding,” “note when patient
expresses desire to void, offer assistance,” etc.).
The article also includes an example of a survey list in operation. Is the reader’s response to
the opening question affirmative or negative? Does your response reflect comment on McCarthy
or on Dickoff, James, and Wiedenbach?
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CHAPTER 19 Historical Writings in Theory 461
McKay, R. (1969). Theories, and models, and systems for nursing. Nursing Research, 18(5), 393–400.
Theory is the cornerstone of all scientific work because the understanding, which is the goal
of science, is expressed in terms of theoretical formulations. The article gives much space to
defining various senses of the term “theory.” Nursing, at present, should use the word in a modest
sense. “Models” are defined and analyzed. Models vary in two ways: level of abstraction and
metaphor used. Two metaphors have been dominant—the machine and the organism. The organ-
ism is currently the dominant model in many fields, and, for both philosophic and practical rea-
sons, it is dominant in nursing.
The concept of “systems” is the ultimate central focus of the article. Various definitions of sys-
tems are offered. Open and closed systems are discussed. Properties of open systems are articulated,
and the suggestion is made that nursing could be represented by such a systems approach. Theo-
rems or propositions based on general systems theory developed by James Miller are endorsed as
particularly appropriate for nursing. Finally, a systems approach to the study of nursing education
is proposed for the study of students and of curricula.
This is a valuable treatment of the subjects considered. Its value is due in great part to the
many clear and careful definitions and to its detailed application of systems theory to nursing. A
crucial question is posed about models and metaphor: Is the model merely a restatement in other
terms, or does it accomplish extension or clarification? The late Dr. McKay was a central figure in
metatheory. This represents a fine example of her writing.
McKay, R.C. (1977). What is the relationship between the development and utilization of a taxonomy and nursing
theory? Nursing Research, 26(3), 222–224.
This essay is a brief description of the purposes and principles of classification schemes. The
definition and arrangement of concepts in a taxonomy, presuming it reflects the natural system, is
a descriptive model of reality and can be considered a theoretical design (factor-isolating or nam-
ing). The value of taxonomies for clinicians and educators are briefly listed.
This is another example of first-level theory; how it relates to the second level is not dis-
cussed. This article is really McKay’s response to a reader’s question.
Menke, E.M. (1978). Theory development: A challenge for nursing. In N.L. Chaska (Ed.), The nursing profession:
Views through the mist. New York: McGraw-Hill.
Menke considers three issues related to theory development in nursing: the importance of
theory development, the present status of theory development, and strategies to facilitate theory
development in nursing.
Theory development is important for any discipline because it prescribes the conceptual
framework for describing, explaining, and predicting phenomena. It serves as a means to iso-
late and classify facts, and it points to gaps in the available knowledge. Definitions and com-
ponents of theories are discussed, as well as levels (Dickoff and James) or stages (Jacox) of
theory development. The importance of lower-level theory development as a sound basis is
emphasized, and the consideration of theories about nursing rather than of nursing is pro-
posed. Lack of theory development may have been caused by the lack of systematic direction
and collaboration among theory developers. An eclectic approach to theory development is
advocated.
This is an excellent, well-written, and substantive review of major issues in theory development.
Moore, M.A. (1968). Nursing: A scientific discipline? Nursing Forum, 7(4), 340–348.
Moore argues that, in our eagerness to break away from the apprenticeship tradition, nurses
are trying to develop a scientific discipline without setting the foundation that is characteristic of
every well-structured discipline. The fallacies and shortcomings of such practices as searching for a
theory of nursing; borrowing concepts, tools, methods, and even questions from other disciplines;
and allowing values to interfere with science are discussed, along with their ramifications. The only
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sensible basis for the development of a content area to be labeled “nursing” involves empirical gen-
eralizations regarding the effects on the patient of the activities we carry out as nurses.
This short, easy-to-read article should be read early in a nursing theorist’s career because it
provides an excellent overview of major issues and pitfalls in the development of nursing theory
and nursing science. Moore’s emphasis on a clear, precise definition of terms is refreshing.
Although you can, now or later, argue about “the only sensible basis . . . ,” Moore is obviously
interested in the theory–practice–research linkage.
Murphy, S.A. and Hoeffer, B. (1983). Role of the specialties in nursing science. Advances in Nursing Science,
5(4), 31–39.
There is some conceptual movement away from specialization in nursing. Three trends have
impact in this regard: (1) defining nursing as a discipline separate from medicine, (2) educating
entry-level generalists, and (3) developing conceptual frameworks.
As to the first, perspectives of the two professions—medicine and nursing—are now clearly
different. Medicine has become more specialized in an attempt to keep abreast of technological
changes and increased knowledge, whereas nursing has become more generalized and holistic in
its approach to health care.
Second, medical-surgical nursing was disease-based, psychiatric nursing was patient-based,
and community health nursing was locus-based. Many schools determined that using specialty
departments as organizing components of the curriculum was no longer efficient; many now offer
a series of concepts basic to nursing, along with the nursing process, and they loosely refer to
these as an integrated curriculum. One of the outcomes is that the specialties are no longer clearly
distinguishable. Also, movement from the hospital setting to the university, as well as changing
patterns of illness, have reinforced this direction.
Third, the new conceptual system in nursing provides direction for practice and educa-
tion. However, none have delineated the role of the specialties. The role of nursing specialties
is supported, nonetheless. The authors bring to their aid the social policy statement on nursing
by the American Nursing Association (ANA): “The effectiveness of the profession is increased
when specialists are available to focus their efforts on a particular aspect of clinical nursing, to
test application of newly available theory to conditions germane to that clinical aspect, and to
translate those theory applications into nursing approaches considered more useful than pre-
vailing ones.”
It appears that nursing specialties can best contribute to nursing science by generating and
testing middle-range or limited-size theories. This type of theory is more directly relevant for
addressing practice concerns. As practice-relevant theory is developed and refined in each spe-
cialty from its particular vantage point, the specialty contributes to nursing science through both
cumulative and didactic processes.
The article concludes with a brief discussion of the theory development process (inductive,
deductive, adapted) and a sustained example drawn from mental health nursing, where a concept
from nursing, “mutual withdrawal,” is identified and traced through its history.
This article is especially important for its focus on a perhaps as yet unassimilated conse-
quence of recent developments in nursing: the de-emphasis of the specialties.
Newman, M.A. (1972). Nursing’s theoretical evolution. Nursing Outlook, 20(7), 449–453.
Following a brief discussion of the evolution of nursing science, Newman elaborates on three
main approaches to the discovery of nursing knowledge that emerged during the 1960s: (1) the
borrowing of theory from other disciplines with an intent to integrate it into a science of nursing;
(2) an analysis of nursing practice situations in search of the theoretical underpinnings; and (3) the
creation of a conceptual system from which theories could be derived. While limitations and diffi-
culties in the first two approaches are discussed, Rogers is credited with initiating the third phase.
The clear-cut delineation of the individual as the focus of nursing gave direction to the develop-
ment of theory that is basic to nursing.
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CHAPTER 19 Historical Writings in Theory 463
Newman cites Hempel to evidence the value of the Rogerian approach and, by comparing
Rogers with other nurse theorists, concludes that a conceptual system of nursing is evolving and
does provide meaningful direction for research. Whether the theory evolves inductively from
ideas conceived in clinical practice or deductively from broad generalizations within the theoreti-
cal framework does not seem particularly important. What is important is that the nursing investi-
gator should determine the relationship of her study question to the overall conceptual system in
nursing and should therefore expand and elaborate the system by the testing of theories that have
derived from it. Nursing is coming of age.
Newman’s article should be contrasted with that of Hardy, who sees nursing in a “preparadig-
matic” stage (from Kuhn). She cites the problem of the past as a dearth of nursing knowledge,
while “the problem of the future will be an acceleration of that knowledge.” Has this prediction
been realized in the 20 years since this article was written? How does your answer attest to the
veracity of Newman’s characterization?
Notter, L.E. (1975). The case for nursing research. Nursing Outlook, 23(12), 760–763.
Slow progress in nursing research is attributed to views of nursing and women, too little
cumulative effort, and the relatively new idea of nursing as an intellectual profession. The follow-
ing are areas for concentrated effort: the need for more research based on theories consonant with
nursing’s domain of responsibility; the need for replication; the need for postdoctoral research and
for individual researchers who select a problem area and continue to study it over time; and the
need for more service agencies to develop clinical research programs that encourage staff partici-
pation in research.
Payne, G. (1973). Comparative sociology: Some problems of theory and method. British Journal of Sociology,
24(1), 13–29.
Comparative sociology is a method of inquiry that allows “explicit testing of sociological the-
ories with data from various sources” and that examines “the nature of society as revealed by . . .
the operation and interrelation of key processes in different societies, or areas of societies (histori-
cal, geographical, social)” (p. 13). The interrelationship of theory and method in the generation of
social theory is examined, with emphasis on methodological issues in comparative analysis.
Societies that are similar in regard to a specific variable (e.g., form, function, or structure) are
studied to generate laws that explain that one type of society only. Problems inherent in this
approach are categorization (defining categories and determining an acceptable level of similar-
ity) and generalization (producing theories that have more than specific application). The purpose
of comparing dissimilar societies is to yield universal laws. Defining and determining the appro-
priate scope of variables, as well as developing specific, meaningful hypotheses, are major diffi-
culties. In both approaches, problems develop in selecting study variables and studying them
outside of their cultural context. Nevertheless, the comparative method provides not only under-
standing and insight but also a means of verifying theory and developing a science of sociology.
This is an excellent, substantive article on a particular methodology for the development of
theory and science. Issues and problems of comparative study are addressed, and insight is given
on the relationship of theory and methodology. What is missing in clarity of expression in this arti-
cle is more than counterbalanced by the salience of ideas and the potential for applicability to
nursing science development.
Payne, L. (1983). Health: A basic concept in nursing theory. Journal of Advanced Nursing, 8(5), 393–395.
The article traces the historical evolution of the concept of health. For centuries, disease has
been the central focus for the examination of the phenomenon of health. Only one major formula-
tion (Sigerist’s in 1941) preceded the critical turning point statements in the constitution of the
World Health Organization (1958): “Health is a state of complete physical, mental, and social
well-being and not merely the absence of disease and infirmity.”
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464 PART SIX Our Historical Literature
Various paradigms have subsequently been developed, among them the ecological model,
based on the relationship of people to the total environment (Blum, 1974; Rogers, 1960), and the
equilibrium model, based on the body’s self-regulatory powers to maintain constancy of the inter-
nal milieu (Dubos, 1965). Psychosocial models came later: sociocultural, philosophical, or relat-
ing health to notions or normality. A new emphasis on quality of life and high-level wellness
emerged (Dunn, 1959) due to people’s dissatisfaction with life despite their affluence; the idea of
holism, originating in Gestalt theory, grew to a multidimensional approach, emphasizing self-
responsibility, the whole person, and the process of care-giving; and the “salutogenic” model of
health (Antonovsky, 1979) originated, in which “the origin of health lies in a ‘sense of coherence,’
that is, the way in which one sees life as meaningful, manageable, and comprehensible.”
Assumptions based on traditional paradigms have bound nursing curricula and practice to the
negative view of health in terms of absence of disease. “The concept of health constitutes a basic
building block for nursing theory. . . . If the goal of nursing is the promotion of health, making this
concept operational is essential for nursing practice.” Finally, a definition of health is offered (a
nursing concept of health): “Health is the effective functioning of self-care resources that ensures
the operation and adequacy of self-care actions.”
The article combines some history, some popularization, some commonplace information,
and perhaps some helpful reminders.
Peterson, C.J. (1977). Questions frequently asked about the development of a conceptual framework. Journal of
Nursing Education, 16(4), 22–32.
The relationship between theory and conceptual frameworks in nursing is examined. A con-
ceptual framework is defined as “a loosely organized set or complex of ideas . . . that provides the
overall structure of a curriculum (p. 25).” A theory is defined as a group of systematically interre-
lated propositions that provides organization to a body of content and, by allowing explanation
and prediction, provides a guide for practice. A conceptual framework is an earlier evolutionary
step that may be developed into theory, thus generating testable hypotheses.
Essential elements of a conceptual framework include the nature of the service provided (nurs-
ing/nursing process), goal or outcome (health), rationale for services (nonhealth or illness), charac-
teristics of the care-giver (nursing practitioner), characteristics of the recipient (patient/client), and
context for service (care setting or environment). Explanations of the relationships of these con-
cepts provide the framework.
The relationship of the conceptual framework to borrowed theories, program philosophy and
objectives, and curricular threads, as well as its role in the development of a nursing curriculum,
are also addressed.
This is an excellent article that demystifies the conceptual framework in a thorough, organ-
ized, and articulate manner. While emphasizing the use of conceptual frameworks in nursing cur-
ricula, the article provides much useful material on theory components (including simple but
excellent definitions) and theory development. Excellent figures summarize major points. Peter-
son’s selection of concepts may be compared with those of Dickoff and James, and her presenta-
tion of the conceptual framework should be contrasted with that of Torres and Yura.
Phillips, J.R. (1977). Nursing systems and nursing models. Image, 9(1), 4–7.
Because the primary goal of nursing theory is the generation of knowledge specific to nurs-
ing, the process of theory building must be couched in a nursing frame of reference. Otherwise,
the obtained knowledge will not be nursing knowledge that can be used to build or expand nursing
science, or that can be used for nursing education, practice, or research. Models that nursing has
borrowed (medical, psychological, ecological, social) are criticized on the grounds that not one of
them views the person as a totality in interaction with the environment. Models of Rogers and
Johnson are proposed as frameworks for nursing theory construction.
There are many points of agreements between the arguments of this article and one by
Newman (1972). Although some good points are made about shortcomings (e.g., of the medical
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CHAPTER 19 Historical Writings in Theory 465
model), many of the arguments could be further developed. Are there any legitimate prototypes
outside of nursing?
Putnam, P. (1965). A conceptual approach to nursing theory. Nursing Science, 3, 430–442.
A theoretical framework is valuable as a stimulus in the development of nursing science. In the
absence of adequate theory, nursing is limited by the concrete here and now; nursing then becomes
restricted to immediate impressions and is unable to explain the past, evaluate the present, or predict
the future. Despite the clear necessity of a generalized theory, development has been slow and piece-
meal; contributing factors include complexity of the subject matter, the proximity (and therefore
influence) of the scientist to the empirical data, and the necessity of delimiting a knowledge base
that will encompass changing objects in changing environmental fields.
A key to the conceptual maze is the identification of the unique domain of nursing. The
knowledge base of the nursing process, nursing science, is at least a four-dimensional synthesis of
knowledge relating to biological function, psychological function, social function, and variations
in organization of these factors. The operational identification of the intermixture of components
in the synthesis, defined and tested through nursing research, would be a genuine contribution to
science. Nurses make it possible for patients to accomplish their own energy exchanges with the
external environment. The abstraction of the idea of how nursing makes these exchanges possible
is an essential step in theory construction. The constant interplay among theory, practice, and
research is stressed.
Although other articles provide more cogent arguments for the value of nursing theory, more
enlightened definitions of nursing, or more pragmatic suggestions for theory development, Put-
nam is particularly eloquent on the problems of lack of adequate theory, the characteristics of con-
ceptual difficulties in nursing theory, and the need to identify the unique domain of nursing.
Quint, J.C. (1967). The case for theories generated from empirical data. Nursing Research, 16(2), 109–114.
This work discusses a research approach in which a given problem area is studied for the
purpose of developing a conceptual framework. Sections are devoted to the research problem and
its overall design, the collection and analysis of data, and the reporting and interpretation of the
findings.
This article is the precursor of an approach that has gained increased interest and credibility
in the ensuing years.
Rogers, M.E. (1963). Some comments on the theoretical basis of nursing practice. Nursing Science, 1, 11–13, 60–61.
This substantive article contains many of the elements that would later be incorporated into
Rogers’ Introduction to the Theoretical Basis of Nursing (1970). It is recommended that this be
read prior to reading the book, but it is not a requisite to understanding the theory.
There is a mix of philosophy, definitions, concepts, and goals—all about life, human beings,
nursing, and nursing science. Elements of the prototype theory—systems theory—are also pres-
ent. These are presented not as a theoretical basis of the nursing process but rather “to stimulate
logical and creative thinking concerning its identification and development.” Despite Rogers’
intent, however, a rudimentary structure of the future theory appears to be taking shape here.
First, the philosophical statements and beliefs are presented, along with assumptions about
human beings. Nursing is defined as a process, and the goal of nursing is also stated. The concept-
building process is discussed, with one concept—the life process—presented. Principles rest on
the definitions of the concepts, and principles are integral to nursing science. As an example of a
basic principle in nursing science, the adaptive mechanism in human beings is identified. Rogers
states, “The human organism has an amazing, innate capacity to adapt: physically, biologically,
socially.” (An assumption!) The purpose of a principle is not discussed in detail.
Finally, Rogers says that the theoretical basis of nursing practice must include a philosophy and
a concept of death as well as life. However, she does not undertake that task. Furthermore, although
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466 PART SIX Our Historical Literature
the term “health” was used, it was not defined. Nor does Rogers discuss the role of nursing as it
relates to or interfaces with other health care givers. These, then, are a few limitations of this article.
The purpose of this article is to stimulate thinking concerning the identification and develop-
ment of nursing science—the theoretical basis of nursing practice. Nursing science is a body of
scientific knowledge characterized by descriptive, explanatory, and predictive principles about the
life process of human beings. These principles rest on the review of the person as a unified “bio-
physicalpsychosocial” phenomenon in constant interaction with all parts of the environment. The
body of knowledge develops through synthesis and resynthesis of selected information from the
humanities and the biological, physical, and social sciences in order to form new concepts and
understanding about the person and environment. It assumes its own “unique scientific mix”
through selection and patterning of this information. The focus of nursing science is central to the
formation and understanding of its theories. This focus is elaborated in the remainder of the article.
This is one of the original and most influential articles by one of nursing’s true sages. This
article, along with that of Johnson (1959), ushered in the era of nursing theory and nursing sci-
ence. Rogers’ characterization of nursing science has been a source of challenge and inspiration,
and sometimes conflict, to all subsequent nurse philosophers and theorists.
For its historical importance and strength of argument, this article should definitely be read.
An introduction to Rogers’ theory is an added bonus.
Rubin, R. (1968). A theory of clinical nursing. Nursing Research, 17(13), 210–212.
This article is part of the 1968 Symposium on Theory Development in Nursing. It is a brief
and simple example of development of a model and its use in research.
Silva, M.C. (1977). Philosophy, science, theory: Interrelationships and implications for nursing research. Image,
9(3), 59–63.
This is an overview of the relationships among philosophy, science, and theory, with implica-
tions for the conduct of nursing research. Science developed into specializations; philosophy “uni-
fies scientific findings so that man as a holistic being might emerge.” Science aims to describe,
understand, predict, control, or explain phenomena. Theory refers to a set of related statements
that have been derived from scientific data and from which plausible hypotheses can be deduced,
tested, and verified.
Implications for nursing research: (1) All nursing theory and research is derived from or leads
to philosophy, (2) philosophical introspection and intuition are legitimate methods of scientific
inquiry, and (3) nursing knowledge arrived at by the scientific method too often sacrifices mean-
ingfulness for rigor.
The author argues that no real distinctions are made between different kinds of knowledge
until the Industrial Revolution; Darwin and Freud set off a proliferation of knowledge. This
appears to ignore much great work, including the obvious contributions of Francis Bacon. Silva’s
comparisons of the realms of philosophy, science, and theory are good beginnings in nursing. Her
pleas for the recognition of nonscientific ways of knowing deserve attention.
Silva, M.C. and Rothbart, D. (1984). An analysis of changing trends in philosophies of science on nursing theory
development and testing. Advances in Nursing Science, 6(2), 1–13.
The philosophy of science and nursing theory are in states of transition. Has nursing theory
kept pace with new trends in the philosophy of science?
Two competing schools in the philosophy of science are traced and examined: logical empiri-
cism (1940s–1960s) and historicism (1960s–present). The schools are compared in terms of their
views of science: (1) its components, (2) its characterization, and (3) its outcomes.
Components: For logical empiricism—deductive system, theories linked to and tested
through empirically observable properties; for historicism—research tradition that includes
many theories, ontological commitments, and methodological commitments.
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CHAPTER 19 Historical Writings in Theory 467
Characterization: For logical empiricism—product, scientific knowledge, theory validation;
for historicism—the human activity of working scientists, theory discovery.
Outcome: For logical empiricism—verification leading to a body of truth; for historicism—
problem-solving effectiveness.
There follows a review of the literature in nursing theory. Three time periods are examined:
1964–1969, 1970–1975, and 1976–present.
1964–69: Logical empiricist position everywhere (e.g., Dickoff and James, Abdellah. The
exception—Leininger offered an ethnoscience research methodology.
1970–75: Culmination of logical empiricism in Jacox and Hardy; conceptual frameworks;
“The irony is that . . . the logical empiricist viewpoints espoused were being strongly
repudiated by a growing number of philosophers of science. . . . [N]ursing’s theoretical
link to philosophy of science was . . . about a decade behind the times.”
1976–present: Continued commitment to logical empiricism; a beginning trend toward his-
toricism (e.g., in Newman, Hardy); revisions of conceptual frameworks and introduction
of new ones, moving more explicitly toward logical empiricism; questioning of strictly
quantitative methods.
Implications: (1) There should not be a single conceptual framework for nursing; (2) there
will never emerge a static set of eternal truths; (3) historicism strongly encourages a care-
ful study of actual practices, belief systems, and external factors; (4) the assessment of
progress will be more practical (i.e., problem solving).
Important recommendations: (1) Cooperation among nursing theorists, researchers, clini-
cians, and scholars; (2) exploration of innovative qualitative methods.
Because this article presents itself as expository rather than argumentative, the major ques-
tions are: Should one, after all, be trendy and in line with the latest fashion in the philosophy of
science? In what ways do the ultimate recommendations differ from what Dickoff and James
would suggest?
Stainton, M.C. (1982). The birth of nursing science. The Canadian Nurse, 78(10), 24–28.
“The birth of nursing science” celebrates the coming-to-terms of the new science by review-
ing its history and describing the conditions necessary for its development. The history is detailed
despite its brevity and is told in a lively style, with the added perspective of the author’s Canadian
nationality and focus.
The list of developmental requirements includes a perception of nursing as a developing science
in the minds and hearts of all nurses; a sense of the significance of each nurse’s contribution; a cadre
of nursing scientists; the conceptualization of nursing as a science; nursing research teams; monies;
the introduction of nursing science to science in general; research and facilities in major centers of
nursing; collaboration and international networks; replication of studies; nursing education at all lev-
els of career development; an individual goal of professionalism; and an expectation that one day a
nurse will be the recipient of the Nobel Prize for excellence in contributing to science.
The significance of this article should be considered in terms of its effects on the intended
readership.
Tinkle, M.B. and Beaton, J.L. (1983). Toward a new view of science: Implications for nursing research. Advances
in Nursing Science, 5(2), 27–36.
This article begins by pointing to two oppositions: the “hard” versus the “soft” science debate,
and the opposition between traditional historians of science and the “historicist” revisionists, such
as Kuhn and Laudan. These oppositions are associated and identified in Sampson’s formulation as
Paradigm I versus Paradigm II. “Context-free generalizations” comprise the object of Paradigm I;
research guided by the view of Paradigm II is “often conducted in naturalistic settings, using obser-
vational methods.”
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468 PART SIX Our Historical Literature
The authors further contend that the dominance of Paradigm I science is a result of “nourish-
ment it has received from a male-dominant, Protestant-ethicoriented, middle-class, liberal, and
capitalistic society.” The implications for nursing are multiple. If scientific truth is acontextual,
then little attention is likely to be paid to the values and biases underlying research endeavors, so
that methodological biases or determinations of proper research subjects may go unexamined.
Further, nursing is, at its most basic level, a relational profession. However, acontextual study
is not likely to focus on interpersonal or person–situation interactions. Such studies are apt to lack
“ecological validity” and to be removed from the “real world.”
The overarching conceptualization of nursing that can be abstracted from nursing theory is
centered around the view of a human being as a holistic being. Nursing involves each person’s
unique bio–psycho–social context. The impact of the environment is a recurrent theme. Sociocul-
tural context is stressed. However, the experimental method is also held in the highest regard.
“What is proposed is a blending of both methodologies to produce a science that retains a
critical concern for objectivity while ensuring that the research it produces has validity in the real
world and the influence of contextual variables is acknowledge.”
This article suffers from the very problems it indicts. It is too abstract and general (i.e., it
rarely provides examples of the kinds of studies it talks about), and when, as in two references to
women’s studies in psychology, it moves toward some specificity, the work is simply alluded to. It
is also too far from real life; the proposal for blending the two methodologies in a future state
moves toward the mystical: “This new synthesis will not consist of the use of Paradigm II methods
in the context of discovery and the use of Paradigm I in matters of verification. Rather, a conver-
gence will involve the higher organization of the opposites in both paradigms.”
Nevertheless, the point of the article—that we must have an explicit awareness of the assumptions
and biases underlying our methods (particularly, in this case, sexist ones)—commands our assent.
Tucker, R.W. (1979). The value decisions we know as science. Advances in Nursing Science, 1(2), 1–12.
Tucker argues that the processes of science necessarily involve the making of value judg-
ments (versus the ubiquitous image of science as “value-free”). After classifying value judgments
along their dimensions: rationale (personal versus objective), subscribership (individual versus
“market”), and explicitness (formal versus contextual), he discusses the “value decision making
contexts in research.” Tucker’s position is that each step of the research process—from selection
of a problem, theoretical framework, and methodology to analyzing and reporting data—involves
value judgments. The principal activity of science is to make well-supported value judgments.
Tucker encourages an explicit awareness of “the value decisions we know as science.” There
are some valuable insights in this article—if you can avoid getting hung up on the PVJs, CVJs,
and VDMCRs.
Wald, F.S. and Leonard, R.C. (1964). Toward development of a nursing practice theory. Nursing Research, 13(4),
309–313.
Nursing practice theory—based on the empirical approach of building knowledge directly
from systematic study of nursing—is proposed as an alternative to “making borrowed concepts
fit.” In developing its own theories, nursing would become an independent discipline in its own
right. In freeing themselves from the burden of looking only for applications of the basic sciences
in their practice, nurses would at the same time take on the responsibility of developing their own
science. This calls for the development of nursing practice theory.
Major sections of this article deal with: (1) the fallacy of nursing as an applied science
(“accepted” principles may be invalid or inappropriate to nursing, nursing problems are being
rephrased as social science cues rather than cues of practice); (2) characteristics of research methods
for practice versus descriptive science (the difference lies in the selection of variables and the kinds
of hypotheses that are entertained); (3) characteristics of practice versus descriptive theory (practice
must contain causal hypotheses); and (4) barriers to the development of research of practice theory
in nursing (related to research attitudes, need to generalize, and skill in research methods).
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CHAPTER 19 Historical Writings in Theory 469
This is the first article written on practice theory in nursing and should definitely be read.
Those interested in nursing theory should certainly contrast “the fallacy of nursing as an applied
science” with the more prevalent view of how nursing science is developed. In addition, consider
the process of practice theory development presented by Wald and Leonard (p. 311) that is clearly
a precursor to the influential work of Dickoff, James, and Wiedenbach.
Weatherston, L. (1979). Theory of nursing: Creating effective care. Journal of Advanced Nursing, 4(7), 365–375.
Effective nursing care requires a theory of nursing—a phrase that connotes the interdepend-
ence between the two concepts. Conceptual analysis of “nursing,” using Wilson’s “model case”
method is presented as a way to determine the “essence of nursing,” and provides a basis for
deciding what nursing theory is. The purpose of theory is to explain, predict, or control phenom-
ena. In order to be a theory of nursing, “the theory must be created and used with reference to the
unique functions and intentions of nursing and the nature of nursing activity.” The relationship
between “microtheory” and “paradigmatic theory” are described. A model is developed to demon-
strate the relationship of theory, practice, and education.
This article addresses several key issues, including the “essence” of nursing; the relationships
among theory, practice, and education; and the rationale for and process of theory building in
nursing. However, more sophisticated treatments of each of these subjects are available elsewhere,
and should be read first. Many of the article’s shortcomings are related to the nonevaluative use of
several frameworks and definitions: Wilson’s Model Case method, Peter’s criteria for education,
and conceptions of nursing that do not stress its scientific aspects.
SECTION II
Abstracts of Writings in Nursing Theory, 1960–1984
Afaf Meleis and Sandra Scheetz
The citations abstracted in this section pertain to selected central writings related to only six of
the nurse theorists presented in this text (Johnson, Levine, Orem, Rogers, Roy, and Travelbee). Only
selected writings related to each of the theorists and others’ writings (based on theories) are described
and analyzed below. The abstracts presented in this section are organized alphabetically, according to
theorist and author. This section is best used in conjunction with Chapter 3 and with the corresponding
chapters in the text that focus on the analysis of the particular theory (Chapters 6, 8, 11, 12, 13, and 18).
DOROTHY JOHNSON
Auger, J.R. and Dee, V. (1983). A patient classification system based on the behavioral system model of nursing:
Part 1. Journal of Nursing Administration, 13, 38–43.
This first article of a two-part series focused on the development of a patient classification
system based on a nursing model, and it was presented from the combined perspectives of admin-
istration and clinical practice. Part 2 (Dee and Auger), to follow, focused on the implementation of
the classification system in the clinical setting. The nursing model used was Johnson’s behavioral
system model and the clinical setting was psychiatric.
The specific intent of such a classification system was for use “as a clinical measure of
patient progress in addition to the administrative determination of staffing levels” (p. 38). The
importance of a framework common to both was stressed. The rationale for such a classification
system versus the use of an existing classification system was discussed.
The rationale for using the Johnson behavioral systems model as the theoretical framework for
the classification system in this psychiatric setting was threefold: (1) it could be used with the exist-
ing programs based on social learning theory; (2) it could be applied to all clinical settings because
of the emphasis on bio-psychosociocultural factors; and (3) it identified universal patterns of
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470 PART SIX Our Historical Literature
behavior applicable to all individuals. The model addresses the eight subsystems outlined by
Johnson: ingestive, eliminative, sexual, dependency, affiliative, achievement, aggressive–protective,
and restorative. These subsystems of behavior are “assumed to be universal and of primary signifi-
cance to all persons” (p. 39).
Integrated with the nursing process, the model provided a focus for the assessment phase and
is intended to link specific patient behaviors with their corresponding nursing interventions. Fur-
thermore, the model can be used in clinical settings other than psychiatry.
The development of the classification tool began with certain people addressing the nursing
care requirements for patients admitted to either the adult or child psychiatric units of the agency
where it was developed. Therefore, the tool had to be both comprehensive and flexible enough to
describe behaviors reflective of a wide variety of diagnoses and age groups. To meet this chal-
lenge, a group of expert clinicians and nursing administrators was organized to develop the tool.
The criteria for item inclusion reflected several dimensions. First, each of the eight subsys-
tems of the Johnson behavioral system model were operationalized in terms of both adaptive and
maladaptive behaviors. The behavioral statements had to meet four criteria: “measurable, relevant
to the clinical setting, observable, and specific to the subsystem” (p. 39). A panel of experts then
evaluated the statements to make certain that they met the four criteria. The behaviors were also
ranked in one of three categories according to their level of adaptiveness, with one being the most
adaptive and three being the least adaptive, or maladaptive. Nursing interventions were also
ranked according to requirements for intensity and frequency of nursing contact. A fourth level
was included to reflect the intensity of one-to-one nursing care required for extremely maladap-
tive behavior.
After the initial set of critical behaviors were formulated, they were tested by letting a sample
of 28 registered nurses, in pairs, serve as observers on seven inpatient units. “Each pair of
observers was asked to rate each subsystem of behavior for all patients present on the unit during
the shift. In addition, the observers rated the overall level of behavior for each patient” (pp. 39–
40). Several exhibits were included to illustrate some components of the process thus far: first, the
eight subsystems, definitions of behaviors, and critical behavior characteristics; second, character-
istic patient behaviors and the requisite nursing intervention; and third, samples of level three
(maladaptive) patient behaviors and nursing interventions for the eliminative and affiliative sub-
systems.
The implementation of the system was described briefly, with mention of the steps taken. The
description does not provide adequate information for anyone trying to duplicate the process.
However, more depth was included in Part 2.
Preliminary testing of the tool revealed several problem areas associated with patient assess-
ment. There were disagreements among staff about ratings of patient behaviors, although it was
recognized that these reflected difficulties inherent in defining and measuring behaviors. Observer
bias was also an uncontrolled variable associated with measurement of patient behaviors. The two
subsystems with the highest level of agreement were eliminative and sexual, probably because
these required the least inference on the part of the observers. The subsystems of affiliative,
dependency, and achievement—requiring a higher level of observer inference—were found to
have lower levels of observer agreement in this preliminary testing.
The importance of minimizing the influence of observer interpretation was recognized, but
only one suggestion about how to accomplish this was made, other than through the use of a
model to structure the observed behaviors. The suggestion was for staff to “consistently identify
and discuss their observations of patient behavior to develop a common frame of reference and
achieve a higher degree of agreement (p. 43).” Instrument testing (specifically, measures of con-
tent validity), reliability, and improving interrater reliability would also be important contributions
to theory validation. In the long run, these would do more to contribute to the overall theory devel-
opment and concept measurement. This is the next important step to be taken with the work done
this far on the classification tool.
A number of the classification tool’s administrative benefits were listed. They all reflected
factors influencing decisions that considered cost-effectiveness and quality-of-care issues.
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CHAPTER 19 Historical Writings in Theory 471
Broncatello, K.F. (1980). Auger in action: Application of the model. Advances in Nursing Science, 2(2), 13–23.
It has long been proposed that continued development of conceptual models is an important
part of the development of nursing as a science; it is also a given that a part of the continued devel-
opment of models is application of the models in a variety of practices. However, what has
become increasingly apparent in the 1980s is that application of the model to practice is insuffi-
cient for theory refinement. This article is a good example; although it demonstrates application to
practice, it does not offer extension or refinement, neither of which are possible in single-case
application.
There are several other limitations. After giving a fairly extensive review (summary) of
Auger’s application of the Johnson behavioral system model to the chronically ill hemodialysis
patient, the author attempts to apply the model using new concepts that are not central to either
Johnson’s model or the extension offered by Auger. The section about applying the model begins
with a discussion of self-concept and body image. A reader could rightfully question the fit of
these concepts with the behavioral systems model.
Stressors are identified that could be extrapolated from the model, including diet, which
affects the eliminative subsystem, and dependence on a machine, which sounds as if it were
related to the aggressive–protective subsystem, although logically, it is more directly a problem of
the dependence subsystem. Careful analysis of relationships with Auger were better provided in
the next section, on the model in practice. Here, the author proposes to examine the consequences
of hemodialysis on the eight subsystems outlined by Auger. The reader may continue to remain at
a loss as to where body image and self-concept fit in the analysis.
This article provides labeling of nursing problems experienced by the chronically ill hemodial-
ysis patient. The author also discusses interventions within the Johnson-Auger subsystems.
Dee, V. and Auger, J.R. (1983). A patient classification system based on the behavioral system model of nursing:
Part 2. Journal of Nursing Administration, 13(May), 18–23.
The patient categorization tool (see Auger and Dee, Part 1), a major component of the classi-
fication system outlined in Part 1, provided a basis for the clinical application in terms of the nurs-
ing process in a child psychiatry inpatient setting. It was designed to be both comprehensive and
flexible enough to allow its use with clients with a variety of diagnoses, as well as a wide age
range. (How this was implemented was the subject of Part 1.) What was required by way of inpa-
tient unit revisions is the focus of this second part.
The plan for developing materials and teaching strategies required revision of nursing assess-
ment forms, teaching materials, staff seminars, and orientation of new employees. First of all,
inpatient unit nursing assessment forms had to be revised to reflect the model. What had previ-
ously been two six-page assessment forms were replaced by four-page forms designed to assess
patient factors or behaviors based on the Johnson model. Whereas the earlier forms had been spe-
cific to the patient populations, the new assessment form was specific to the Johnson model and
was therefore useful in all clinical settings. In view of the fact that nurses vary in levels of educa-
tion, clinical experience, and abilities, an interview guide was constructed to assist the nurses in
eliciting information from the patient and family. The questions included reflected content from
the eight subsystems of the Johnson Behavior System Model (JBSM) as they related to the spe-
cific psychiatric setting and patient population.
The clinical nurse specialists (CNS) and the nursing coordinators (NC) of each unit devel-
oped a package of the teaching materials to illustrate the clinical application of the model. “The
materials consisted of samples of completed nursing assessment forms, nursing care plans, and a
list of recommended readings pertinent to the behavioral systems model and each subsystem”
(Dee and Auger, 1983, p. 19).
Two exhibits contribute to the overall presentation of the teaching materials developed; these
stand alone, not needing additional narrative to describe them to the reader. Exhibit 1 illustrates
two pages of the nursing assessment form (with sample data) developed for one of the specific
inpatient units; Exhibit 2 shows portions of a sample nursing care plan based on the assessment.
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472 PART SIX Our Historical Literature
Staff seminars conducted totaled four hours and were required for all nursing staff on each
unit. These were followed up by actual application on the units. All newly admitted patients were
assessed, and care plans were developed based on the model using the new materials. Integration
and follow-up of the nursing process was provided by the CNS through weekly nursing care plan
meetings or individual clinical supervision.
The orientation of new employees consisted of didactic presentations of purpose and theory,
audiovisual materials of examples of different levels of patient behaviors and the corresponding
nursing intervention, and unit orientation. Subsequently, the orientee was required to complete a
nursing assessment and care plan with supervision from an experienced R.N.
While theoretical advantages of using the model were anticipated, the practical advantages
were realized only with continued use. There were many practical advantages. Some of the clini-
cal advantages included more systematic patient behavioral assessment, resulting in a comprehen-
sive baseline of behavior at time of hospitalization; more specific and expedited nursing care
plans; a focus on patient strengths versus pathology; and improved monitoring of patient behavior
over the course of hospitalization. These factors consequently provided more objective means for
evaluating the quality of nursing care.
Administrative advantages included improved ability to determine required levels of staffing
based on more accurate assessment of patient behaviors, and also a more appropriate assignment
of new admissions to a unit based on the level of patient need and level of staffing available, thus
achieving a better match of patient needs with staff resources. The corollary would then be that, as
the overall identified need rose and fell, staffing levels could be raised or lowered accordingly,
affecting (conversely influencing) scheduling, budgeting, and nursing hours. Overall efficiency in
the integration and balance of scheduling, budgeting, and nursing hours would be improved,
resulting in more cost-effective management.
Although the work was written primarily for administrators and clinicians, this scholarly
approach to applying theory to practice demonstrates the utility of the JBSM for practice in vari-
ous inpatient psychiatric units and gives direction to research. It also provides a working model of
the “how to” in implementing theory in a practice setting and provides a blueprint for those who
might choose to implement this or another theoretical model. (See more recent publications by
Dee under Johnson references in Chapter 20.)
Derdiarian, A.K. (1983). An instrument for theory and research development using the behavioral systems model
for nursing: The cancer patient, Part I. Nursing Research, 32(4), 196–201.
Clearly stated by the author in the introduction are both the main purposes of the research
carried out and the scope and content of each part of this two-part series. The purpose was to
develop a valid and reliable research tool to describe the behavioral changes of cancer patients as
perceived by them. The research was conceptualized from the behavioral system perspective, and
therefore much of the content of Part I is a synopsis of the Johnson behavioral systems model for
nursing. For a reader who is unfamiliar with the model, this is an excellent review. The author’s
concise writing style makes the theoretical overview quite understandable, and the author remains
true to Johnson’s original work. Each of the seven subsystems (achievement, affiliation, aggres-
sive–protective, dependence, eliminative, ingestive, and sexual) and the eighth subsystem that was
added later (restorative) are reviewed, terms are defined, and relationships among concepts are
spelled out. The goal of nursing is also stated.
In the rest of the article, the author reviews the support from the literature for the existence of
each subsystem, both from work by Johnson and Auger, as well as from others writing on the
same topic. The author then identifies the major dimensions extrapolated for each of the subsys-
tems. The impact of cancer on each subsystem is then described using previously reported
research. The Johnson model provides a conceptual reservoir within which research findings find
a coherent existence.
This is a fine example of how theory can be used to guide research findings. The author then
presents a table containing each subsystem, the determinants of behavior, and behavioral manifesta-
tions. It is upon these that the variables of interest for measurement were based. These then comprised
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CHAPTER 19 Historical Writings in Theory 473
the items of the instrument developed by the author. The development of the items and the frequencies
in the table are not clear to the reader, and are incongruent with the theoretical discussion. The table
fits in with Part II of the article, published in the next issue, where it is discussed and described.
Derdiarian, A.K. and Forsythe, A.B. (1983). An instrument for theory and research development using the behav-
ioral systems model for nursing: The cancer patient, Part II. Nursing Research, 32, 260–267.
The focus and scope of Part II of this two-part series is on the process of establishing validity
and reliability for an instrument that will test perceived behavioral changes of cancer patients,
based on Johnson’s behavioral systems model. One hundred twenty-one change items, based on
each subsystem, were delineated from previous research and were given to a homogeneous sam-
ple of 163 cancer patients. The criteria for subject inclusion and exclusion are listed. The authors’
rationale for the “limitation of selection criteria was to maximize the homogeneity of the sample
in terms of salient intervening variables such as visible, extensive body disfigurement, level of
awareness, comprehension, absence of additional stress caused by a new treatment or procedure,
and variables of adult life cycle (p. 261).” What is not clear is why there are such broad parameters
for inclusion of subjects. The extreme age variation (20–70), various cancer diagnoses, and range
of treatments do not logically suggest a homogeneous sample to achieve the desired results.
Patients were asked to identify changes they perceived happening due to or since they
became ill and to add or subtract changes. They were also asked to indicate quantitatively and
quantitatively the extent of the changes and, finally, their perceptions of the consequences of the
changes. Figure 1 in Part I presents the frequency distribution of responses. The authors did not
discuss what decisions they made based on these frequency distributions.
Several approaches were used to estimate the instrument’s content validity and reliability.
What appears to be the first step was to use an expert panel of six members, divided into two
groups. “The first group evaluated the comprehensiveness of the theoretical framework and its
consistency with known theories, and the consistency of the operational definitions with the theo-
retical framework. The second group evaluated the consistency of the operational definitions with
the categories and the times. The panel judged independently” (p. 262). A supplemental assess-
ment of empirical validity was done using the theta coefficient estimation, which was derived
from a factor analysis.
Described later in the “method” section are two other methods of evaluation of comprehen-
siveness. Here, a panel of three clinical nurse specialists in oncology independently judged the
“other” changes added by the patients (p. 262). Because of these various methods used to evaluate
comprehensiveness, some confusion is generated about the sequential timing of these evaluations,
as well as about when the pilot testing and the reliability testing were completed.
The Derdiarian behavioral system model (DBSM) instrument was pilot tested after construc-
tion and estimation of content validity, using three male and three female subjects. Test–retest relia-
bility was assessed by administering the instrument to, apparently, all 163 subjects. The instrument
did not have identifying information on it, and “a randomized permutation schedule always places a
subsystem questionnaire designed for retesting for reliability in the third place in the sequence of the
subsystem questionnaires” (p. 262). Time to complete the instrument as reported by subjects was
approximately 1.75 hours. After a 15-minute respite, the patient was asked to complete the retest
subsystem questionnaire.
Also evaluated in the overall process was the performance of each of the eight trained
research assistants. Interviewer reliability was an ongoing concern, as manifested by regular
review of the tapes and rating of the interviewer behavior by two independent raters who were not
involved in the data-gathering process.
Grubbs, J. (1980). An interpretation of the Johnson behavioral system model for nursing practice. In J.P. Riehl and
C. Roy (Eds.), Conceptual models for nursing practice. New York: Appleton-Century-Crofts.
The purpose of this article is an attempt to operationalize the model so that it could be used as
a systematic guide to nursing practice. The author indicates that this is her own interpretation of
the Johnson behavioral system model.
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The most obvious difference between Grubbs’ interpretation and the original model is the
addition of the restorative subsystem, with its goal being “to relieve fatigue and/or achieve a state
of equilibrium by reestablishing or replenishing the energy distribution among the other subsys-
tems” (p. 228). The additional subsystem was articulated by faculty members at the University of
California, Los Angeles after long discussions and debates. Johnson continued to remind the fac-
ulty that restoration is a requirement for each subsystem, and its addition may therefore be teleo-
logical and tautological. Also described are the functional requirements, which are better defined
in Auger (1976).
This article makes an important contribution to use of this model in the prospective develop-
ment of tools (e.g., sample flow sheet and work sheet, which illustrate use of the model to guide the
nursing process). There is even an appendix describing items, by system, that should be included in
the assessment. Furthermore, the language and terminology used in the examples are consistent
both with systems theory in general and with the behavioral system model more specifically.
Overall, this article is a contribution to the understanding of the behavioral system theory and, if
read with Johnson’s own account of her theory in the same book, will help to clarify the theory com-
ponents. The process demonstrated here shows thought and solid construction based on the model.
Holaday, B. (1980). Implementing the Johnson model for nursing practice. In J.P. Riehl and C. Roy (Eds.), Con-
ceptual models for nursing practice (2nd ed.). New York: Appleton-Century-Crofts.
The focus of this article, which follows the Grubbs article, is the operationalization of the
model and application of the nursing process to care of the individual patient, using Johnson’s
model. The author designed a new assessment tool and synthesized Piaget’s definition of cogni-
tion with Johnson’s view of a human being as a system of behavior.
This author devotes the entire article to cognition—not even one of the behavioral subsystems—
and to the eliminative system, which was defined by Johnson to include the excretion of physiological
wastes and which was expanded by Grubbs (and the faculty of UCLA) to include the expulsion of
one’s feelings, beliefs, and emotions.
Had the author developed a rationale for incorporating Piaget’s theory and refined the inte-
gration of it within either a subsystem or a cultural or psychological variable, the argument would
have been more defensible.
Overall, the article is limited because of its narrow focus on the redefined eliminative subsys-
tem, even though the author does follow through with each phase of the nursing process in accord
with the purpose of the article. The article offers some clarification of the use of the behavioral
systems model in practice. Refinement and extension were not provided.
Johnson, D.E. (1959). A philosophy of nursing. Nursing Outlook, 7(4), 198–200.
At the time this article was written, the author had identified factors impinging on nursing
that resulted in a confusion of goals and the division of nursing into two camps. The camps were
divided into those who believed the professional nurse of the future would have largely supervi-
sory and managerial responsibilities and, on the other side, those who believed that nursing could
and would take its place as a professional discipline in relation to direct service to people who are
“in need of nursing care.”
Johnson belonged to the latter camp: the science of nursing and the art of nursing. The first of
these—the discussion of the science of nursing, centered around the patient, the recipient of
care—is phenomenal in that it is as relevant today as it was in the late 1950s. In fact, the discus-
sion might almost be considered prophetic because three decades later, the client was identified as
one of the nursing phenomenon. Nursing process, nursing diagnosis, and nursing science are no
longer as esoteric as they seemed in 1959 when Johnson’s article was published. Nursing art, to
Johnson, represented ministration of the basic unmet needs of the patient. Also identified are those
activities that are delegated and controlled by the physician.
A sociological analysis of the nursing role is used as a vehicle for understanding the division
of labor between nurses and physicians. We will also see, much later in time, just how much of an
impact this sociological analysis has had on Johnson’s own theory.
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CHAPTER 19 Historical Writings in Theory 475
Johnson, D.E. (1961). The significance of nursing care. Nursing Outlook, 61(11), 63–66.
This is a very significant—indeed, classic—work in nursing knowledge. Here, Johnson intro-
duces the notion of stability rather than change as the goal of nursing. Meeting the needs of the
patient helps bring about that stability.
Because of pressures from the medical and hospital management on nursing to take on non-
nursing tasks, Johnson believes that the view of nursing as a direct and individualized service has
become less goal-oriented and more blurred. Three major components or types of nursing services
were identified: (1) nursing care, (2) delegated medical care, and (3) health care. Of the three, only
one—nursing care—has “no well-delineated theoretical framework or conceptual basis to give it
meaning or direction (p. 64).”
The purpose of this article, then, is to delineate such a framework within the context of nurs-
ing’s distinctive contribution to patient welfare and the specific purpose of nursing care.
Using concepts of physiological homeostasis borrowed from Cannon and stability in patterns
of social interaction from Parsons, Johnson synthesized them and related them to individuals who
are ill. Instability causes tension; if tension is intense, an individual experiences discomfort and
displeasure.
Speculating from these, Johnson attempted to evolve a basis for nursing care using concepts
of equilibrium, stress, and tension. Each of these is defined in general terms, and then as it applies
to an individual patient (or group) or how the nurse might identify or assess stress, tension, or
equilibrium. The conceptualization of equilibrium, stress, and tension presents a way of viewing
the nature of disturbances that a patient might have, as well as the purpose of nursing care, or what
might be considered nursing’s specific responsibility in nursing care.
Two nursing interventions within this framework are also suggested. First, reduction of the
stressful stimuli through the management of the physical and psychological environment, and sec-
ond, support of the patient’s “natural defenses and adaptive processes” through “protective and
sustaining measures.” The focus of nursing is on immediate situations, universal needs, and pat-
terns that belong to the patient and are gratifying to him. The seeds for Johnson’s theory were
planted in this writing.
Johnson, D.E. (1980). The behavioral system model for nursing. In J.P. Riehl and C. Roy (Eds.), Conceptual mod-
els for nursing practice (2nd ed.). New York: Appleton-Century-Crofts.
Dorothy Johnson, for the first time in writing, clearly presents the whole of her theory. Much
of her unpublished work had been alluded to by her protegees and, although available in manu-
script form, it suffered from limited distribution. This was the first time the original behavioral
systems theory for nursing was published in its entirety.
According to its author, the behavioral systems model has its origins in a philosophical per-
spective and has been supported by an expanding empirical and theoretical base (i.e., systems
theory). (It would be helpful to read three of the author’s early publications, two in 1959 and one
in 1961, in conjunction with this one.) It is Johnson’s perspective that both nurses and physicians
theoretically have viewed a human being as a system. However, nurses view the patient as a
behavioral system, whereas physicians view him as a biological system. It is the nursing view of
the human being as a behavioral system that underlies this model. A review of this article shows
that the underlying assumptions of the model are explicit. The concepts are embedded in the
context and are not specifically defined. The system is identified as having seven subsystems,
which are briefly defined. The four structural elements of each subsystem are listed and dis-
cussed.
The basic elements of the model, which are briefly touched upon and that are implicit rather
than explicit, include values, goal of action, patiency, and source of difficulty. The latter is dis-
cussed only minimally; noticeably missing is a discussion of intervention.
In summarizing, the author indicated that the behavioral systems model “seems defensible
and promising by three criteria.” The criteria were named in the 1974 article and are social con-
gruence, social significance, and social utility. She also said that the model has “proved its utility
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476 PART SIX Our Historical Literature
in providing clear direction for practice, education, and research.” Although the present work does
not provide any evidence to support this, some available documentation exists and is discussed in
the section on Johnson in this book.
Despite these limitations of the model—that is, underdevelopment of some of the elements
and lack of supportive evidence for the model’s utility—this theoretical model for nursing is one
of the major contributions to nursing theory development in the past two decades. Furthermore,
Johnson’s thinking has impacted on a great number of graduate students in nursing who have
since gone on to develop other theoretical models. Johnson’s stimulus for progress should not be
underestimated; it has resulted in the advancement of nursing as a science.
Lovejoy, N.C. (1983). The leukemic child’s perceptions of family behaviors. Oncology Nursing Forum, 10(4), 20–25.
Contributing to theory development and testing through the development of instruments to
measure concepts is of utmost importance to the advancement of nursing science.
The author states that the Johnson model was selected as the theoretical framework “because
of its basic premise that human behavior in health and illness is the independent domain of nurs-
ing” (Lovejoy, 1983, p. 20). In table form, as part of the background materials, the author pre-
sented a comparison of the Johnson behavioral system model (JBSM) goals by subsystem and by
theorist, showing differences between theorists. The theorists compared are Johnson, Grubbs,
Auger, and Lovejoy, all of whom have elaborated upon and used the model. This provides a help-
ful summary and review of the subsystems for the reader familiar with the model. It is assumed,
however, that the reader has some knowledge of the model. The author notes the disparity among
the theorists regarding the scope of the goal-directed behaviors of the subsystems, but concludes
that “the goals used in this research appeared to parsimoniously and discretely define special
domains of behavior (Lovejoy, 1983, p. 21).” The reader is left wondering where the support for
such a conclusion is. Little additional elaboration of or support for “discretely defined domains of
behavior” was given.
The Family Relations (FR) test, the instrument upon which the family assessment instru-
ment was modeled, was then described. The FR test situation was designed as a play situation in
which a child was to decide what feelings fit which members of the family. The family assess-
ment instrument (Lovejoy) consists of 47 items apparently designed to reflect the eight subsys-
tems of the JBSM. The number of questions ranges from four to eight for each subsystem. No
explanation is provided for having a variable number of items per subsystem. The items are
shown in Table 2 and stand alone without additional explanation. Items for the assessment tool
were generated and formulated based on a review of major growth and development theorists
and a review of chronic illness research. Statements reflecting functional and dysfunctional fam-
ily member behaviors were formulated from this review. The statements describing these behav-
iors were then placed on individual cards for later test administration. Noticeably missing was
reference to how items were formulated to reflect the eight subsystems of the JBSM. This is an
important omission, given that the author purported that the instrument was “based on the John-
son Model for nursing (1983, p. 20).”
There are several major limitations with this instrument. First, there is little or no evidence of
content and face validity within the context of either growth and development theory or the John-
son model. No evidence is presented indicating that the items were subjected to a review by
experts, either in growth and development or the Johnson model. This was also true of the review
of the scoring guide, as discussed previously. Although it is a time-consuming and arduous task,
some attempt to develop content validity is crucial, even for initial instrument development, and
this was overlooked in the development of this instrument.
Second, the scoring guide and the method of scoring described suggest that the rating of 0 to
2 is a scale, with equal distances between each measure. In application, these appear to be discrete
categories and therefore not conducive to the summation-scoring method used.
It may be more appropriate to standardize the instrument by developing norms for each age
group.
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CHAPTER 19 Historical Writings in Theory 477
Rawls, A.C. (1980). Evaluation of the Johnson behavioral model in clinical practice: Report of a test and evalua-
tion of the Johnson theory. Image, 12, 13–16.
In the introduction, the author clearly identifies the importance of model testing for the future
of nursing in general and, specifically, her rationale for choosing to evaluate the application of the
Johnson theory. The purpose and scope of the report are also identified. The title might suggest
that the “test” was research when, actually, it was an exercise in whether or not the theory was
clinically useful.
As background for the study, a brief history and an overview of other authors’ contributions
to the model is presented. Johnson’s model is briefly reviewed to provide readers with an outline
of how the model was used as a framework by the author. The subsystems and their components
and the structure and function of the theory are all defined. For purposes of discussion only, the
structure, function, and functional requirements of the subsystems are discussed in detail. After
clarification of a few other components of the model, the use of the Johnson model (JM) as a
guide for the nursing process is illustrated.
Each stage of the nursing process—assessment through evaluation—is described within the
context of the JM subsystems using the Grubbs assessment tool and nursing process worksheet.
These process and description are similar to those described by Janelli (1980) with Roy’s model.
Prior to the beginning of the “study,” variables that may have influenced the outcome were
explored. The identified variables were: “limited knowledge of Johnson’s theory,” “lack of experi-
ence in utilizing Grubbs’ assessment tool and nursing process worksheet,” and patient’s response
to the researcher, to the assessment tool, and to the plan of care developed. Time available for the
study and the size of the study group were also identified. The author chose to limit the sample
size to one “due to the variables cited previously” (Rawls, 1980, p. 13).
The study focused on a case presentation of one subject, beginning with patient background,
followed by first- and second-level assessment. The patient selected for the study was a white
male who had been hospitalized for evaluation of an accidental injury, resulting in painful amputa-
tion of the left hand and distal phalanges approximately six months earlier. The first-level assess-
ment appeared to be more in keeping with the medical model, in that information about past and
present history of the problem, psychological assessment, family, and social, environmental, and
development history were reviewed.
From the perspective of the JM, no examples of subsystem assessments were presented. An
exception was a statement indicating that, because no problems were noted in the review to that
point, a complete review of the behavior subsystems was conducted using Grubbs’ assessment
tool. Two problem areas in the achievement subsystem were identified. Because there were prob-
lem areas in only this one subsystem, the discussion was limited to it. Second-level assessment
proceeded from there. One concept—the concept of body image—was explored in depth.
The assessment phase was followed by a plan for care, again focusing on intervention for the
two problems in the achievement subsystem only. The plan focused on how the patient’s loss of
his left hand and its function prevented him from meeting the conceptual goal of the achievement
subsystem (i.e., to achieve or master). Variables that might have influenced the patient’s care were
explored and identified. “The developmental, psychological, sociological, and level-of-wellness
variables were all viewed as influencing variables that could be manipulated to benefit the patient”
(Rawls, 1980, p. 16).
The next step was the identification of nursing problems. This step may be confusing in that
problems were identified earlier in the assessment phases of the nursing process. Furthermore, the
author did not clarify why this additional step of problem identification was necessary. Further
reading led me to conclude that these additional problems were refinements of previously identi-
fied problems in the achievement subsystem. The nursing interventions for these problems were
detailed, with numerous examples used for illustration. Both long- and short-term goals of nursing
intervention were formulated. The plan of care was evaluated and found to be appropriate, as
measured by changes consistent with the short-term goals. The plan of care, with minor revisions,
was also found to be appropriate to the patient’s postoperative course.
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The author’s “evaluation of the Johnson Model” was more of an evaluation of the usefulness
of the model for clinical practice than a critical review of the model itself. The author recom-
mended that the model be tested further in a variety of settings with clients who have a variety of
complex problems in each of the subsystems. To have stated this limitation is to the author’s
credit. Disadvantages of the model, as perceived by the author, included complex and unique ter-
minology and the requirement of a knowledge of systems theory in order to use the model more
effectively. The author concluded that the advantages of the model for practice, in essence, out-
weighed the disadvantages; she believed that the Johnson model “offers the nurse a tool which
will allow her to accurately predict the results of nursing interventions prior to care,” and “formu-
late standards for care” (1980, p. 16).
The nursing educator who is interested in teaching the JM or in demonstrating the application
of theory to practice (as well as the nursing theorist concerned about the utility of the model for
practice) would find this article of some interest. The beginnings of the elaboration of the concept
of body image as it relates to the achievement subsystem are present in this author’s assessment
phase.
Small, B. (1980). Nursing visually impaired children with Johnson’s model as a conceptual framework. In J.P.
Riehl and C. Roy (Eds.), Conceptual models for nursing practice (2nd ed.). (pp. 264–273). New York: Appleton-
Century-Crofts.
Although nursing research that tests hypotheses of nursing theories is critical for the
advancement of a particular theory, this study does not test hypotheses evolving from Johnson’s
theory, but it demonstrates that the theory could be utilized in working with visually impaired
children.
The report of a research study form the first of two parts of this chapter. The second includes
implications for nursing. The major assumptions underlying the theoretical framework of the
study were derived from Piaget and cognitive developmental psychology. Two null hypotheses
were tested and rejected. The first stated that “there would be no significant difference between
the perceived body image of visually impaired and normally sighted preschool children.” The sec-
ond stated that there would be no significant difference between the spatial awareness of visually
impaired preschoolers and those who were normally sighted.
The author explains results of the study using Johnson’s theory. Vision plays an important
role in the development of object permanence and the relation of objects in space. These two con-
cepts are necessary for the development of a child’s body image and for his awareness of his body
in space. Therefore, if a child is visually handicapped, the implications are that nurses can inter-
vene to meet his needs and to facilitate the development of his self-concept.
Once this line of reasoning was developed, and once a brief description of Johnson’s model
was presented, the author tended to focus more on interventions with the parents than with the
child, therefore supporting Johnson’s recommendations for intervention: manipulation of the
environment to reduce tension.
MYRA LEVINE
Esposito, C.H. and Leonard, M.K. (1980). Myra Estrin Levine. In the Nursing Theories Conference Group, Nurs-
ing theories: A base for professional practice (pp. 150–163). Englewood Cliffs, NJ: Prentice-Hall.
The content of this article is organized to include a summary of the components of Levine’s
theory, its application to the nursing process, and the relationship of the theory to five major con-
cepts (humanity, society, health, learning, and nursing). In addition, a brief case study is included
to demonstrate application to practice (i.e., the utility of the theory for clinical practice).
One of the major contributions of this chapter is the identification of the explicit assumptions
underlying Levine’s theory. This is helpful because the assumptions are implicit in Levine’s writing.
There is one important omission in this discussion of Levine’s theory: the major theoretical
underpinning—namely systems theory—is not identified. Given that systems theory is not
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CHAPTER 19 Historical Writings in Theory 479
acknowledged, it becomes clearer why Levine’s theory is identified as having a close kinship to
Maslow’s hierarchy of needs. One might agree that parallels could be drawn between the conser-
vation principles and Maslow’s levels of needs, but Maslow’s theory must not be construed as the
prototype for Levine’s principles. Nowhere in Levine’s writing is there any reference to Maslow’s
needs hierarchy.
Two potential problems in this chapter are the lack of identification between Levine’s and
Esposito’s and Leonard’s additions, and that the parallels between Maslow’s hierarchy of needs
and conservation principles (tenuous at best) may be accidental and therefore do not justify
this as a prototype paradigm. More support could be given to system or adaptations as guiding
paradigms.
Hirschfeld, M.J. (1976). The cognitively impaired older adult. American Journal of Nursing, 76(12), 1981–1984.
In a very straightforward discussion of the possible cognitive impairments of older adults,
and in the only published work on utilization of Levine’s theory in practice, Hirschfeld demon-
strates how Levine’s four principles of conservation can be applied to give direction to nursing
interventions when impairments are present. The goal of the interventions is specified as trying to
keep remaining cognitive capacities intact and in use.
Each conservation principle, and examples demonstrating problems in the area it covered, is
discussed separately. For example, a variety of problems are described wherein the balance of
activity and rest were disturbed. Focusing on conservation of energy in this case gave the nurse
direction for intervention.
Levine, M.E. (1966). Adaptation and assessment: A rationale of nursing intervention. American Journal of Nurs-
ing, 66(11), 2450–2453.
Levine introduced “trophicognosis” as an alternative concept to replace “nursing diagnosis”
(Levine, M.E. [1966]. Trophicognosis: An alternative to nursing diagnosis. In Exploring progress in
medical surgical nursing practice [pp. 55–70]. New York: American Nurses Association. A series of
papers presented at the 1965 Regional Clinical Conferences, November 3–5, 1965, Washington,
D.C.). The latter conjures up medicine and disease orientation, whereas the former focuses attention
on judgments related to nursing care utilizing the scientific method. In that earlier writing, it
becomes apparent that Levine is interested in delineating nursing goals and differentiating them
from medical goals.
In this second of four articles that precede the publication of her book, Introduction to Clinical
Nursing, Levine further demonstrates her conceptualization of nursing as utilizing the scientific
method and as a coherent theory in guiding nursing actions. She argues that nursing practice and edu-
cation have long been influenced by the prevailing beliefs about health and disease. As a result of a
carry-over or a carry-through of earlier theories, nursing care has become “an unsynthesized ‘total,’ a
sum of many disparate parts” (p. 2451). Thus, there is an urgent need, as Levine sees it, for a restate-
ment of the theoretical basis for nursing practice. This is what she attempted to do in this article.
Drawing from a variety of sources—philosophy, physiology, and sociology—a few basic ideas
about human beings become implicit assumptions of the theory. Central ideas are (1) a human
being’s life is multidimensional, (2) a human being is in constant interaction with the environment,
(3) a human being’s internal environment is integrated and is dynamically balanced, (4) a human
being responds to forces in the environment in a unique but integrated manner, (5) health and dis-
ease are patterns of adaptive change, and (6) the nurse is part of every patient’s environment. One
sees here the influence of systems theory: wholeness of human being, dynamic equilibrium, human
being–environment interactions, and adaptation.
The author revived Nightingale’s ideas of multicausality of illness, disease as a “reparative
process,” and nursing’s goal as establishing a health environment that would enhance healing and
reparative processes. Levine refocused nursing’s attention on the wholeness of human beings, the
uniqueness of each human being, and on the fact that a broad knowledge base is required by the
nurse in order to give nursing care.
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Levine’s discussion of adaptation raises some questions. Adaptation is introduced but not
really defined per se. For example, “all the processes of living are processes of adaptation,” “dis-
eases represent patterned responses or adaptations,” “health and disease are patterns of adaptive
change” (p. 2452). But what is adaptation? Levine indicates that a criterion of successful adapta-
tion is the attainment of social well-being, which is neither defined nor related to the preceding
physiological discussion.
The major ideas expressed about nursing are that the nurse is an agent who intervenes
between a patient and his environment to facilitate adaptation and that the interventions are
based on coherent and systematic knowledge and a scientific process in collecting data about
the patient.
Levine, M.E. (1967). The four conservation principles of nursing. Nursing Forum, 6(1), 45–59.
This article is the third that this author wrote in an attempt to lay down a framework for nursing
intervention. It is helpful to read this after reading the first two, on trophicognosis and on adaptation
and assessment, in order to fully understand the process that Levine used in theory development:
redefining central concepts, reconceptualization of nursing goals, and then nursing actions. She
identified central concepts, stated assumptions, and proposed four central propositions.
The concept of adaptation as developed by Levine in her earlier article remains undefined. In
the introduction alone, adaptation may be conceived or interpreted in three different ways. First,
one can infer that it “can be manifested in patterns” and “has a course.” One could also infer that
adaptation is an outcome because it can be measured by “renewed social well-being.” Third, in
another context, one can infer that adaptation can be a capability or a characteristic of a person.
Aside from adaptation, the major focus of this article and Levine’s major contribution to the-
ory is the introduction of four conservation principles that are central to the mission of nursing.
Levine identifies nursing principles as “fundamental assumptions which provide a unifying struc-
ture for understanding a wide variety of nursing activities” (p. 45). Here, each principle (labeled
assumptions, but they may be the theory’s propositions) is listed separately, along with a state-
ment about nursing intervention, and is then followed by a discussion that supports the principle
and the rationale for it. Clinical examples are included as supportive evidence. The four principles
are all conservation principles. Conservation is defined as “keeping together,” but the author
emphasizes that this “should not imply minimal activity,” especially on the part of the nurse.
The four principles are: “(1) The Principle of the Conservation of Patient Energy, (2) The
Principle of the Conservation of Structural Integrity, (3) The Principle of Conservation of Personal
Integrity, (4) The Principle of Conservation of Social Integrity.” For each of these, nursing inter-
vention is based on the conservation of the particular patient’s need in focus. The four principles
evolved from an assumption of the unity and integrity of the individual; they are well-developed
and supported with clinical examples; and they are, in part, consistent with some assumptions
from the systems theory.
Three critical questions are raised: (1) How did the author come to the point of identifying
four and only four principles? (2) In principle 2, given the complex interrelationships of human
structure and function (which Levine does discuss), why is the principle not stated in terms of
both structural and functional integrity, or why weren’t two separate principles for these devel-
oped? What is the rationale for focusing on structural integrity versus both structure and function?
(3) Why aren’t personal integrity and social integrity specifically defined?
Considering the dearth of theoretical frameworks for nursing available in the late 1960s, this
framework made a substantial contribution to the science of nursing. Levine proved herself to be
an insightful, forward-looking theorist.
Levine, M.E. (1969). The pursuit of wholeness. American Journal of Nursing, 69(1), 93–98.
Consistent with the first three articles and with systems theory, Levine views a human being
as a system in constant interaction with the environment: “patients are complete persons, not
groups of parts.”
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CHAPTER 19 Historical Writings in Theory 481
This article provides a view of the human being from a nursing perspective, as a system in
a constant dynamic interchange with the environment and as part of a larger ecosystem. Infor-
mation is exchanged between the human system and the larger ecosystem by way of the per-
ceptual subsystem. Disturbances in the perceptual subsystem, as well as the levels of
organismic response used to protect the organism as it responds to the environment, give direc-
tion to nursing.
When the environment changes, the human being must change. Levine makes a fairly suc-
cinct theoretical statement here about what adaptation is. This process of change “whereby the
individual retains his integrity—his wholeness—within the realities of his environment” is labeled
adaptation (p. 95). The goal of the individual is to defend his wholeness.
There are at least four levels of organismic response, each physiologically predetermined.
(This is an implicit assumption on Levine’s part.) The responses are used to protect the organism,
so that it can make a viable adaptation to the environment. The four levels include: response to
fear, inflammatory response, response to stress, and sensory response. These four levels are fairly
well-documented.
Alone, this article does not contribute substantially to our understanding of Levine’s theory;
it must not be read in isolation. In the context of earlier articles and ones that come later, the per-
spective of this one becomes clearer.
Levine, M.E. (1971). Holistic nursing. Nursing Clinics of North America, 6(2), 253–264.
No new material is presented here. Instead, this is a synthesis of previously published material
that contributes to a better general understanding of the theory. The author brings together all the
ideas, the separate parts, of the earlier four articles into a whole. The parts of Levine’s theory—the
assumptions, central concepts, definitions of person (who is the nursing client), goals of nursing, and
nursing intervention—are put together, and the interrelationships between parts are then described.
Levine views holistic nursing as a challenge before nurses. This approach to nursing takes
place at the interface between the organism (human being) and the environment. In other words,
nursing is an interaction, and the nurse, in a sense, mediates between the organism and his envi-
ronment, whether the environment in question is the organism’s internal or external environment.
For the person desiring an overview of the theory, or some help in piecing together the earlier
parts of the theory, this article could be most helpful and should then be read before the first four
articles.
Levine, M.E. (1971). Time has come to speak of . . . health care. AORN Journal, 13, 37–43.
In a speech to the annual congress of the Association of Operating Room Nurses (AORN),
focusing on the viability concerns of that group, Levine indirectly presents arguments in support
of her theoretical framework for nursing. Ostensibly, the focus of the speech is the threat of
increased technological change and innovation to the roles of nurses, especially with the concomi-
tant requirement for technicians to manage the machinery. The health care field has responded to
technological advances by increasing the number of technicians. Although operating room nurses
were the first to be threatened by this influx, theirs is not the only are inundated by technicians.
For example, ICUs, CCUs, trauma, dialysis, burn, coma, respiratory, and hyperbaric units each
requires its own complement of technicians.
Nevertheless, Levine argues that, in all these settings, both technical and professional roles
remain to be filled. She further argues that, although new threats from increasing numbers of tech-
nician positions continue to appear, the real concern is for the quality of patient care. What will
happen if physician assistants, for example, go into underserved areas to provide a second-class
kind of medical care? If this becomes a trend, then nursing must make itself heard to prevent these
inadequacies from occurring. Those in society who are already underserved, already suffering,
would be most affected by these health care inadequacies.
Confusion in the roles of workers, both professional and technical, has been a result of the
great changes in health care. However, there still remains one need that nurses can recognize and
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482 PART SIX Our Historical Literature
sustain: self-respect and humanity of the patient. The nurse traditionally has been and must remain
the patient’s advocate. Unless the effort is made to reach out and establish human contact, the
patient will become just another part of the elaborate machinery of technology. The technical role
in this situation is supportive and essential, but it is the professional nurse who must be the patient’s
advocate, the humanizing agent, the one who brings “compassion, protection, and commitment to
the bedside.”
Given the changes in health care, the education of nurses must change too. In order to be the
professional nurse, as described previously, Levine believes that the achievement of the education
of a patient’s advocate requires knowledge and skills of a global kind. Furthermore, there needs to
be a conceptualization of nursing. She presents her formulations as valid forms of nursing inter-
vention. She also suggests that the concepts inherent in the generalizations can be readily applied
to all kinds of nursing intervention. It is here that we see Levine’s support for her theoretical
framework for nursing as one way to counter the threat of technological advances to nursing,
patients, and health care.
DOROTHEA OREM
Allison, S.E. (1973). A framework for nursing action in a nurse-conducted diabetic management clinic. Journal of
Nursing Administration, 3(4), 53–60.
This article is based on and follows the 1974 Backscheider article, although this one was pub-
lished first. The author provides a comprehensive picture of the health care system, using the self-
care model as a basis for the nurse-conducted diabetic management clinic. The author synthesizes
some of Orem’s and Backscheider’s concepts: universal self-care, health deviation self-care
(Orem), and mental, physical, motivational, emotional, and orientational capacities to follow a ther-
apeutic regimen (Backscheider). The article provides a highly useful example of the use of Orem’s
ideas in a nurse-run diabetic clinic. Three models—self-care, health status, and environment—are
offered as a framework for assessment and intervention. The author provides a very useful discus-
sion of areas of responsibility, and differentiates between traditional nursing roles (administrative)
and practitioner roles (clinically oriented) as shared and as delineated for nursing, medicine, and
other health services. Although this is an ideal setting for theory testing, the focus of the article is
on application.
Anna, D.J., Christensen, D.G., Hohn, S.A., Ord, L., and Wells, S.R. (1978). Implementing Orem’s conceptual
framework. Journal of Nursing Administration, 8(11), 8–11.
The authors present a descriptive account of the implementation of Orem’s model by a group
of graduate students in a nursing home setting for adult patients (geriatric setting). In doing so, the
authors provide a short summary of the theory, the use of the nursing process according to Orem,
the strategies the students used in implementing the theory in the setting, and the obstacles prevent-
ing implementation by students, patients, and nursing staff. Difficulties experienced by the students
in shifting to Orem’s conceptualization (terminology, concept definitions, mechanization) are those
that could be universal and could apply to all initial attempts at implementing any nursing theory.
The conceptualization of a patient’s role as that of a significant decision maker and eventually a
performer of self-care activities presented another obstacle. Patients felt more comfortable as recip-
ients of care. As expected, the nursing staff was resistant to change initiated by a group of tempo-
rary students. Evaluation of the implementation process was done by review of students’ personal
diaries. Themes were an increase in patient participation, motivation, and cooperation.
Backscheider, J.E. (1974). Self-care requirements, self-care capabilities, and nursing systems in the diabetic nurse
management clinic. American Journal of Public Health, 64(12), 1138–1146.
This author provides a conceptualization of the diabetic-related component of therapeutic
self-care, encompassing a set of patient responsibilities (related to the patient’s own condition and
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CHAPTER 19 Historical Writings in Theory 483
therapy and to the effects of his condition and therapy) and a set of action capabilities (physical,
mental, motivational, emotional, and orientational). Nursing care is needed when a patient has
limited capability to meet therapeutic self-care goals (self-care deficit). Nursing is a mediating
system and is divided into four types. Nursing care (nursing system) is focused on the patient as a
recipient of one-time guidance or teaching, on long-term assistance that is oriented toward main-
tenance and support, on more permanent compensatory care oriented toward some changes in the
patient, or on compensatory care using changes in the environment.
When a given health care deviation occurs, the capabilities essential to meet that portion of
therapeutic self-care are determined first and foremost. Criteria can then be established. The nurse
can assess the patient’s capabilities against the established criteria to determine whether or not the
patient can meet self-care demands. This is a more positive approach, a more scientific one to
establishing nursing interventions than by estimating the patient’s abilities or limitations.
This is an important article to read in relation to the theory of self-care. It demonstrates the
interaction between practice and theory development and shows potential for researchable questions.
Bromley, B. (1980). Applying Orem’s self-care theory in enterostomal therapy. American Journal of Nursing,
80(2), 245–249.
The author, an enterostomal therapist, begins with a discussion of her own personal philoso-
phy of nursing practice, with the most useful tool being the nurse. Her choice of Orem’s theory
was made because of the apparent congruency between her own and Orem’s philosophies. The
usefulness of this article lies in the author’s synthesis of her perceptions of Orem’s theory and the
use of an exemplar to demonstrate the theory–practice fit, particularly around nursing interven-
tions. The author writes clearly and does a particularly nice job of showing how the nursing sys-
tems of self-care are implemented in an inpatient (hospital) setting. Using an example, she shows
how she has moved with a client from a wholly compensatory system, through the partly compen-
satory system, to the supportive–educative system.
For those interested in the appropriateness of Orem’s model for inpatient practice in a surgi-
cal setting, this is a good example because the author followed the theory closely throughout.
Buckwalter, K.C. and Kerfoot, K.M. (1982). Teaching patients self-care: A critical aspect of psychiatric discharge
planning. Journal of Psychiatric Nursing and Mental Health Services, 20(5), 15–20.
While ostensibly presenting clinical applications under the umbrella of Orem’s self-care
framework, this article is about discharge planning and teaching; it appears that the notion of self-
care has been added after the fact. The abstract clues us in to the fact that self-care is not an integral
part of the conceptualization of discharge planning.
The content covers understanding the diagnosis, stressors, signs and symptoms, resocializing
issues, community support, and medication compliance. Each topic is briefly described and illus-
trated with clinical examples. A sample standardized protocol for depressed patients and their
families is included.
The only references to Orem are the use of her definition of self-care and two references to
kinds of nursing assistance, namely teaching and self-care guidance. Self-care concepts are not
applied to the content. To be consistent with the theoretical framework, the content must also fol-
low. For example, the summary of the five areas to be covered with patient and family in the dis-
charge planning interview (p. 16) lend themselves to the six health deviation self-care requisites as
elaborated by Orem (1980, pp. 48–51).
This article covers an important topic of present concern for all mental health practitioners—
not just nurses—regarding maintaining the mentally ill in the community. Overall, the article is
written in a straightforward and understandable style, and presents important clinical content. Of
concern is that the authors state that they are using Orem’s perspective; although they do include
topics under the rubric of self-care, Orem’s framework in fact does not guide the conceptualiza-
tion of the teaching and guidance plan.
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Caley, J.M., Dirkensen, M., Engally, M., and Hennrich, M.L. (1980). The Orem self-care nursing model. In J.P.
Riehl and C. Roy (Eds.), Conceptual models for nursing practice (2nd ed.). (pp. 302–314). New York: Appleton-
Century-Crofts.
The intent of the chapter is to offer an example of the use of Orem’s theory in a psychiatric
setting, using a suicidal patient as the case study. The discussion of the model, brief and limited, is
organized around the goal of action, patiency, actor’s role, source of difficulty, intervention
focus/mode, and consequences, both intended and otherwise.
It would be helpful for a theory novice who is focused on a theory–psychiatric practice link
to read this chapter in conjunction with Orem’s work, with the understanding that it is a limited
exposé and does not do complete justice to Orem’s theories. The authors freely used concepts
from Backscheider (1971, 1974) and the Nursing Development Conference Group (1973) in addi-
tion to Orem (1971).
Chang, B.L. (1980). Evaluation of health care professionals in facilitating self-care: Review of the literature and a
conceptual model. Advances in Nursing Science, 3(1), 43–58.
The purpose of this article is stated in terms of needs. “A need exists for the evaluation of
health professionals in facilitating self-care. Such an evaluation must take into account lay per-
sons’ judgments regarding the health care received. A conceptual framework is needed for the
evaluation of the role of health professionals in facilitating self-care” (p. 44). The “why” of this,
its importance, is not spelled out.
The author states that the derivation of her framework for the evaluation of health professionals is
in part from Orem’s work and in part from other literature related to the evaluation of quality of care.
The dimensions of the framework are listed as “(1) patient or layperson characteristics, (2) health care
professional characteristics, and (3) patient outcomes” (p. 44). A diagram illustrates the relationship
of these dimensions and serves to introduce the components of these dimensions. The diagram con-
tains all the dimensions and their components and the direction of the linkages. The third and last
dimension, influenced by the preceding two, is the focus of the review of literature. Why only the third
dimension—evaluation of outcomes of self-care—is reviewed in detail is not stated.
Although the author has presented a broad definition of self-care, a strong statement about
the overall importance of the topic and why this particular definition of self-care was chosen over
others commonly used in the literature has thus far not been presented.
There are numerous opportunities to use Orem’s framework to guide the conceptualization of
the model proposed, and they are not taken advantage of. In the review of literature on evaluation
of outcomes of self-care—specifically the three components—the author appears to have neg-
lected to use important articles relevant to the framework presented. Examples of this include
writings by Allison (1973), who addresses nurses and other health team members and their role in
assisting patients to perform self-care regarding diabetic management, and by Backscheider
(1974), who also addresses the role of nurses in assisting with the self-care practices of diabetics
and the self-care competencies required by ambulatory diabetics.
Although the author may have accomplished her overall goals of presenting a conceptual
model and reviewing some literature related to evaluation of health care professionals, conceptual
linkages between the different dimensions are missing.
Coleman, L.J. (1980). Orem’s self-care concept of nursing. In J.P. Riehl and C. Roy (Eds.), Conceptual models for
nursing practice (2nd ed., pp. 315–328). New York: Appleton-Century-Crofts.
The primary purpose of this article is to describe the implementation of Orem’s theory in one
nursing service department of a large metropolitan hospital. Therefore, Orem’s model is first sum-
marized by the author, with particular emphasis on those concepts and ideas that would be most
useful for the nursing service department of a hospital (e.g., nursing assistance, nursing process).
The language of the chapter, to be sure, is the language of nursing administration, such as classifi-
cation of patients, techniques essential for nursing practice, utilization of nursing personnel, and
operational documents. The author then describes what is involved in revising operational
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CHAPTER 19 Historical Writings in Theory 485
documents of a nursing service, including departmental philosophy and goals, departmental poli-
cies, divisional philosophy and objectives, position descriptions, nursing tools, and nursing care
evaluation instruments in the process of operationalizing Orem’s model. Also briefly described is
the preparation of the nursing personnel for understanding and using Orem’s concepts.
This chapter offers a “how to” contribution to the nursing administrator who wishes to imple-
ment the theory in practice.
Dickson, G.L. and Lee-Villasenor, H. (1982). Nursing theory and practice: A self-care approach. Advances in
Nursing Science, 5, 29–40.
The stated purpose of this article is “to bridge the gaps between theory and practice through
the research of the application of an evolving theory” (p. 29). The authors also present a “new
nursing model in which to ‘think nursing’” (p. 30). The findings described were from a field study
carried out by the authors in their own independent practice settings using their own clients.
The framework of self-care developed by Orem and modified by Kinlein was chosen as the
theoretical model for practice and research because the beliefs underlying the model were in keep-
ing with the authors’ philosophy. The authors adequately describe and document these back-
ground materials sufficiently for those familiar with the model. For those unfamiliar with the
model, the review is not adequate.
A nonexperimental, descriptive design was used. The source of data was the written record-
ing of nurse–patient interactions from 35 time periods with four clients. Although the authors
describe the four female subjects, they do not tell us why eight other prospective subjects were not
included.
The research process proceeded as follows: during the clients’ appointments and during the
process of providing nursing care, the nursing researchers recorded their clients’ words. At the
time that a “need” was expressed, the nurse then identified self-care assets, the self-care demands,
and the self-care measures with the client. The next step was a period of introspection for reflec-
tion on the nursing phenomena observed. Operational definitions were established, and four
research questions were generated.
The data analysis yielded four categories of care: (1) the client’s expression of need, (2) self-
care asset, (3) self-care demand, and (4) self-care measures. These were analyzed using content
analysis from the grounded field theory methodology. Further analysis, in keeping with the induc-
tive method of research being used (Glaser and Strauss), focused on the integration of categories
and their properties. Specifically, data were analyzed to determine properties of expressions of
need and self-care assets. The latter were found to be similar to the indicators of self-care agency
as identified by Kearney and Fleischer (1979).
In summary, the authors reflect on the limitations of the research, namely sample size and
bias, implications for practice and research, and directions for future research. The authors
demonstrate clarity in describing both the procedures and the process of their experiences in relat-
ing theory to practice and research. The complex helical relationship of the three is clearly illus-
trated, and the scholarliness of their approach and writing adds to the overall readability. The
model was their guide for practice and research and, with the model in mind, it helped to maintain
their focus on their goals. For these reasons, this study would be of interest to theorists,
researchers, and clinicians alike who espouse the self-care framework. More important, the article
provides an exemplar for theory development using the practice-theory strategy.
Karl, C.A. (1982). The effect of an exercise program on self-care activities for the institutionalized elderly. Jour-
nal of Gerontological Nursing, 8, 282–285.
Although the title of this short report of a research study includes the concept of self-care,
and although Orem is mentioned in the section, “Program Background,” the self-care framework
does not seem to guide the conceptualization of the study. The review of the research literature
focuses on general topics of feelings of well-being and physiological benefits of exercise rather
than on self-care. Furthermore, liberties are taken with Orem’s framework when the author states
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486 PART SIX Our Historical Literature
that “the theoretical defense for a study of the positive effects an exercise program can have on the
institutionalized elderly and their ability to care for themselves has been formulated by Orem in
her theory of self-care” (p. 283). Also misstated were the “assumptions”; in fact, these are really
the hypotheses tested by the study.
Miller, J.F. (1980). The dynamic focus of nursing: A challenge to nursing administration. Journal of Nursing
Administration, 10(1), 13–18.
Although the title of this article suggests that the focus will be on nursing administration,
and despite the introductory statement that “nursing administrators are challenged to establish a
climate that facilitates the use of appropriate frameworks to guide nursing” (p. 13), this article
is really about the application of a nursing framework—Orem’s—to acute care. However, there
is very little evidence of the self-care theory, which the author purports to use. What the author
did, in fact, was to pull out the idea of changes in the health–illness continuum, suggesting that
nurses focus on changes in the patient’s health status as a model to guide intervention. The
author presents three conceptual phases for acute care patients (acute illness, convalescence,
and restored health), problems and nursing care strategies related to each, and a patient case
study to demonstrate application. Only phases 2 and 3 are linked to patient development of self-
care skills.
Although it takes into account where the person is on the health–illness continuum (which
phase), the proposed “model for dynamic nursing practice” essentially ignores Orem’s nursing
systems, which give direction for nursing intervention based on the person’s health self-care
needs or self-care deficits regardless of where he is on the health–illness continuum. Therefore,
this article offers a very limited application of Orem’s theory.
Miller, J.F. (1982). Categories of self-care needs of ambulatory patients with diabetes. Journal of Advanced
Nursing, 7, 25–31.
The stated purpose of this paper is to report a study of the identification of need categories of
ambulatory diabetic patients within the context of the self-care nursing framework. The title of the
article reflects this purpose. The method used to discover the categories of self-care needs was that
of participant observation. The need for the research was identified, but why the self-care frame-
work is “especially appropriate” (p. 25) was not explained.
The sample of 65 men and women, ranging in age from 22 to 83, came from different socioe-
conomic classes and were from various cultural backgrounds. No rationale for sample selection
was presented. The clinic where the subjects were treated used the self-care concept for nursing
practice. Data collection initially involved an assessment of the patient’s self-care agency using an
instrument designed by the researcher and published elsewhere.
Additional self-care evaluation was completed during later patient contacts, with all patients
in the study having a minimum of three contacts. “The evaluation consisted of four parts: an inter-
view, physical assessment, interpretation of findings, and mutually determined goals” (p. 26).
During this process, nursing care was provided during the contact. “Data gathered were recorded
on a care plan and collection continued until no new categories were discovered and each category
had been saturated with examples” (p. 27). Ten categories of needs were identified: “acquire skills
for self-care management, receive feedback regarding self-care management, become aware of
own resources, have feelings of self-esteem enhanced, grieve over losses, work towards accept-
ance of chronic disease, have new or continuing health concerns evaluated, obtain services from
various support agencies, alleviate physical and mental discomforts, identify positive role of the
health care agency and feel like a full participant in determining care goals, and maintain family
solidarity and support or assist ill member” (p. 27).
These findings reveal an interesting contrast to the findings of Dickson and Lee-Villasenor
(1982), who similarly used the method of participant observation. The latter also made observa-
tions in a clinical setting with a quite different sample and gleaned their need categories from
statements of needs as expressed by their subjects.
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CHAPTER 19 Historical Writings in Theory 487
In the discussion and conclusions, there is a certain eagerness to apply the findings to the
practice setting as the next step. Here, that application is premature. More appropriate to the
Orem’s present stage of theory development is the phase of reanalysis and refinement of the self-
care need categories for this subpopulation.
This study makes an important contribution to nursing science by using the theoretical for-
mulations of Orem to guide the organization into need categories of the observations made of 65
ambulatory diabetic clients. These data and categories contribute important information for con-
tinued theory development, for the inductive approach, and, more specifically, for the develop-
ment of the concept of self-care needs.
Murphy, P.P. (1981). A hospice model and self-care theory. Oncology Nursing Forum, 8(2), 19–21.
This brief article describes how Orem’s self-care framework was used as a guide for nursing
practice in a hospice setting. The focus of the article is on the role of nursing in this setting, using
the three basic systems of nursing care described by Orem: (1) supportive–educative, (2) partially
compensatory, and (3) wholly compensatory. Examples of interaction level between the nurse and
the patient for each system and a diagram illustrate how the hospice team operates using the self-
care framework.
Although this article is not based on research but rather on clinical application, and although
it does not provide any new insights or interpretations of Orem’s work, it does demonstrate that
the self-care framework is a useful guide for practitioners in a setting with terminally ill patients.
Petrlik, J.C. (1976). Diabetic peripheral neuropathy. American Journal of Nursing, 76, 1794–1797.
While this article does not mention Orem’s theory as a basis for the discussion of self-care, it
is based on the earlier article by Backscheider on self-care requirements and self-care abilities and
should be read in conjunction with it. In this case, the author focused on assessment of the self-care
abilities of patients who have peripheral neuropathy and the concomitant long-term problems. The
theory–practice analysis is useful in helping the reader delineate some research propositions.
Porter, D. and Shamian, J. (1983). Self care in theory and practice. Canadian Nurse, 79(8), 21–23.
Self-care as theory originated in the early 1950s. Orem was perceived as visionary, and the
theory was labeled as revolutionary by the authors. Self-care was defined, and the assumptions of
the theory and the goal of nursing were identified; the scope of practice—the role of nurse in
relation to the client—was also discussed. How nurses might achieve the goal of nursing accord-
ing to Orem was also explored in this article.
The basic needs of clients, which nurses assist in meeting, are classified by Orem as univer-
sal, developmental, and health deviational. While these are consistent with Orem’s theory, only
brief listings suggest what makes up each of these categories of needs. Citing Orem, the authors
suggested that nursing interventions corresponding to the first two categories of needs could be
considered primary prevention. Secondary and tertiary prevention would be those interventions
related to health deviation self-care needs.
Within the context of Orem’s theory, nursing care planning is facilitated by the development of
nursing systems. Nursing system was defined, and the hierarchical components of the nursing sys-
tem were outlined. These included wholly compensatory, partly compensatory, and supportive–
educative, all of which were defined indirectly within the context of examples. Patients were to be
categorized into one of these three systems through the nursing process when the nurse planned care.
The nursing process within the context of self-care theory included the identification of a
number of factors influencing a person’s ability to perform self-care. Some were listed. This con-
cluded the brief description of the assessment phase. Likewise, the intervention phase was only
briefly described.
Intervention is required when self-care abilities are inadequate to meet self-care demands.
Nursing measures that help the client to achieve the goal of self-care as defined by Orem include:
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488 PART SIX Our Historical Literature
(1) acting or doing for; (2) guiding; (3) teaching; (4) supporting; and (5) providing a developmental
environment. None of these was discussed by the authors. The meanings of major terms and con-
cepts were illustrated within the context of a clinical situation and were offset for emphasis. This
clinical example was titled “Self-care theory in practice at the JGH” (Jewish General Hospital).
Overall, the authors’ description was in keeping with the theory, and the few omissions of
concepts were not significant in terms of the model. The article provides a clear distillation or syn-
opsis of the theory presented in an easy reading style, and although it is merely informative, it
might be of interest to the newcomer to Orem’s model. It might also be of interest to clinicians
wishing a quick overview of the model and its potential utility in the practice setting.
Smith, M.C. (1979). Proposed metaparadigm for nursing research and theory development: An analysis of Orem’s
self-care theory. Image, 11(3), 75–79.
The purpose of this article is to “propose a classification scheme to structure the analysis of
existing research and the design of future research in nursing.” The author uses Orem’s theory to
illustrate the proposed scheme. The ultimate purpose is to “formulate a cohesive, organized body
of knowledge for theory building and development in nursing” (p. 75), as well as to organize
existing research and design future research studies from a nursing framework.
Having developed a scheme and labeled a metaparadigm, the author illustrated how the
premises and propositions of this particular nursing theorist are or can be classified. The author
acknowledges and makes explicit her personally biased assumptions regarding the sine qua non of
professional nursing practice.
This article is relevant to discussions of central phenomena in nursing and to the relationships
among nursing research, theory development, and nursing practice.
Sullivan, T.J. (1980). Self-care model for nursing. In New directions for nursing in the ‘80s. Kansas City, MO:
American Nurses’ Association.
The introduction to this article is very broad, discussing the issues for nursing and society for
the 1980s. This leads the reader to the present focus of self-care and its appropriateness for clients
and for the nursing profession, specifically because of the values it embraces and their similarity
to those embedded in our American sociocultural value system. Nowhere in the introduction is the
reader made aware that the author has taken what she perceived to be a broad, abstract, and other-
wise static grand-level theory and operationalized the concept of self-care to make it more usable.
She undertook to organize a body of knowledge for nursing the aged, which resulted in a self-care
model for nursing the aged.
More than one-half of the article focuses on a review of Orem’s self-care model. This review
includes a fairly comprehensive picture of the model and a description of its components. The
nature, philosophy (including four underlying assumptions), and conceptual framework of the
self-care model are all presented. The conceptual framework includes definitions of the three
major conceptual constructs: therapeutic self-care demand, self-care agency, and nursing agency.
The relationships among these parts of the framework are also explicated. Nursing agency is
defined, and the hierarchical systems and their hierarchical subsystems—technological, interper-
sonal, and social—of nursing care are further described and linkages noted.
In the author’s discussion of the philosophy of self-care—more specifically within the discus-
sion of the nurse–patient relationship—the author has taken what she described as a “lawlike gener-
alization” and restated it as a proposition. Another statement of a corollary could also have been
restated as a propositional statement. These statements were almost incidental to the purpose of this
paper, yet they are critically needed to move this theory to the point of being tested by research.
Elaboration of the concepts, development of propositional statements, and subsequent hypothesis
generation are basic requirements for validation of the self-care model. This author’s brief discus-
sion provides an important step in this direction.
The development of the self-care model for the aged was accomplished following “analysis
and review of nursing literature on the aged and self-care.” The outcome was a self-care model for
nursing the aged. The four levels of the self-care system that emerged were listed and discussed.
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CHAPTER 19 Historical Writings in Theory 489
Conclusions that were reached following identification of these four self-care systems were also
listed. The author also addressed the reality that clients might be functioning partly on one level
and partly on another, and that the four levels of the self-care system are therefore fluid; they rep-
resent a continuum. The model also allows for movement over time, indicating that clients may
move vertically from one level of self-care to another as well, in several identifiable directions.
The technological and interpersonal subsystems of the nursing systems overlap in the process
of accomplishing the goals of self-care. These were discussed, and approaches for applying meth-
ods of assistance to the aged emerged as a result of the study. These approaches were listed from
the highest level to the lowest level of client capability for self-care. Also listed from the highest
level of client capability to the lowest were four interpersonal subsystems. The social subsystem
dimension of the nursing subsystem was also briefly discussed. Horizontal linkages with the
model were also discussed. The author noted that, while it was not within the scope of the paper to
present the concrete referents identified in the model, they had been identified.
Implications for use of the self-care theory in general, and the self-care model for nursing the
aged more specifically, were succinctly summarized. Implications for model development for
nursing groups other than the aged, for nursing practice with an emphasis on health versus illness,
for hypothesis generation leading to research, for nursing leadership roles in health care, and for
issues in nursing such as accountability, legal and ethical, were all presented.
This article would be of interest to practitioners, educators, and researchers who desire to use
the self-care model for any of those areas, and it is recommended reading. For the student of the
self-care model, it would be helpful as a succinct summary of the model, with examples of state-
ments of propositions. It would also be of interest to those working with the elderly and those who
are interested in the self-care model. Furthermore, for students of epistemology, it illustrates the
process of model development through the operationalization of a grand-level theory. The article
is clearly written and logically developed; overall, it is a scholarly work that suggests that the
model can be used as a curriculum model for gerontological nursing.
MARTHA ROGERS
Egbert, E. (1980, January). Concept of wellness. JPN and Mental Health Services, 18(1), 9–12.
Based on the opening sentence in this article, it appears that Rogers’ use of the term health
(not wellness) in a statement about what nursing is was the stimulus for developing the concept of
wellness. At no other time is there any reference to Rogers’ work, nor is the concept of wellness,
as it is developed, related back to her theory.
The concept of wellness, as developed here, was, in essence, distilled from a variety of defini-
tions as a result of a literature review. Based on the review, the author determined that wellness
could not be clearly defined. Instead, she delineated a list of characteristics of wellness from the
conceptions described by several authors and institutions that attempted to define health, such as
Freud, Maslow, Jourard, Perls, Jahoda, Wu, and the World Health Organization. The author sug-
gested that, although health and wellness could not be clearly defined, the list, a synthesis of many
definitions, could provide guidelines for nursing intervention and prevention.
This article does not contribute to our understanding of Rogers’ theory but provides us with a
summary of some of the definitions of health.
Falco, S.M. and Lobo, M.L. (1980). Martha E. Rogers. In the Nursing Theories Conference Group, Nursing theo-
ries: The base for professional nursing practice. Englewood Cliffs, NJ: Prentice-Hall.
Consistent with the other chapters in this edited volume, there is a brief history about the the-
oretician whose theory is presented. This summary of Rogers’ Theoretical Basis of Nursing by
Falco and Lobo is generally written clearly and concisely.
The authors present Rogers’ definition of nursing and the five major assumptions about
human beings that underlie the nursing science explicated by Rogers. Not listed are the more gen-
eral, broader assumptions underlying the four principles of homeodynamics, which are explicitly
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490 PART SIX Our Historical Literature
stated by Rogers. The second set of assumptions, similar to those about human beings, is
grounded in systems theory. The four principles of homeodynamics are identified and elaborated
on by the authors.
In the remainder of the article, the authors compare Rogers’ theory with others, present clini-
cal examples, and demonstrate the principles of homeodynamics, and then show how the princi-
ples might be used in the nursing process. This illustration shows the potential application of the
model to clinical practice. Examples include series of questions to be used in the assessment phase
to reflect each of the principles of homeodynamics. Examples are also given of nursing diagnoses,
planning, and implementation within the framework. Tables illustrate the relationship of the prin-
ciples of homeodynamics to the nursing process. This use of Rogers’ principles in the nursing
process is only one of two known published uses (see also Whelton, 1979) and is an important
contribution to the theory.
The authors also discuss limitations of Rogers’ principles (i.e., that they are too abstract and
that terms have not been sufficiently operationalized).
For the reader unfamiliar with Rogers’ Theoretical Basis of Nursing, this article presents a
brief overview and summary. The examples of application to practice using the nursing process
show the utility of the theory for practice, and this makes it more useful for the practitioner. In this
way, the article contributes to our understanding and use of this theory and therefore to the science
of nursing.
Katz, V. (1971). Auditory stimulation and developmental behavior of the premature infant. Nursing Research,
20(3), 196–201.
Although not explicitly stated by the author, she was a student in Martha Rogers’ program,
and because this research was based on other research carried out at the same institution, it is
assumed that Katz’s study was developed based on assumptions of Rogers’ theory. If this is cor-
rect, not presenting the theoretical framework would be a limitation.
If one were to try to guess which of Rogers’ assumptions underlie this study, the following
might be included: (1) a human being and his environment are continuously exchanging matter
and energy with one another, (2) the life process evolves irreversibly and unidirectionally along
the space/time continuum, (3) pattern and organization identify a human being and reflect his
innovative wholeness (Rogers, 1970).
“The focus of this study was to determine whether a variation in the environment of the low-
birth-weight premature infant by the introduction of the maternal voice can influence behavior”
(p. 196). The design of the study was quasi-experimental, using a control group; it had a sample
size of 62. The major statistical analysis was an analysis of variance, comparing those premature
infants who received a regimen of auditory stimulation with those who did not. The behavioral
outcomes measured were motor, tactile-adaptive, auditory, visual, muscle-tension, and irritability
responses. All tools used had reliability and validity data available.
The same two raters (not the investigator) who were used to test all infants were blind as
to which groups the infants were in. Interscorer agreement between the raters and the investi-
gator was obtained after the raters were trained. These and other measures are important safe-
guards that were used in this study to reduce the potential for bias in the data. In general, based
on the write-up, it appears that the study was well-designed.
The study supported previous findings that had indicated that variations in behavioral devel-
opment are evident after changes are made in sensory input in low-birth-weight premature infants.
More important, and consistent with Rogers’ belief that the purpose of nursing as an empirical sci-
ence is to describe and explain the phenomena central to its concern (i.e., persons) and to predict
about them, this study provides empirical data from which nursing intervention can then be
planned. In Rogers’ terms, “the identification of relationship between events provides for an
ordering of knowledges and for the development of nursing’s hypothetical generalizations and
unifying principles” (1980, pp. 84–85).
For these reasons, this study supports Roger’s theory and contributes both to empirical vali-
dation of it as well as to the science of nursing in general by the rigor of the research. An important
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CHAPTER 19 Historical Writings in Theory 491
omission in the write-up, however, is that the researcher did not indicate other potentially testable
hypotheses generated by this research.
Porter, L.S. (1972). The impact of physical-physiological activity on infants’ growth and development. Nursing
Research, 21(3), 210–219.
This rigorous experimental study was explicitly based on two assumptions of Martha Rogers’
theory: (1) the human organism is an open system in constant interaction with the environment,
and (2) growth and developmental processes are unitary and integrative. The study was developed
with the conceptualization that the human organism is an energy field in continuous motion. The
researcher postulated a direct relationship between environmentally imposed motion and a speed-
ing up of infant growth and development.
The research was built on earlier studies that also used Rogers’ theory as a conceptual frame-
work, as well as the researcher’s own earlier study of infants. Because the researcher believed that
the results of her earlier study were not generalizable enough, this study was undertaken as a fol-
low-up study to corroborate the earlier findings. (An earlier study by Luz Sobong tested Johnson’s
proposition of stimulation and growth.)
The study is methodically and systematically described, clearly enough so as to be repro-
ducible. Background, hypotheses, methodology, data collection, and results are all described in
detail. Tables showing the data are included, as well as a summary of the analyses performed on
the six measures of growth and development used in the study. The six measures of growth and
development were gains in weight, length, motor, adaptive, language, and personal-social behav-
ior. The design of the study was experimental, with random assignment of subjects who were then
matched with a control group. One limitation in the data collection was that the investigator col-
lected the data and was not blind to whether subjects were in the experimental or control group (or
so it appears from the write-up).
A question is raised here regarding the data analysis. For example, the subjects were
pretested on the six measures. Results presented showed that the heaviest control subject initially
weighed 325 ounces, while the corresponding experimental subject weighed 369 ounces. There is
a difference between these two of 44 ounces. In the discussion, the author indicated that there was
“no important initial difference” (p. 216) between the groups. The question is, Is this a significant
difference between the two groups? A t-test would have provided this information and, although it
may have been done by the investigator, the results were not reported here.
This research study has contributed to the science of nursing not only by contributing to
knowledge about infants, with implications for nursing intervention, but also by providing support
for the assumptions upon which it was based, namely those of Martha Rogers. This was a rigorous
study and a scholarly report.
Rogers, M.E. (1970). An introduction to the theoretical basis of nursing. Philadelphia: F.A. Davis.
In this book, Martha Rogers first formally presents her ideas about the theoretical basis of
nursing. Some of the origins of her ideas, her earlier thinking, is seen in her 1963 article, which it
is helpful to read either prior to or in conjunction with this book. (Rogers uses “man” to refer to
the nursing client in this early writing.)
Essentially, the book is divided into three main sections. In the first section, “Book of Modern
Nursing,” she presents background material related to man’s beginnings, the evolution of man’s
thinking, and theories of this century about how man and life originated. “The Phenomenon of Man:
Nursing’s Concern” is the second section. Here, Rogers states what she sees as the central concern
of nursing: man in his entirety. Man as a whole, man as a system, is the prototypic theory used to
present the underlying assumptions Rogers makes about man. The assumptions are explicitly num-
bered and labeled as such. Five assumptions upon which nursing science builds are identified.
In the third section, “Nursing’s Conceptual System,” Rogers clearly points out the aims of nurs-
ing, nursing’s conceptual model, the principle of nursing science, the principles of homeodynamics,
evidence to support the concepts, ideas about formulating testable hypotheses, ways in which to
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translate the conception into practice and, finally, some ideas about the future. The essence of the the-
ory is expressed in the first part of this section. The assumptions about man, the focus of nursing, were
identified in the earlier section, but it is here that the concepts and principles are defined—the internal
structure, aspects of the goals and consequences, and some dimensions of the theory are outlined.
An important chapter in this section relates to the potential of this theory for research. In fact,
a whole body of research attempting to verify the principles of the real world (being carried out by
doctoral students under Rogers’ direction) is presented. The limitation in this chapter discussing
the findings is that about 95% of it includes unpublished doctoral dissertations and is not gener-
ally available. Nevertheless, the important thing is that numerous studies, including cluster stud-
ies, have been and continue to be undertaken in attempts to accumulate evidence in support of the
principles postulated by Rogers. This fact alone makes Rogers’ formulations stand out from all of
the other nursing theories and models, even to this day. Furthermore, implications of many of the
studies give direction for practice as well as provide direction for additional research.
The major limitations of Rogers’ formulations are well known. These are that the principles
of homeodynamics—reciprocity, synchrony, helicy, and resonance—are all quite abstract and
have not been adequately operationalized. Some would say that because the principles are not eas-
ily understood, they are difficult to translate into practice. Also, because of the lack of operational
definitions, the research carried out to verify the principles provides questionable results. The
major counter argument, if one were to think along the lines of Rogers’ theory and writing, is that
research must focus on the range of human phenomena and that this will give substance to nurs-
ing’s abstract system. There is, to a degree, an element of inductive reasoning, and an inductive
approach is suggested; that is, the principles provide the framework, the direction for research, but
the research results really provide the substance of the theory.
A chapter in the third section, in addition to discussing research, addresses the potential of
the theory for practice. With the exception of citing four research studies suggesting direction for
nursing practice, the discussion is more or less an abstract discussion of nursing interventions that
purportedly are based on the different principles of homeodynamics. It does not indicate whether
the theory is actually used in any practice settings.
In closing, we would recommend to anyone interested in Rogers’ theory to read, at the mini-
mum, the third section of the book; then for additional understanding of the assumptions about
human beings, the second section, and for background in general, the first. The book is clearly and
logically developed and very readable. In general, reading the whole book, elegant in its simplic-
ity, sophisticated in its presentation, and as erudite as its author, is highly recommended. Rogers
stands out among nursing theorists, and her work in theorizing, research, and education presents a
major contribution to nursing as a science.
Rogers, M.E. (1975). Euphemisms in nursing’s future. Image, 7(2), 3–9.
The focus of this paper is an argument against the many forms of nursing services parading
under the guise of nice-sounding titles, when in fact they are cover-ups for physicians’ assistants.
This controversy was at its height in the early to mid-1970s, and Rogers was strongly opposed to
the development of new roles or any new title, such as family health practitioner, pediatric associ-
ate, and primary care nurse. She believed that these acted as cover-ups for physician’s assistants,
were “perpetrated to deny a future to nurses and nursing” (p. 3), and were coined to enhance the
economic gains of the physicians.
This article bears little if any relevance to Rogers’ theoretical basis of nursing per se. What
comes through are her beliefs about the roles and levels of education needed to prepare nurses and
what the scope of nursing is. Her theme that a baccalaureate preparation for nursing is important is
repeated here.
For those unfamiliar with the more personal side of the professional Martha Rogers, this arti-
cle provides a touch of that side. It gives one a feel for the spontaneous way in which she makes
her arguments and for the strength of her convictions. Her wit, sense of humor, and a touch of cyn-
icism are well demonstrated in this article. For this alone, this article is worth reading.
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CHAPTER 19 Historical Writings in Theory 493
Rogers, M.E. (1980). Nursing: A science of unitary man. In J.P. Riehl and C. Roy (Eds.), Conceptual models for
nursing practice (2nd ed.). New York: Appleton-Century-Crofts.
In this chapter, Rogers brings us up to date on her thinking about nursing and a conceptual
system in nursing. She in fact presents a few changes in the underlying assumptions and in the
principles of homeodynamics, compared with her earlier book (1970). No explanation is set forth
as to why the changes were made. In essence, no specific assumptions about man are identified.
Rather, Rogers states that four building blocks are essential in the conceptual system presented in
this paper. They are: (1) energy fields, (2) universe of open systems, (3) pattern and organization,
and (4) four-dimensionality. Each is briefly discussed.
The principles of homeodynamics have been reduced from four to three, and one of the three
is different from the original. The original four were the principles of reciprocity, synchrony,
helicy, and resonance. The new three are the principles of helicy, resonance, and complementarity.
The first two remain essentially the same in definition. The principles of complementarity have
elements of the original principle of reciprocity, with the added idea of interaction between man
and environment.
Some elements of the theory appear to have been updated; for example, the title. Here, the
underlying assumptions are broadened to include more than those five assumptions about the
human being. And, they are also described as building blocks rather than assumptions. As already
discussed, the principles of homeodynamics have changed somewhat.
Also updated are the theories deriving from the proposed conceptual system. Only a few of
these are discussed. These include theory of accelerating evolution, explanations of paranormal
events, and rhythmical correlates of change. Rogers also takes into account the implications that
advances in technology have for change.
The last of these updates is in the discussion of implications for practice. Changes in nurs-
ing practice must result from changes in man, such as the evolutionary emergence of new
behavior patterns (e.g., hypertension and hyperactivity), new knowledge, and changes in values.
This is an interesting point that Rogers makes and, indeed, one not commonly mentioned by
most theorists.
It is recommended that this chapter be read in conjunction with Rogers’ 1970 book.
Whelton, B.J. (1979). An operationalization of Martha Rogers’ theory throughout the nursing process. Interna-
tional Journal of Nursing Studies, 16, 7–20.
This is the second of only two known articles referring to situations in which Rogers’ theory
is used throughout the nursing process. This whole article essentially focuses on that, whereas
Falco and Lobo (1980) only present the nursing process in a section of their chapter.
The introduction clearly states the purpose of the paper and describes the content to be cov-
ered and then, clearly and precisely, the authors carry out their plan. This makes the paper very
readable.
The version of Rogers’ theory used here is the earlier (1970) version rather than the 1980
updates. In the presentation of the theory, the structural components are clearly spelled out; that is,
basic assumptions about man, the five nursing concepts (stated more explicitly than Rogers really
did), and the nursing principles of homeodynamics derived from the concepts. The five nursing
concepts identified by this author are wholeness, openness, pattern and organization, unidirection-
ality, and sentience and thought.
The clinical population of interest identified as the focus of the operationalization of Rogers’
theory are those patients with decreased cardiac output and impaired neurological function. For
example, the assessment of these patients would include data related to the five general concepts
already mentioned. Tables are included that show what is assessed under each of these categories.
For example, under wholeness, physical integrity and psychological integrity are listed. Then, in a
later table for a patient with impaired neurological functioning, the subitems are listed.
The general format is carried out in detail through each phase of the nursing process, here
identified as assessment, nursing diagnosis, plan of care (including goal), and implementation and
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494 PART SIX Our Historical Literature
evaluation. Detailed tables present an actual nursing care plan showing diagnosis, plan, and goal.
No examples are given for implementation and evaluation.
At least one example in this area would have complemented the other phases. In summariz-
ing, Whelton indicates that assessment tools will vary with the patient population. However, it is
not entirely reasonable to have an assessment tool for each and every different patient population.
Therefore, the tool described here could be developed in more general terms and could thus be
more generalizable to other patient populations.
This article has contributed significantly to the applicability of Rogers’ theory to practice by
making the somewhat abstract notions of the theory more concrete and by operationalizing the
theory within the nursing process.
SISTER CALLISTA ROY
Brower, H.T. and Baker, B.J. (1976). Using the adaptation model in a practitioner curriculum. Nursing Outlook,
24(11), 686–689.
The practitioner curriculum described here is a geriatric nurse practitioner program that uses
Roy’s adaptation model. The authors forthrightly state that Roy’s model meets the following cri-
teria: it outlines the features of the discipline and provides direction for practice, research, and
education; it considers the values and goals of nursing, the client, and practitioner interventions;
and, in essence, it is a theory at the prescriptive or situation-producing level. Because these criteria
were met, the model was incorporated into this curriculum.
Another important identified aspect of the model was that it was helpful in differentiating
between those aspects of care unique to nursing versus medical practice within the context of
Roy’s four modes of adaptation. Furthermore, in describing the application of the model, it
appeared that examples used are the authors’ interpretation of Roy’s model. Although the
potential of the model for practice is supported (e.g., another area of practice is covered), the
application offers neither refinement nor extension. On the other hand, some insights in
the form of interventions for nursing are suggested. For example, to promote client adaptation,
nursing interventions might include facilitation of adaptive tasks of aging through counseling,
effective communication techniques, health education, active manipulation, providing support,
and identifying resources. However, here the points of entry for the nursing intervention are
not clearly spelled out. It is stated: “If inadequate adaptation is occurring, the practitioner can
attempt to modify or manipulate focal stimuli, thereby making a positive response possible”
(p. 687). This example simply is not specific enough; it suggests where to intervene but not
when.
The third focus in this article is curriculum application. In this section, an elaboration of the
content taught provides information about what these authors draw on from other fields and other
theoretical models for a knowledge base as it relates to this model. For example, crisis intervention
theory, health anthropology, attitudes, life review, stage theory, and role theory are all included. This
information may be interesting to those who want to plan a similar practitioner program.
Farkas, L. (1981). Adaptation problems with nursing home application for elderly persons: An application of the
Roy adaptation nursing model. Journal of Advanced Nursing, 6(5), 363–368.
The author suggested at the outset that the elderly are often dependent on significant others to
provide care supplementary to home care, so that they can remain at home. The importance of this
study, then, was to “assess the life circumstances surrounding nursing home applications for eld-
erly people” (p. 364), and the Roy adaptation model was chosen as the framework to organize data
collected about adaptation problems of elderly people and their significant others.
Three research questions were identified:
1. In what way can a conceptual framework in nursing provide for the understanding of
adaptation problems of elderly persons and significant others that contribute to nursing
home applications?
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CHAPTER 19 Historical Writings in Theory 495
2. If two groups of elderly persons are receiving at least one home care service, what simi-
larities and differences exist in adaptation problems that allow one group to remain at
home while the other group must apply for admission to a nursing home?
3. To what extent do the adaptation problems on the part of the elderly person and of those
persons closest to him contribute to the nursing home application for the elderly person?
(p. 364)
The discussion of the conceptual framework that followed those research questions briefly
presented the underlying beliefs of the Roy adaptation model and identified the four adaptive
modes and what was considered an “adaptive response.” The nurse’s role within the model was
identified as promoting adaptation that involved two factors in the nursing process: assessment
and intervention. Other than this brief overview, the author assumed that the reader was familiar
with the model. Only one study was cited that documented characteristics or problems of elderly
applicants to long-term care facilities, and no research, related to adaptation or to use of the adap-
tation model, was cited.
In the purpose statement, the general purpose to assess factors associated with nursing home
application was repeated. A general statement that five hypotheses were formulated and tested
was made, as well as a statement that they related to overall adaptation problems, powerlessness,
role reversal guilt, and knowledge and utilization of services, but the hypotheses were not explic-
itly stated. Furthermore, no theoretical connections between the hypotheses and the Roy model
were explicated. It is not clear that all the hypotheses flowed from the research question. This led
me to conclude that the conceptualization of this research within the Roy model was extremely
limited; that is, it was conceptually inadequate.
The study group and the control group were described, but criteria for each subject group
were not specific.
The method used in this study was described as an ex post facto design, appropriate to this
population because admission to a nursing home is not a variable that can be controlled. Statistical
analyses were completed using chi-square. Both the elderly subjects and their significant others
were interviewed in their homes.
The limitations of this research outweigh the contributions it might have made to the testing
of the Roy adaptation model. What is more, in the conclusion, neither the limitations of the
research nor the implications for future research are discussed.
Galligan, A.C. (1979). Using Roy’s concept of adaptation to care for young children. American Journal of Mater-
nal Child Nursing, 4(1), 24–28.
Given the psychosocial as well as the physical needs of hospitalized children, this author has
chosen Roy’s concept of adaptation “as a means of guiding nurses in a more conscious effort to
assist the child during hospitalization.” Rationale for the choice of this model was not provided.
The author has divided the hospital stay into four different stages: prehospitalization, preopera-
tive, postoperative, and discharge. The rationale for these divisions was that, because “man” (child?)
is in constant interaction with a changing environment, the nursing assessment and appropriate inter-
ventions must be revised periodically during the patient’s stay. Each stage is briefly discussed
regarding the potential for assessment and intervention. Then, to illustrate how the Roy adaptation
model might be used to assess and intervene with a young child, a hypothetical case was presented.
For three of the four stages of hospitalization, omitting discharge, each mode is discussed
with examples of assessment—including focal, contextual, and residual stimuli—and interven-
tion. In the second and third stages, the dimensions of diagnosis and evaluation were added. The
discharge stage was discussed only very briefly, indicating that the child should be evaluated
again in each of the four adaptive modes, and a discharge plan should be formulated.
For those interested in the applicability of the model for practice, especially with patients
other than adults, this is an important contribution, demonstrating that the model is useful in the
nursing care of children. On the whole, however, it does not increase our understanding of the Roy
model itself.
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496 PART SIX Our Historical Literature
Janelli, L.M. (1980). Utilizing Roy’s adaptation model from a gerontological perspective. Journal of Gerontologi-
cal Nursing, 6(3), 140–150.
The title of this article clearly indicates its focus, but more specifically, the author discusses
two purposes. The first is general background about how the author came to use the theory and an
overview of the model. Selye’s stress theory was identified as the paradigmatic origin of the theory.
The second purpose of the article is to present use of the model with specific clinical examples in
gerontologic nursing.
As far as contributions to the theory, the author presents her conception, in diagrammatic
form, of a human being as a biopsychosocial being interacting with the environment. Although the
Roy adaptation model is basically a systems model, Roy does not use the word “tension” as it is
used in this description. Other than the diagram, this article does not substantially add to our
understanding of the model. It does, or at least did in this case, provide enough direction for prac-
tice with an elderly clientele.
This article is useful for those interested in gerontologic nursing. Tables of needs and the
schematic presentation of the human being–environment interactions are also useful.
Jones, P.S. (1978). An adaptation model for nursing practice. American Journal of Nursing, 78(11), 1900–1906.
The adaptation model described here is not related to the Roy adaptation model and, in fact,
uses a different prototype theory as a basis for its development. The author suggested that having
this second framework based on the idea of adaptation (in this case modeled after Selye) might be
confusing, but she thought her model might have more to offer than other theories. She suggested
that there were difficulties with other existing theories; however, the difficulties were not identified.
In addition to using Selye’s theory as a prototype, Maslow’s hierarchy of needs was also used
“to provide structure and guidance for assessing all needs.” Based on the hierarchy, the author
developed an elaborate assessment tool.
In terms of the structural components of the model, assumptions and concepts were explicit.
Eight underlying assumptions were listed. The major concepts used included wholeness, needs,
adaptability, illness, and wellness. The author did not specifically develop propositional state-
ments that described the relationship of the concepts.
On the whole, this article does not contribute to our understanding of Roy’s adaptation
model, although it may have contributed another perspective to the concept of the health–illness
continuum (in this case, illness–wellness continuum), which is not terribly clear in Roy’s model.
Jones illustrates her model using a triangle to demonstrate the interaction of the three variables in
an average person. This conceptualization helps to determine wellness when the person is physi-
cally ill but “well” in other areas, a problem in Roy’s model.
Mastal, M.F. and Hammond, H. (1980). Analysis and expansion of the Roy adaptation model: A contribution to
holistic nursing. Advances in Nursing Science, 2(4), 71–81.
Although believing that the Roy adaptation model has much to offer nursing by way of pro-
viding a framework to organize its body of nursing knowledge, these authors are highly critical of
the model in its present form. Specifically, the criticisms focus on a lack of explicit theoretical
components of assumptions and concepts, simple propositions, and relational propositions (criti-
cisms noted in earlier critiques also).
The purpose of this article, then, is to make up for some of these deficits. Assumptions under-
lying the mode, heretofore implicit, are explicitly stated. (Roy’s 1980 edition of Conceptual Mod-
els was not yet published when this article was written because in that edition, the assumptions are
outlined by Roy. Readers are encouraged to compare the two sets of assumptions.)
The five major concepts within the framework are identified, summarized, and discussed.
These include: (1) person, (2) environment, (3) adaptation, (4) health–illness, and (5) nursing.
The authors focus on the lack of theoretical and operational definitions, as well as on the nar-
row scope of health–illness. In attempting to elucidate this concept and to answer some questions,
a continuum is defined, a new idea of transition is introduced, and nursing assessment along the
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CHAPTER 19 Historical Writings in Theory 497
continuum is clarified. This addition is justified on the basis that it expands the model’s scope.
However, based on this brief discussion, this is a critical addition to the concept of health–illness.
Two other major additions to the theory are a diagram depicting the relationships between the
major concepts of the model and a set of propositional statements. The latter is a particularly
important contribution because it is what the model lacked at the time this article was published.
Overall, the article is clearly written and adds to our understanding of the theory. The contri-
bution of propositional statements adds to the researchability of the theory, and ultimately to nurs-
ing as a science.
Mastal, M.F., Hammond, H., and Roberts, M.P. (1982). Theory into hospital practice: A pilot implementation.
Journal of Nursing Administration, 12(6), 9–15.
This article describes both the process involved when the Roy adaptation model was imple-
mented in one unit of a small community hospital, and how the process contributed to the valida-
tion of nursing theory. The description of the process is detailed enough to give guidance to
clinicians or administrators who might choose to implement a theoretical model. Each step of the
process is outlined and described.
Adequate review and understanding of any theoretical model to be used in a clinical setting is
requisite. In this case, the review revealed that not all components (philosophical basis, assumptions,
concepts, and propositions) had been specifically identified and defined. This led the authors to pur-
sue this end directly with the theorist, Sister Callista Roy. From this, specific components were clar-
ified, and what were perceived by the authors to be the model’s components were depicted visually.
This effort was later used to make the model understandable and usable for the hospital’s nursing
staff. (This process of clarification of the components of the model and the communications with
Sister Roy would also make another significant contribution to the theory’s validation.) Once com-
ponents of the model had been clarified, the administrative processes were initiated.
Planning and organizing were the major steps required administratively to start the pilot.
Approval was sought, starting with the top levels of hospital and nursing administration. Congru-
ence with the hospital philosophy, standards of patient care, and cost effectiveness were all
explored. One unit was selected for the pilot, with justification for that choice outlined.
Organization was based on Di Vincenti’s theoretical framework for change and required three
major steps: (1) establishing the change structure, (2) developing appropriate procedures, and (3)
determining requirements and allocating resources. Each of these steps was described and dis-
cussed in some detail. In the change structure, shared power was the category of “how” to change.
Group problem solving and group decision making, as part of shared power, was emphasized.
Open communication and a method for addressing problems in an ongoing way was also impor-
tant to the success of the project.
The development of procedures included review of existing forms and required revision of
nursing assessment, although not of the nursing care plan. Procedures affecting unit function
required guidelines for the following: “(1) using the assessment and planning tools, (2) nursing
reports and rounds, (3) patient care conferences, (4) nursing documentation, (5) orientation of new
personnel, (6) standards of performance and job descriptions for nurses involved in the project,
and (7) audit criteria” (p. 13). Costs for these services and required materials were assumed by the
hospital. The planning and organizational phase was reported to have taken five months.
Staff education required the next major block of time. One-hour sessions weekly for a period
of 15 weeks were structured for all the staff—RNs and LVNs—on the pilot unit. Cooperation of
the head nurse and other departmental heads to cover staffing on the unit during this time period
was critical to the success of the classes.
The authors believed that the overall components of success of the pilot implementation were
authority, leadership, and communication. Clear lines of authority and administrative sanction for
the implementation of the adaptation model were critical. Furthermore, open communication was
fostered and facilitated through weekly group meetings, through frequent one-to-one talks
between project directors and staff nurses, and through the use of an on-unit community log book
for staff to express feelings.
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498 PART SIX Our Historical Literature
Outcomes were measured indirectly, both by improved patient care and by nurses’ satisfac-
tion with enhanced professional practice. Since then, patient satisfaction is being documented by
conducting further research. There were more concrete measures of enhanced nursing practice.
Namely, the development of a new tool to assess the biopsychosocial status of patients (illustrated
by Exhibit 1), more complete nursing care plans phrased in terms consistent with the model, and
greater collegial sharing and rapport were reported.
This report was written clearly in a conversational style, without sacrificing scholarliness and
thoroughness. It would be of interest to theorists, researchers, and clinicians alike who are inter-
ested in the Roy model because it clearly illustrates the helical nature of theory, research, and
practice. What is more, it makes an important contribution to the science of nursing by demon-
strating application to practice and by stimulating research.
Roy, C. (1970). Adaptation: A conceptual framework for nursing. Nursing Outlook, 18(3), 42–45.
The purpose of this article is to describe the framework of a conceptual model for nursing
that was in the early stages of development by a nursing faculty group. Implications of the model
for nursing science, practice, and education are suggested.
Implicit in the section “Theoretical Model” are the functional components of assumptions
and concepts. Examples of the underlying assumptions are: (1) man is a biopsychosocial being,
(2) man is constantly interacting with a changing environment, and (3) man has both innate and
acquired coping mechanisms. The major concepts of the model are adaptation and coping, health
and illness, and man and the environment. However, Roy, in this first publication on her theory,
does not yet explicitly identify either the assumptions or the concepts.
In the discussion of the concepts, the major concept of adaptation is described in terms of its
origin in the physiologic theory of Harry Helson. The definition is technical and somewhat tauto-
logical and does not answer the questions raised by the author, which are: “How does this adapta-
tion take place?” and “What is behind the process?” These are difficult questions, and it was too
early to answer them. Furthermore, when the author tries to answer the question about how the
concept of adaptation applies to nursing, the answer is in terms of the function of nursing, which
is “to support and promote patient adaptation.”
Although the term “elements,” as applied to conceptual models, was not used at the time this
article was published, except in a course taught by Dorothy Johnson at the University of Califor-
nia, Los Angeles, where Roy was studying for her master’s degree, this analysis reveals that the
following elements are present: goal of action—to support and promote patient adaptation; and
actor’s role—to assess and intervene and to promote adaptation. Less clear are the elements of
patiency, which is when the nurse becomes involved with the patient on the health–illness contin-
uum, and the source of difficulty (although it is similar to patiency). The recipient of nursing care
is the human being. The intervention focus or mode is to promote adaptation by changing the per-
son’s response potential. Specific examples are given. Understanding man in health and illness is
the essential focus of adaptation nursing.
That this developing theoretical model presents rudimentary outlines of a nursing science is
an overstatement on the part of the author. However, considering that this is one of the earlier the-
oretical models developed in nursing, it is an important contribution to the growth of nursing as a
science. This is a useful article to read for those interested in analyzing the development of theo-
retical thinking in nursing.
Roy, C. (1971). Adaptation: A basis for nursing practice. Nursing Outlook, 19(4), 254–257.
This article picks up where the earlier one (1970) left off; it is helpful to read both together. It
offers a description of man as an adaptive system with four modes of coping. Assumptions underly-
ing the model are offered; the four modes of adaptation and their components, as well as examples,
are listed. The four modes—later called effector modes—are physiologic needs, self-concept, role
mastery (later, role function), and interdependence. All four modes were identified based on sam-
ples of behavior collected by the author’s nursing students, as well as on a synthesis of work done
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CHAPTER 19 Historical Writings in Theory 499
by other nurses. The other nursing sources included Abdellah and McCain. Ultimately, it appears
that the categories are a synthesis of several sources, which may raise some questions about the
validity of the categories. What data and what research supported these four choices? Are there
other modes, such as the cognitive mode, which might be included?
A more rigorous approach that may have helped in the development of nursing knowledge
would have been for the author to develop a research orientation and a scientific approach, rather
than a curricular one. Hindsight aside, the leap was immediately made to clinical application.
Within the context of clinical application, new concepts then came up that had had insufficient
elaboration. Examples of these included health–illness continuum, “positive” responses versus
“negative” needs, and a diagram/figure describing the nursing process and first-level assessment.
The nursing goal, clearly stated, is “to bring about an adapted state in the patient, which frees
him to respond to other stimuli which may be present.” This remains a nursing goal of the theory
in 1984, and continues to raise questions about what the nature of the adapted state is and its
intended consequences (being [in 1984] the quality of life and the integrity of the individual).
To demonstrate the applicability of the model of adaptation to nursing, two case studies were
presented. In each, the nurse used the model as a basis for assessment and intervention. Because it
is clearly stated that the nurse establishes a nursing care plan and later evaluates it, and because
the nursing process as it was known at the time encompasses four stages—assessment, planning,
intervention, and evaluation—one wonders why Roy chose instead to use a nursing process
including only two of the four—assessment and intervention. That question aside, the steps grew
to six in 1984.
Although there is a discussion about planning, the “how to” of choosing nursing approaches
is left to the process of nursing judgment outlined by McDonald and Harms. Additionally, the
unintended consequences of the nursing intervention are not discussed.
Overall, this article continues to contribute to our understanding of processes, strategies, and
phases of theory development in nursing.
Roy, C. (1976). The Roy adaptation model: Comment. Nursing Outlook, 24(11), 690–691.
Sister Callista Roy, who developed the Roy adaptation theory, herein presents her reactions to
two articles by Brower and Baker (1976) and by Wolfer (1976). She thinks that the authors did a
fine job in implementing ideas from her writings, considering that they used only her published
material as a basis.
After more general reactions to Brower and Baker’s article regarding the importance of a
nursing model as a basis for role identification, Roy goes on to clarify her views, to identify what
could be considered limitations, and to acknowledge difficulties with the model. Among these are
the fact that the model “has not yet been submitted to the rigors of clinical research that will be
necessary to establish its validity,” and that the model is a deductive one and has not been devel-
oped by formal theory construction methods.
This interaction and feedback is an important process for the growth of nursing knowledge,
and the thinking of scholars was evident later on in the development of Roy’s theory.
Roy, C. (1979). Relating nursing theory to education: A new era. Nurse Educator, 4(2), 16–21.
This article examines the relationship between nursing theory and nursing education, from
the meaning of theory to mechanisms of theory utilization, within a department of nursing.
Roy, C. (1980). The Roy adaptation model. In J.P. Riehl and C. Roy (Eds.), Conceptual models for nursing prac-
tice (2nd ed.). New York: Appleton-Century-Crofts.
Data from research are notably still missing in this updated version of the Roy model, pub-
lished a decade after the first publication appeared in Nursing Outlook.
Presented here is the more formal theory construction work that was promised in the earlier
“Comment” (1976). Clearly presented and labeled as such are the basic assumptions underlying
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500 PART SIX Our Historical Literature
the model and the elements of the model, namely, values, goal of action, patiency, source of diffi-
culty, and intervention. What is still missing is an elaboration of the major concepts and the propo-
sitions, or those statements that show the relationship among the concepts. This important
omission is not acknowledged by the author. More seriously at issue here is that the model is now
10 years old, is widely used as a curricular framework and in nursing practice settings, and yet
research is still not being carried out.
A new diagram depicting the “source of difficulty” is not clarified in the text. The source of
difficulty is first “described as the originating point of deviations from the desired state or condi-
tion.” However, the discussion continues in the vein of how the modes and coping mechanisms
are called into play (i.e., like a feedback system), rather than truly defining the source of diffi-
culty. The discussion closes with this summary explanation: “‘The source of difficulty,’ then, is
coping activity that is inadequate to maintain integrity in the face of a need deficit or excess.”
This does not match the diagram, which shows that there can exist either adaptive or maladaptive
behaviors. The question unanswered by either the diagram or the text description is: When does a
source of difficulty really exist? And, particularly and more importantly, When does the nurse
intervene: at the originating point of deviation, or at a later time, when the coping mechanisms
called up are inadequate? The diagram is somewhat confusing in light of the discussion in the
text.
In summarizing, the author points to areas in which “continuing development” is needed,
such as validation of assumptions, explication of values, and clarification of elements.
Schmitz, M. (1980). The Roy adaptation model: Application in a community setting. In J.P. Riehl and C. Roy
(Eds.), Conceptual models of nursing practice (2nd ed.) (pp. 193–206). New York: Appleton-Century-Crofts.
The Roy adaptation model was applied here in the home setting, which is different from the
inpatient setting where it has heretofore exclusively been applied. This necessitated an expansion
of the concept of client from individual with an identified need to include the “family of care.” If
this broadened definition of the client is accepted, and it seems appropriate to do so, this will be an
important contribution to the model.
In the introduction, the author is careful to identify differences between the home and hos-
pital, especially in terms of nursing goals and nursing interventions. Also identified in the home
setting were variables influencing care. The introductory remarks laid the groundwork for a
detailed case study, with a family requiring home nursing care, which was the major focus of
the study.
The care presentation included six detailed tables describing the client behaviors with focal,
contextual, and residual stimuli for each mode and an accompanying nursing care plan for each.
The author summarized how the Roy adaptation model was used to assess and intervene with
a family. Application of the model was the focus of this article. A more theoretical discussion
would also have been appropriate because an expansion of the concept of client resulted from the
thinking and work of this author, which is an important theoretical contribution.
Starr, S.L. (1980). Adaptation applied to the dying client. In J.P. Riehl and C. Roy (Eds.), Conceptual models for
nursing practice (2nd ed.). New York: Appleton-Century-Crofts.
In this brief descriptive article, the author has elaborated on “elements of adaptive death”
within four modes (Roy’s): (1) physiologic mode, (2) self-concept mode, (3) role mode, and (4)
interdependence mode. Within each mode, adaptive behaviors of the dying client are identified,
stimuli affecting the behaviors are listed, and the nursing goal and interventions appropriate to
each mode are presented.
Although this article is included in a set of three articles about the Roy adaptation model,
there is no direct reference to Roy’s work by the author. If one assumes that this is an application
of the Roy model to practice, it is clear that it is timely, that the model can be applied to this group
of patients, and that it is appropriate to nursing practice in this area. However, the article does not
extend the Roy adaptation model.
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CHAPTER 19 Historical Writings in Theory 501
Wagner, P. (1976). The Roy adaptation model: Testing the adaptation model in practice. Nursing Outlook, 24(11),
682–685.
According to this author, the potential for practice in both episodic and distributive settings
using the Roy adaptation model has been realized. Graduate students who tested the feasibility of
the model for practice concluded that “the model provided a good framework for ordering a variety
of observations,” and using the model for nursing enhanced assessment and intervention as well
as the overall nursing process.
Before field testing the model, the graduate students reviewed materials published about the
model. They found discrepancies between sources and also, although not stated directly, they
found limitations in the original assessment tools. They also identified limitations with a tool they
subsequently developed, even though their tool met the criterion that it was both theoretical and
practical. These authors also expressed concern with overlap between the four modes as devel-
oped by Roy.
The author gives an indication that the model provides enough direction to affect practice in a
variety of settings. Who is acted upon is not as clearly described as where or in what setting the
person is acted upon. We are not any clearer as to the focus of the theory, nor are any definitions
clarified such as health–illness, modes, positive and negative behavior, and adaptation.
Wagner added two dimensions—nursing diagnosis and evaluation—to Roy’s nursing process
of assessment and intervention. These later (1984) became an integral part of Roy’s nursing
process.
Overall, this article supports the notion that the conceptual model currently applies to prac-
tice and that it does have relevance for the way nursing is practiced today.
JOYCE TRAVELBEE
Travelbee, J. (1963). What do we mean by rapport? American Journal of Nursing, 63(2), 70–72.
This article provides an excellent example of an attempt to conceptualize a phenomenon. It
could be used as an early exemplar in concept development. However, the lack of clinical refer-
ents limits its wide utility and curtails its research potential. The term “rapport” is commonly used
in nursing but had previously been neither conceptualized, operationally defined, nor researched.
Frequently, rapport is defined by what it is not rather than by what it is. The explicit assumption
underlying this development is that a controlled type of emotional involvement with the patient is
allowed to establish and maintain rapport. Implicit in this is the value judgment that rapport is
good or positive and to be valued.
Rapport is described in a number of ways here. It is a process in the way people perceive and
relate to each other. It is an entity with empathy, compassion, and sympathy as components. It is
also an outcome, being the ability to communicate creatively and intelligently to others. To estab-
lish rapport, certain ingredients are essential. A patient has to feel a sense of trust in the nurse. The
nurse’s needs should have been met in the past to be able to give of herself, but a bit of previous
“suffering” would help nurses in understanding others. Stages of rapport development begin with
empathy, then sympathy (equated in 1964 with caring), and then rapport.
Travelbee’s major concepts, which later evolved into her theory, were introduced in this article.
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C H A P T E R 20
The purpose of this chapter is to provide the reader with a comprehensive bibliography related to
nursing theory and theorizing in nursing. The chapter is divided into 53 sections. Sections 1
through 12 include literature related to metatheory and theorizing in nursing. Sections 13 through
37 include nursing theories organized alphabetically by theorist. Sections 38 through 48 include
major paradigms that have influenced nursing or have been used in nursing. Sections 49 through
53 include video and audio tapes on theory. More specifically, the sections are:
THEORY AND THEORIZING IN NURSING
1. Philosophy and Methods (p. 503)
2. Nursing Theory: General (p. 506)
3. Metatheory and Theory Development in Nursing
(p. 508)
4. Forces and Constraints in Theory Development:
Women as Scientists (p. 517)
5. Forces and Constraints in Theory Development:
Nursing Profession (p. 518)
6. Theory and Science (p. 519)
7. Theory and Research (p. 520)
8. Theory and Practice (p. 522)
9. Theory and Nursing Taxonomies: Diagnosis and
Intervention (p. 528)
10. Theory and Education (p. 532)
11. Theory and Administration (p. 538)
12. Theory Analysis and Critique: Factors
Affecting the Acceptance of Scientific Theories
(p. 542)
NURSING THEORY AND THEORISTS
13. Faye Abdellah (p. 548)
14. Patricia Benner (p. 550)
15. Betty Jo Hadley (p. 550)
16. Beverly Hall (p. 550)
17. Mary Harms and Fred McDonald (p. 551)
18. Virginia Henderson (p. 551)
19. Douglas Howland (p. 551)
20. Dorothy Johnson (p. 551)
21. Imogene King (p. 554)
22. Madeleine Leininger (p. 559)
23. Myra Levine (p. 560)
24. Afaf Ibrahim Meleis (p. 562)
25. Betty Neuman (p. 563)
26. Margaret Newman (p. 570)
27. Florence Nightingale (p. 571)
28. Dorothea Orem (p. 573)
29. Ida Orlando (p. 585)
30. Rosemarie Parse (p. 588)
31. Josephine Paterson and Loretta Zderad (p. 590)
32. Hildegard Peplau (p. 594)
33. Martha Rogers (p. 595)
34. Callista Roy (p. 603)
35. Joyce Travelbee (p. 610)
36. Jean Watson (p. 613)
37. Ernestine Wiedenbach (p. 615)
PARADIGMS THAT HAVE INFLUENCED NURSING
38. Psychoanalytic Theory (p. 616)
39. Symbolic Interaction (p. 617)
40. Holism (p. 618)
41. Organizational Theory (p. 619)
42. Developmental Theory (p. 619)
43. Systems Theory (p. 621)
44. Stress and Adaptation (p. 622)
45. Role Theory (p. 623)
46. Physiological Nursing Theory (p. 624)
47. Critical Theory and Hermeneutics (p. 625)
48. Feminist Perspectives (p. 626)
MIDDLE-RANGE THEORY (P. 631)
SITUATION-SPECIFIC THEORY (P. 632)
VIDEO AND AUDIO TAPES ON THEORY
49. Video Productions from the National League for
Nursing (p. 632)
50. Video Productions from FITNE (p. 633)
51. Video Productions from the Health Sciences
Consortium (p. 634)
52. Conference Videotapes (p. 634)
53. Conference Audiotapes (p. 634)
There are several points to remember when
using the bibliography.
1. Citations preceded by asterisks refer to works that
have been abstracted in Chapter 19, Section I.
Citations preceded by daggers refer to works that
have been abstracted in Chapter 19, Section II.
2. Most of the abstracts in Chapter 19 are expansions
of citations in Chapter 20, Sections 3, 6, 7, 8, 10,
and 11. The emphasis was on providing a compre-
hensive view of literature cited in Sections 3 and 11.
3. There are many ways to use the bibliography,
such as systematically reading within a section,
reading within chronological themes, selecting
readings according to years or decades of publica-
tion, and reading sections in conjunction with
appropriate book chapters.
Historical and Current Theory
Bibliography
LWBK821_c20_p502-636 07/01/11 8:22 PM Page 502
CHAPTER 20 Historical and Current Theory Bibliography 503
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McEwen, M. (2002). Middle-range nursing theories.
In M. McEwan and E. Wills (Eds.), Theoretical
basis for nursing (pp. 202–205). Philadelphia: Lip-
pincott Williams & Williams.
Meleis, A., Sawyer, L.M., Im, E., Messias, D.K.H.,
and Schumacher, K. (2000). Experiencing transi-
tions: An emerging middle-range theory. Advances
in Nursing Science, 23(1), 12–28.
Olsen, J. and Hanchett, E. (1997). Nurse-expressed
empathy, patient outcomes, and development of
middle-range theory. Image: Journal of Nursing
Scholarship, 29(1), 71–76.
Orticio, L.P. (2007). Sensing presence and sensing
space: A middle range theory of nursing. Insight,
32(4), 7–11.
Peterson, S.J. and Bredow, T.S. (2004). Middle range
theories: Application to nursing theory. Philadel-
phia: Lippincott Williams & Wilkins.
Polk, L.V. (1997). Toward a middle-range theory
of resilience. Advances in Nursing Science, 19(3),
1–13.
Ryan, P. and Sawin, K.J. (2009). The individual and
family self-management theory: Background and
perspectives on context, process, and outcomes.
Nursing Outlook, 57(4), 217–225.
Sanford, R.C. (2000). Caring through relation and dia-
logue: A nursing perspective for patient education.
Advances in Nursing Science, 22(3), 1–15.
Sieloff, C.L., Frey, M.A., and King, I.M. (2007). Middle
range theory development using King’s conceptual
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Smith, M.J. and Liehr, P. (1999). Attentively Embrac-
ing Story: A middle-range theory with practice and
research implications. Scholarly Inquiry for Nurs-
ing Practice, 13(3), 187–204.
Smith, M.J. and Liehr, P. (2003). Middle range theory
for nursing. New York: Springer Publishing.
Thurmond, V.A. and Popkess-Vawter, S. (2003).
Examination of a middle range theory: Applying
Astin’s Input-Environment-Outcome (I-E-O) model
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Tsai, P.F. (2003). A middle-range theory of caregiver
stress. Nursing Science Quarterly, 16(2), 137–145.
Whittemore, R. and Roy, Sister C. (2002). Adapting to
diabetes mellitus: A theory synthesis. Nursing Sci-
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Woods, S.J. and Isenberg, M.A. (2001). Adaptation as
a mediator of intimate abuse and traumatic stress in
battered women. Nursing Science Quarterly, 14(3),
215–221.
SITUATION-SPECIFIC THEORY
Clingeman, E. (2007). A situation-specific theory of
migration transition for migrant farmworker
women. Research and Theory for Nursing Practice,
21(4), 220–235.
Im, E.O. (2005). Development of situation–specific
theories—An integrative approach. Advances in
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Im, E.O. (2006). A situation-specific theory of Cau-
casian cancer patients’ pain experience. Advances
in Nursing Science, 29(3), 232–244.
Im, E.O. (2008). The situation-specific theory of pain
experience for Asian American cancer patients.
Advances in Nursing Science, 31(4), 319–331.
Nelson, A.M. (2006). Toward a situation-specific the-
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Riegel, B. and Dickson, V.V. (2008). A situation-spe-
cific theory of heart failure self-care. Journal of
Cardiovascular Nursing, 23(3), 190–196.
VIDEO AND AUDIO TAPES ON THEORY
49. Video Productions from the National
League for Nursing
A Conversation with Virginia Henderson
Interview with Virginia Henderson about her life and
work, conducted by Patricia Moccia.
Available from: NLN Customer Service, National
League for Nursing, 350 Hudson Street, New York,
NY 10014 (800) 669–9656, ext. 138, FAX (212)
989–3710. Send Internet e-mails (queries only) to:
Custserv@nln.org
Nursing in America: A History of Social Reform
Video that examines nursing’s history of social reform
while chronicling social, political, and economic
influences that shaped American nursing.
Available from: NLN Customer Service, National
League for Nursing, 350 Hudson Street, New York,
NY 10014 (800) 669–9656, ext. 138, FAX (212)
989–3710. Send Internet e-mails (queries only) to:
Custserv@nln.org
Nursing Theory: A Circle of Knowledge
Video hosted by Patricia Moccia that examines issues
related to philosophy of nursing science, particu-
larly the relevance of nursing theory to practice.
Features discussions with Patricia Benner, Virginia
Henderson, Dorothea Orem, Martha Rogers, Cal-
lista Roy, and Jean Watson.
Available from: NLN Customer Service, National
League for Nursing, 350 Hudson Street, New York,
NY 10014 (800) 669–9656, ext. 138, FAX (212)
989–3710. Send Internet e-mails (queries only) to:
Custserv@nln.org
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CHAPTER 20 Historical and Current Theory Bibliography 633
Theories at Work
Video hosted by Patricia Moccia about innovative
applications of nursing theory in nurse-managed
health care systems. Moccia visits centers of nursing
practice around the country and talks with Dorothy
Powell, Bernadine Lacey, Jean Watson, and Janet
Quinn about their theory-based nursing care.
Available from: NLN Customer Service, National
League for Nursing, 350 Hudson Street, New York,
NY 10014 (800) 669–9656, ext. 138, FAX (212)
989–3710. Send Internet e-mails (queries only) to:
Custserv@nln.org
Therapeutic Touch: Healing through Human Energy
Fields
A three-part video hosted by Janet F. Quinn. Part I
explores the theoretical framework of therapeutic
touch, defines key concepts, and highlights
research studies documenting the clinical effective-
ness of therapeutic touch. Part II explains the
method nurses use in performing therapeutic touch,
and Part III explores the clinical application of
therapeutic touch in clinics, private practice, and
hospitals.
Available from: NLN Customer Service, National
League for Nursing, 350 Hudson Street, New York,
NY 10014 (800) 669–9656, ext. 138, FAX (212)
989–3710. Send Internet e-mails (queries only) to:
Custserv@nln.org
Critical Thinking in Nursing: Lessons from Tuskegee
This video examines the story of nurse Eunice Rivers
and the infamous Tuskegee Syphilis Study in which
400 African American men were left untreated for
the disease as part of a government study. The pres-
entation brings forth a number of social and ethical
issues that warrant critical thinking among nurses.
A companion book is also available.
Available from: NLN Customer Service, National
League for Nursing, 350 Hudson Street, New York,
NY 10014 (800) 669–9656, ext. 138, FAX (212)
989–3710. Send Internet e-mails (queries only) to:
Custserv@nln.org
A Conversation on Caring with Jean Watson and Janet
Quinn
A video in which Jean Watson and Janet Quinn dis-
cuss the elements of caring.
Available from: NLN Customer Service, National
League for Nursing, 350 Hudson Street, New York,
NY 10014 (800) 669–9656, ext. 138, FAX (212)
989–3710. Send Internet e-mails (queries only) to:
Custserv@nln.org
A Guide to Applying the Art and Science of Human Care
A set of two videos in which Jean Watson gives an
overview of her Theory of Human Science and
Human Caring and a panel, moderated by Peggy
Chinn, discusses the implementation of the car-
ing model in diverse practice and educational set-
tings.
Available from: NLN Customer Service, National
League for Nursing, 350 Hudson Street, New York,
NY 10014 (800) 669–9656, ext. 138, FAX (212)
989–3710. Send Internet e-mails (queries only) to:
Custserv@nln.org
The Power of Nursing
A discussion of the concept of power and of nurses’
relation with health policy.
Available from: NLN Customer Service, National
League for Nursing, 350 Hudson Street, New York,
NY 10014 (800) 669–9656, ext. 138, FAX (212)
989–3710. Send Internet e-mails (queries only) to:
Custserv@nln.org
Nursing in America: Through a Feminist Lens
A video in which the issues of autonomy and control
are compared in relation to nurses’ historic struggle
for independence and feminists’ battle to empower
women.
Available from: NLN Customer Service, National
League for Nursing, 350 Hudson Street, New York,
NY 10014 (800) 669–9656, ext. 138, FAX (212)
989–3710. Send Internet e-mails (queries only) to:
Custserv@nln.org
50. Video Productions from FITNE
The Nurse Theorists: Portraits of Excellence
Series of 16 videos about the lives and scholarly
accomplishments of notable nurse theorists. Each
video contains a biographical sketch of the theorist,
an interview conducted by Jacqueline Fawcett, and a
summary of the nursing theory. Videotapes include:
(1) Virginia Henderson, “Definition of Nursing”; (2)
Dorothy Johnson, “Behavioral Systems Model”; (3)
Imogene King, “Interacting System Framework”;
(4) Madeline Leininger, “Transcultural Nursing
Care”; (5) Myra Levine, “The Conservative Model”;
(6) Betty Neuman, “Neuman Systems Model”; (7)
Florence Nightingale, “Special Edition”; (8)
Dorothea Orem, “Self Care Framework”; (9) Ida
Orlando Pelletier, “The Deliberative Nursing
Process”; (10) Hildegard Peplau, “Interpersonal
Relations in Nursing”; (11) Martha Rogers, “Sci-
ence of Unitary Human Beings”; (12) Callista Roy,
“The Adaptations Model of Nursing”; (13) Reva
Rubin, “Theory of Maternal Identity”; (14) Jean
Watson, “A Theory of Caring”; (15) Margaret New-
man, “Health as Expanding Consciousness”; and
(16) Rosemarie Parse, “Man-Living Health.”
Available from: FITNE, 5 Depot Street, Athens, OH
45701, (614) 592–2511.
From Beginner to Expert: Clinical Knowledge in Crit-
ical Care Nursing
Dr. Patricia Benner and her research team discuss the
methods and major findings of a study of clinical
learning and skilled clinical judgment among criti-
cal care nurses, and the implications in terms of the
process of becoming an expert nurse.
Available from: FITNE, 5 Depot Street, Athens, OH
45701, (614) 592–2511.
Adaptation Model in Practice
The application of Callista Roy’s adaptation model,
which promotes the biological, psychological and
sociological aspects of patients in relation to a con-
stantly changing environment, is demonstrated at
two different health care institutions. Available
from: FITNE, 5 Depot Street, Athens, OH 45701,
(614) 592–2511.
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634 PART SIX Our Historical Literature
Self-Care Framework Model in Practice
This video describes Dorothea Orem’s self-care deficit
nursing theory and presents case studies to demon-
strate the application of the theory to nursing practice.
Available from: FITNE, 5 Depot Street, Athens, OH
45701, (614) 592–2511.
51. Video Productions from the Health
Sciences Consortium
Care with a Concept
This program by Mary Hale and Gates Rhodes dis-
cusses the application of Dorothea Orem’s self-care
conceptual model in a pediatric rehabilitation cen-
ter. As Orem’s model is applied, nurse-managers
are enabled to evaluate the effects of the nursing
care rendered.
Available from: Health Sciences Consortium, 201 Sil-
ver Cedar Court, Chapel Hill, NC 27514–1517,
(919) 942–8731, FAX (919) 942–3689.
52. Conference Videotapes
Nurse Theorist Conference 1985
Videotaped presentations include (1) Dorothea Orem,
“Presentation”; (2) Hildegard Peplau, “Nursing Sci-
ence: A Historical View”; and (3) “Panel Discussion
with Theorists” with Dorothea E. Orem, Callista
Roy, Imogene M. King, Martha E. Rogers, Rose-
marie Rizzo Parse, and Hildegard E. Peplau.
Available from: Discovery International’s Nurse The-
orist Conferences, Veranda Communications, Inc.,
4229 Taylorsville Road, Louisville, KY 40220,
(502) 485–1484, FAX (502) 485–1482.
Nurse Theorist Conference 1987, Pittsburgh, PA
Videotaped presentations include (1) Hildegard
Peplau, “Art and Science of Nursing: Similarities,
Differences and Relations”; (2) Imogene King,
“King’s Theory”; (3) Rosemarie Parse, “Parse’s
Theory”; (4) Callista Roy, “Roy’s Model”; (5)
Martha Rogers, “Rogers’ Framework”; (6) Jean
Watson, “Watson’s Model”; (7) Rozella Schlotfeldt,
“Nursing Science in the 21st Century”; and (8)
“Panel Discussion with Theorists.”
Available from: Discovery International’s Nurse The-
orist Conferences, Veranda Communications, Inc.,
4229 Taylorsville Road, Louisville, KY 40220,
(502) 485–1484, FAX (502) 485–1482.
Nurse Theorist Conference 1989, Pittsburgh, PA
Videotaped presentations include (1) Afaf Meleis,
“Being and Becoming Healthy: The Core of Nurs-
ing Knowledge”; (2) Betty Neuman, “Health as a
Continuum in Neuman’s Model”; (3) Rosemarie
Parse, “Health as a Personal Commitment in Parse’s
Theory”; (4) Martha Rogers, “Evolutionary Emer-
gence: Infinite Potential”; (5) Nola Pender,
“Expressing Health Through Beliefs and Actions”;
(6) Imogene King, “Health as the Goal of Nursing
in King’s Theory”; and (7) “Panel Discussion with
Theorists.”
Available from: Discovery International’s Nurse The-
orist Conferences, Veranda Communications, Inc.,
4229 Taylorsville Road, Louisville, KY 40220,
(502) 485–1484, FAX (502) 485–1482.
Nurse Theorist Conference 1993, Pittsburgh, PA
Videotaped presentations include (1) Rosemarie Rizzo
Parse, “Quality of Life and Becoming Human”; (2)
Madeleine M. Leininger, “Quality of Life and Tran-
scultural Nursing”; (3) Martha Rogers, “Quality of
Life and the Science of Unitary Human Beings”; (4)
Marlaine C. Smith, Cheryl Forchuk, Gail J.
Mitchell, and Jacqueline Chapman, “Nursing The-
ory-based Practice and Research: A Glimpse of the
Canadian Scene”; (4) Hildegard Peplau, “Quality of
Life: An Interpersonal Perspective”; and (5) Imo-
gene King, “Nursing and the Next Millennium”
moderated by Marlaine C. Smith.
Available from: Discovery International’s Nurse The-
orist Conferences, Veranda Communications, Inc.,
4229 Taylorsville Road, Louisville, KY 40220,
(502) 485–1484, FAX (502) 485–1482.
53. Conference Audiotapes
Nursing Theory Congress 1986, Toronto, Canada
Audiotapes of plenary sessions by Betty Neuman,
Imogene King, Callista Roy, Rosemarie Parse,
Martha Rogers, and Myra Levine. Other audiotapes
include (1) Moyra Allen, “A Developmental Health
Model: Nursing as Continuous Inquiry”; (2) Patri-
cia James and James Dickoff, “Overview of the
Concept of Theoretical Pluralism”; (3) Bonnie
Holaday, “Adaptation of Johnson’s Framework”;
(4) Susan Taylor, “Presenting Orem’s Framework”;
(5) Phyllis Kritek, “Impact of Nursing Theory on
the Diagnostic Process”; and (6) Marian McGee,
“Criteria for Selection and Use of a Nursing Model
for Clinical Practice.”
Available from: Audio Archives International, 100
West Beaver Creek, Unit 18, Richmond Hill,
Ontario, Canada, L4B 1H4, (905) 889–6555.
Nursing Theory Congress 1988, Toronto, Canada
Audiotapes include (1) Carol Lindeman, “Nursing
Theory: Elitism or Realism in 1988”; (2) Virginia
Henderson, “Nursing Theory: A Historical Per-
spective”; (3) Jean Watson, “One Model or Many
Models”; (4) Marjory Gordon, “Nursing Diagno-
sis: The Interface of Nursing Theory and Nursing
Process”; (5) Rosemarie Parse, “Nursing Science
as a Basis for Research”; (6) Phyllis Kritek and
others, “Impact of Nursing Theory on the Profes-
sion”; and (7) Phyllis Kritek, “Agendas for the
Future.”
Available from: Audio Archives International, 100
West Beaver Creek, Unit 18, Richmond Hill,
Ontario, Canada L4B 1H4, (905) 889–6555.
Nurse Theorist Conference 1985, Philadelphia, PA
Audiotapes include (1) Presentations by Dorothea
Orem, Callista Roy, Imogene M. King, Martha E.
Rogers, Rosemarie Rizzo Parse; (2) Hildegard
Peplau, “Nursing Science: A Historical Overview”;
(3) Mary Jane Smith, “Theorist: Dorothea E.
Orem”; (4) S.J. Magan, “Theorist: Imogene M.
King”; (5). J.R. Phillips, “Theorist: Rosemarie
Rizzo Parse”; (6) A. Whall, “Theorist: Martha E.
Rogers”; (7) M.H. Huch, “Theorist: Callista Roy”;
(8) “Panel Discussion with Theorists”; and (9)
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CHAPTER 20 Historical and Current Theory Bibliography 635
“Small Group Discussions” led by Jean Watson,
Imogene King, Rosemarie Parse, Martha Rogers,
and Callista Roy.
Available from: Veranda Communications, Inc., 4229
Taylorsville Road, Louisville, KY 40220, (502)
485–1484, FAX (502) 485–1482.
Nurse Theorist Conference 1989, Philadelphia, PA
Audio tapes include (1) Afaf I. Meleis, “Being and
Becoming Healthy: The Core of Nursing Knowl-
edge”; (2) Betty M. Neuman, “Health as a Contin-
uum in Neuman’s Model”; (3) Rosemarie Parse,
“Evolutionary Emergence: Infinite Potential”; (4)
Nola J. Pender, “Expressing Health Through Beliefs
and Actions”; (5) Imogene M. King, “Health as the
Goal of Nursing in King’s Theory”; and (6) “Panel
Discussion with Theorists.”
Available from: Discovery International’s Nurse The-
orist Conferences, Veranda Communications, Inc.,
4229 Taylorsville Road, Louisville, KY 40220,
(502) 485–1484, FAX (502) 485–1482.
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AUTHOR INDEX 637
A
Abbott, C.A., on conc-ept
analysis, 377
Abdellah, F.G.
on concept of client, 99
on decision making process,
119
on interaction theories, 162
as Levine influence, 297
need theory and, 162t–164t
on nursing concepts, 129
on nursing functions, 171
on nursing process, 103, 119
on nursing science, abstract,
440
on Orem influence, 216, 217
on role nurses play, 176t
on theory in education, 198
theory of, 70, 198
bibliography on, 548–550
Aber, C., on Roy, 334
Abraham, I.L., on theory testing,
201
Adam, E., as theory advocate, 76
Adams, A., on nursing concepts,
121
Adams, J., on conceptual
barriers, 50
Adams, M.
on flexibility, 53
on intuition, 53
Adams-Leander, S., on
discipline, 88
Adamsen, L., on Wiedenbach,
270
Adolfsson, R., on Orem, 220
Agan, R.D.
on caring, 117
on intuition, 141
on knowing patterns, 141
Agronow, S.J., on role strain in
faculty, 201
Agüero-Torres, H., on Orem, 219
Ahlström, G., on concept
analysis, 379
Ailinger, R.L., on Orem, 211b, 221
Ainsworth, M., affiliation
concepts of, 285
Akyol, A.D.
on Orem, 218, 219
on Roy, 337
Al-Islamiah, Rufaida Bent Saad,
as founder of Eastern
nursing, 60
Alexander, J.W., on Johnson, 288
Algase, D. L., on nursing
perspective, 88
Ali, S.
on integrative theory, 153
on postcolonialism, 150
Allan, J.
on biomedical model, 355
on Orem, 220
Allan, J.D., on self-use, 106
Allcock, N., on theory in nursing
education, 366
Allen, A., on Orem, 218
Allen, D.
on critical theory, 148
on health, 98, 106
on health orientation of
discipline, 93
on knowing patterns, 138
on nursing concepts, 77, 145
on nursing theory, 149
Allen, D.E., on Orlando, 248
Allen, D.G.
on knowledge development
approaches, 77
on knowledge-research
congruency, 367
on theory development, 107
Allen, J., on medical models as
theory source, 117
Alligood, M.R.
on behavioural system, 286
on borrowed theory, 132
on King, 240, 241
on theory in nursing education,
132, 366
Allison, S.E.
on Orem, 213, 218, 223
abstract, 482
Allmark, P., research to theory
strategy, 398
Allvin, R., on Levine, 300
American Nurses Association,
social policy statement
of, 10
An, J., on self-care practices, 67
Anastasio, C., on Orem, 220
Andersen, C., on Weidenbach, 270
Andersen, V., on Orem, 222
Andershed, B., on concept
development, 393
Anderson, B., on Neuman, 307
Anderson, G., on concept
exploration, 373
Anderson, J.
on cultural safety, 79
on post colonialism, 150
Anderson, J.A., on Orem, 222
Anderson, J.M., on post
colonialism, 155
Anderson, R.A., on theory in
administration, 367
Andreoli, K.G.
on epistemology, 136
on science in nursing, abstract,
441
Andrew, N., on nursing, 434
Andrews, C.M.
on Orlando, 244
on patient-centered care, 270
Andrews, H., on Roy, 324
Andrews, H.A.
on domain concepts, 330t
on Roy, 325, 326, 332
on self-concept, 326
Andrist, L.C., on menopause, 137
Androwich, I., on technology
challenges, 359
Anna, D.J.
on Orem, 210, 211
abstract, 482
A U T H O R I N D E X
637
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Aponte, J., on Orem, 217
Aranda, K., on integrative theory,
153
Araujo, T.L., on King, 237, 240
Archbold, P., on nursing
diagnosis, 120
Ardetti, R., on theory
development, 53
Argon, G., on self-care practices,
220
Arietti, S., on theory
development, 123
Armiger, B.
on scholarliness, 12, 17
on theory development, 123
Armour, L.
on pragmatism theory, 152
on theories of truth, 150
Armour, S.
on feminist knowing, 146
on gender orientation, 44
on male registered nurses, 146
Arndt, C., on theory in
administration, 366
Arruda-Neves, E., on comfort, 11
Arslanian-Engoren, C., on
poststructuralism, 150
Arthur, D.G., on perinatal
bereavement care, 256
Artigue, G.S., on Levine, 296
Artinian, N.T.
on Orem, 213
on Roy, 334
on self-care behaviors, 222
Arzola, S.M., on Roy, 337
Asay, M.K., on King, 237
Ashley, J.A.
on gender orientation, 146
on paternalism, 43
Atwood, J.R., on Rogers, 320
Auger, J.A.
on extension of Johnson
theory, 282
on theory context, 289
Auger, J.R.
on domain concepts, 189
on theory context, 194
on theory evaluation, 189
on patient classification,
abstract, 469, 471
on Johnson, abstract, 469–471
Austin, J.K., on King, 230, 238
Avant, K.C.
on concept analysis, 189, 376,
377
on concept development, 371,
372, 380
on nursing process, 103, 378
on theory development, 74t,
372, 393
Averill, J.B., on multiple patterns
of knowing, 368
Axelsson, K., on Orem, 220
Azevedo, N.A., on Paterson-
Zderad theory, 258
B
Bachrach-Lindström, M., on
extension of theory, 221
Backes, V.M., on Paterson-
Zderad theory, 258
Backman, K., on middle-range
theory, 414
Backscheider, J., on theory
development, 397
Backscheider, J.E.
on diabetes management,
abstract, 482
on Orem, 218, 219
abstract, 482
Bacon, E., on knowledge, 199,
466
Baer, E.D., on epistemology, 136
Baggs, J.G., on discipline of
nursing, 380
Bailey, P.H., on concept
development, 372
Bain, C., on evidence-based
practice, 78
Baisch, M.J., on community
health, 381
Bakan, G.
on Orem, 218, 219
on Roy, 337, 338
Baker, B.J., on Roy, abstract, 494
Baker, D.J., on Roy in curricula,
335
Baker, H., on Travelbee, 265
Baker, K., on role
supplementation, 414
Baker, L.K.
on Orem, 218
on self-care, 221
Baker, L.M., on self-care, 218
Baldursdottir, G., on caring, 171
Baldwin, B., on scientific
method, 139
Bandura, A.,, on role modeling,
55
Banfield, B.E., on Orem, 216
Banks-Wallace, J., on discipline
of nursing, 88
Barnard, K.
on nursing therapeutics
definition, 105
on research and theory, 122
on scholarliness, 14
theory of, development of, 399
Barnum, B.J.
on borrowed theory, 132
classification method of, 247
on control over subject matter,
36
on discipline of nursing, 189
on domain definition, 102, 189
on interaction, 102
on Levine, 297
on Neuman, 306
on Orem, 103, 119, 194, 217
on Paterson-Zderad, 254
on process theory, 103
on Rogers, 194, 316
on theory analysis, 254
on theory definition, 30
on theory development, 181,
194
on theory evaluation, 181,
184t, 194
on theory-research links, 75
on Wiedenbach, 267
Barnum, B.S., on theory-research
links, 75
Barone, S.H., on Roy, 334
Barrett, E.
on knowing patterns, 141
on theory testing, 200
Barrett, E.A., on Rogers, 314,
317, 318, 319, 321, 323
Barrett, E.A.M., on Rogers, 323
Barrett-Leonard, G.T., on
Travelbee, 265
Barron, M.A., on Orlando, 250
Barrow, E.
on intuition, 141
on knowing patterns, 141
on intuition, 410
Bates, M., on Levine, 291
Batey, M.V.
on research conceptualization
abstract, 441–442
on theory development, 139,
154, 433
on theory-research links, 11, 75
on values, abstract, 441
Batra, C., on theory in nursing
education, 366
Bauer, M.S., on Orlando, 250
Bauer, R., on King, 238
Bauer-Wu, S., on scholarship, 15
Baumbusch, J.L., on theories of
truth, 155
Baumgartner, R.G., on Orem,
220
Bayley, E., on Roy, 337
638 AUTHOR INDEX
LWBK821-Au-index_637-662 07/01/11 8:01 PM Page 638
Beal, M.W., on nursing as carrier,
42
Beare, P.G., on nursing curricula,
51, 76
Beaton, J.L., on nursing science
and research, abstract, 467
Beck, C.T., on gender influence,
47
Becker, C.H., on concepts
abstract, 442
Beckman, S., on Neuman, 307
Beckstead, J.W.
on epistemic origins of nursing
theories, 191
on multidimensional analysis,
160
Beckstead, L.G.
on epistemic origins of nursing
theories, 191
on multidimensional analysis,
160
Beckstrand, J.
on practice theory, 131
abstract, 442–445
on theory development, 154
on theory needs, 75
Beckwitt, A.E., on Orem, 218
Beddome, G., on Neuman, 307
Beeber, L.S., on concept
clarification, 376
Begat, I.B.E., on Travelbee, 265
Behi, R., on Orem, 219
Beland, I.L.
on decision making process, 119
on Orem influence, 216
on patient-centered nursing, 70
Belcher, H.C.
on concept clarification, 121
on nursing concepts, 121
on observation, 381
Belenky, M.F., on knowers, 8, 16
Beliz, L., on adolescent
psychiatry, 287
Benedict, M.B., on Neuman, 307
Benham, G., on Roger, 318
Benner, P.
on caring, 65, 93, 117
on critical theory, 149
on experience as knowledge
source, 52
on interaction, 149
on intuition, 15, 141, 410
on knowers, 16
on knowing patterns, 138, 141
on knowledge development
approaches, 138
on knowledge-research
congruency, 64
on novice versus expert
practice, 395
on theory development, 77,
393, 398
theory of, bibliography on, 550
Bennett, A.M., on Wiedenbach,
267
Bennett, J.G., on Orem, 218
Benoliel, J.Q.
on competition in research, 44
on dying, 193
on intuition, 11
on life-threatening disease, 392
on sensitivity, 53
on social climate for nursing,
42
on theory and research
interaction, abstract, 445
on transition, 100, 392
Benonis, B.C., on Rogers, 321
Berardo, F., on concepts and
theory, 126, 128
Berbiglia, V.A., on Orem, 213,
223
Berg, G.V., theory–research–
theory strategy, 403t, 404
Berg, K.
on concept analysis, 378
on Levine, 300
Bergstrom, D., on Neuman, 308
Berman, H., on power of
children, 79
Bernard, C., on Levine, 290
Bernstein, J., on pluralism, 12
Bernstein, R.J., on critical theory
thinking, 148
Berry, J.A., on communication
styles, 102
Berry, T., on domain concepts,
331t
Bertalanffy, L. von
as Levine influence, 290, 297
on Johnson, 285
on King, 234, 235
on Neuman, 306
on open systems, 235
on subsystem development,
332
on systems theory, 234
Berthold, F.S.
on theory development
abstract, 445
on theory usefulness, 198
Betts, C.E., on nursing practice,
358
Beveridge, W.I.B., on
observation, 381
Beynon, C.E., on Neuman, 309
Biasio, H.A., on nursing
discipline, 88
Bickel, L., on Orem, 221
Biggs, A., on Orem, 216, 223
Biley, F.C., on Rogers, 319
Bjorkander, J., on Orem, 222
Bjorvell, H., on Orem, 222
Bjørk, I.T., on clinical skills
deemphasis, 90
Black, N., on evidence-based
practice, 78
Blackwell, B.
on concept clarification, 121
on nursing concepts, 121
Blair, C., on Rogers, 318
Blalock, H.M. Jr., on theory
development, 402
Blegen, M.A., on taxonomy
development, 393
Bleier, R.
on sex roles, 52
on tentative realities, 25
Blessing, B., on theory in
administration, 198, 367
Blue, C., on postcolonialism, 79
Blum, on health, 464
Bochnak, M.A., on Orlando, 250
Bockenhauer, B., on Orlando,
248
Bockenhauer, B.J., on Orlando,
249
Boggatz, T., on concept analysis,
378
Bonamy, C., on Orem, 218
Bond, E.F., on domain of
knowledge, 95
Bonin, J.P., on Roy, 336
Bonis, S.A., on discipline of
nursing, 380
Bositis, A., on Levine, 300
Bottorff, J.L.
on caring, 93
on concept clarification, 375
on concept exploration, 373
on practice orientation, 90
Bourbonnais, F.F., on Neuman,
308, 309
Bouwsema, M.
on human relatedness, 77, 409
Bowen, J.E., on touch therapy,
318
Bowling, S., on Neuman, 311
Boyer, E., on scholarship, 7, 8, 9,
17
Boykin, A., on knowing patterns,
142
Brackley, M.H., on parental
caregiver, 414
AUTHOR INDEX 639
LWBK821-Au-index_637-662 07/01/11 8:01 PM Page 639
Bradbury-Jones, C., on
poststructuralism, 149
Bradshaw, A., on knowledge
consequences, 65
Brahe, T., on planetary motion,
12
Brakefield, J.A., on Roy, 337
Braun, M.A., on Orem, 211b, 221
Breckenridge, D., on evidence-
based practice, 310
Breckenridge, D.M., on Neuman,
307, 308
Bredow, T.S., on middle-range
theory, 410, 411
Brester, M.H.
on Johnson, 289
on patient indicators, 289
Breu, C.S., on Orlando, 250
Bridges, W., on transition, 415
Brinchmann, B.S., on humanity,
256
Brink, L.W., on Neuman, 308
Britt, T.
collaboration theory of, 379,
410
on concept analysis, 378
Britton, A., on evidence-based
practice, 78
Brixey, J.J., on interruption, 378
Brody, J.K., on caring, 92
Bromley, B., on Orem, 218
abstract, 483
Broncatello, K.F.
on hemodialysis nursing,
abstract, 471
on Johnson, abstract, 471
Bronowski, J., on creativity, 13
Brooten, D.A., on transitional
care, 106
Brower, H.T.
on King, 240
on Roy, 335, 499
abstract, 494
Brown, M.I.
on conceptual frameworks,
abstract, 446
on social theory in geriatrics,
abstract, 446
on theory development,
abstract, 446
Brown, N.H., on science, 28
Brown, R., on Roy, 334
Brown, S., on Orem, 223
Brown, S.J., on situation-specific
theory, 368
Brown, S.T., on King, 239
Browne, A., on cultural
safety, 79
Browne, A.J.
on discipline of nursing, 8
on postcolonialism, 150
Bruce, G.L., on Johnson, 289
Bryant, L., on ontology, 27
Buber, M., as Levine influence,
297
Buchanan, B.F.
on Neuman theory
modification, 308
on theory in administration, 198
Buckingham, C.D., on nursing
concepts, 121
Buckley, W., on sociology, 285
Buckner, E.B.
on adolescents, 334, 337
on Roy, 334, 338
Buckwalter, K.C.
on clinical skills deemphasis,
90
on Orem, 218
abstract, 483
on self-care in psychiatric
nursing, abstract, 483
Budinger, J.M., on Orem, 218
Bullough, B., on intellectual
subordination, 42
Bultemeier, K., on Rogers, 319
Bunting, S., on King, 231
Bunting, S.M., on Roy, 333
Burd, C., on Levine, 300
Burgess, G., on personal
development, abstract, 447
Burke, Sr. M.E., on Neuman, 308
Burkhardt, H., on ontology, 27
Burks, K.J.
on intentional action by clients,
393
on Orem, 207, 218
Burney, M.A., on King, 235
Burns, C., on nursing diagnosis,
120
Burns, D., on Roy, 336
Burr, H.S., as Rogers influence,
316
Burrage, J., on theory of
integration, 434, 435
Burst, H.V., on Wiedenbach, 267,
270
Bush, H.A., on nursing models,
abstract, 447
Butcher, H.K., on Rogers, 320, 323
Buus, N., on humanistic theory,
257
Byrne, M.L.
on concept clarification, 121
on nursing concepts, 121
Byrne-Coker, E., on King, 239
C
Caley, J.M., on Orem, 218
abstract, 484
Callaghan, D.M., on Orem, 222
Cameron, J., on Orlando, 250
Cammuso, B.S., on Neuman,
309
Campbell, H., on Orem, 218
Campbell, J.C., on Orem, 221,
222
Campbell, R.L., on transitional
care, 106
Campbell, V., on Neuman, 307
Campbell-Yeo, M., on concept
analysis, 378
Campesino, M., on spirituality,
11
Campuzano, M., on Orem, 218
Canales, M.K., on concept
clarification, 121
Canam, C.J., on educational
system, 42
Candee, D., on decision making,
119
Cannon, W.B., as Levine
influence, 290, 297
Cao, F.L., on perinatal
bereavement care, 256
Capers, C.F., on Neuman, 308,
310
Caplan, G., as Neuman
influence, 306
Capra, F., on holistic world view,
54
Carboni, J.T., on Rogers, 318,
321
Carey, T.S., on beat evidence, 78
Carkhuff, R.R., on Travelbee,
265
Carlin, B.P., on Roy, 334
Carlson, C.E.
on concept clarification, 121
on nursing concepts, 129
Carlsson, M.
on Roy, 335
on Travelbee, 265
Caroselli, C., on nurse executive,
321
Carper, B., on personal
knowledge, 16
Carper, B.A.
on epistemology, 136
on intuition, 52
on knowing patterns, 137, 138
abstract, 447
on knowledge, 65, 117
on philosophy and research, 64
on single theory, 75
640 AUTHOR INDEX
LWBK821-Au-index_637-662 07/01/11 8:01 PM Page 640
Carrieri, V.K.
on dyspnea, 393
on theory testing, 201
Carroll, G., on Neuman, 309
Carson, M.A., on Roy, 337
Carter, K.F., on King, 238, 239
Cartwright, R.D., on Travelbee,
265
Carty, B., on situation-specific
theory, 67
Caruana, E., on health, 106
Casalenuovo, G.A., on Neuman,
305
Cash, P.A., on scholarliness, 13
Cassedy, P., on Paterson-Zderad
theory, 257
Catanzariti, P.M., on theory in
administration, 366
Cetinkaya, Y., on Orem, 218
Chambers, D., on scholarliness, 15
Champage, M.T., on recovery, 77
Champion, V.L., on King, 230,
238
Chan, M.F., on perinatal
bereavement care, 256
Chang, B.L.
on Orem, 223
abstract, 484
Chang, C.K., on Roy, 334
Chang, N.J., on Neuman, 307
Chang, W.C.
Taiwanese nurse practitioners,
transition of, 423
Chapman, C.M., on social
theories and models,
abstract, 448
Chardin, P.T., as Roy influence,
332
Chardin, T., as Rogers influence,
316
Charlton, C.R., on nurse
practitioners–patient
interaction, 102
Chase, S.K., on Roy, 338
Chassy, P.
on intuition, 410
on perceived view, 141
Chater, S., on scholarliness, 17,
55
Chen, C.C.H., on Roy, 334
Chesla, C., on perceived view,
141
Chick, N.
on concept analysis, 189
on concept differentiation, 385
on transition, 100, 189, 414,
415
on transition antecedents, 385
Chin, R.
on Johnson, 285
on models, 126
on nursing models, 126
on Travelbee, 262
Chinn, P.L.
on clarity, 195
on concept analysis, 376
on concept clarification, 375
on concept development, 77,
380
on empirical theory, 140
on feminist perspective, 147
on knowing patterns, 137, 138
on nursing as human science,
89
on phenomenon, 182, 356,
384, 436
on “post” epistemologies, 150
on propositions, 386
on scholarliness in nursing, 15
on simplicity/complexity, 196
on theory as power, 51
on theory clarity, 195, 196
on theory definition, 29, 29t,
30
on theory development, 74t
abstract, 448
on theory evaluation, 182, 184t
on theory testing, 200
Chinsky, J.M., on Travelbee, 265
Choi, S.S., on Neuman, 307
Chopoorian, T.J.
on environment, 101
on theory analysis, 77
Christensen, D.G.
on Orem, 210, 211, 218
abstract, 482
Christman, L., on nursing, 107
Christmyer, C.S., on theory in
administration, 366
Chung, S.C., on Roy, 338
Chyun, D.A., on Roy, 334
Cisar, N., on Roger, 319
Clark, J., on theory development
abstract, 449
Clark, M.D., on Orem, 218
Clarke, A.E., theory development
and, 397
Clarke, J.B.
on evidence-based practice, 78
on truth, 154
Clarke, M., on clinical skills-
deemphasis, 90
Clarke, P.N.
on King, 231, 234
on Orem, 213, 223
on Rogers, 321
Cleland, V.S.
on passivity, 42
on theory development, 42
on theory use, abstract, 449
on women’s role, 46
Clements, I.W., on conceptual
models, 127
Clements, P.T., on multiple
patterns of knowing, 368
Clifford, C., on caring, 93
Cliffordson, C., on Orem, 221
Clift, J., on theory testing, 200
Clinchy, B.M., on knowers, 8, 16
Clingerman, E., on middle-range
theory, 422
Clinton, J.F., on Orem, 221
Closs, S.J., on postmodernism, 149
Cloutier, J.D., on concept
development, 372
Cloyes, K.G., on feminist
perspective, 147
Cockerham, W., on
postmodernism, 149
Cody, W.K., on nursing as human
science, 89, 171
Cohen, J.A., on caring, 91
Cole, J.R.
on women as nurses, 44, 46
on women’s roles, 53
Cole, N., on organizational
infrastructure, 78
Coleman, D.L., on scholarship of
application, 8
Coleman, L.J.
on Orem, 218
abstract, 484
Collaizzi, J., on nursing science,
abstract, 449
Colling, J., on Pattern Urge–
Response Toileting, 288
Collins, R.J., on practice theory,
abstract, 450
Compton, P., on Orem, 218
Condon, E.H., on caring, 92
Connolly, C.A., on
transdisciplinarity, 356
Cook, J.A., on gender sensitive
research, 147
Cook, L., on Travelbee, 264
Cook, P.R., on caring, 91
Cooley, M.E., on Roy, 336
Copleston, F., on knowledge
development, 40, 113
Copleston, S.J., on wisdom, 436
Copp, L.A., on recovery, 77
Cora, V.L. on Neuman, 307
Corbin, J., theory development
and, 399
AUTHOR INDEX 641
LWBK821-Au-index_637-662 07/01/11 8:01 PM Page 641
Corcoran-Perry, S.A.
on caring, 93
on nursing definition, 107
Corliss, C.P., Roy collaboration
with, 325, 327, 332
Cormack, D.F.
on criteria-based language, 24
on Johnson, 287
Cormack, D.F.S., on theory
utilization, 24
Cornu, A., as Neuman influerice,
306
Cottrell, B., on Roy, 337
Covell, C.L., on middle-range
theory of nursing, 413
Covington, H.
on concept definition, 385
on Rogers, 323
Cowan, D., on Orem, 221
Coward, D.D.
on collaborative theory of, 410
on concept analysis, 378
on Johnson, 288
Cowie, M.R., on Orem, 221
Cowling, W.R.
on caring, 171
on feminist perspective, 147
on nursing as human science,
89, 171
on Rogers, 321
Cox, K.R., on Orem, 213, 218
Cox, R.A. Sr., on Levine, 298
Cox, T., on Rogers, 323
Coyle, M.K., on Orem, 218
Craig, D.I., on Roy, 334
Craig, D.M., on Neuman, 309
Crane, M.D., on Orlando, 244
Crawford, G.
on theory analysis, 75
on theory development,
abstract, 450
on theory issues, 76
Crigger, N.J., on marginalized
populations, 357
Cronenwett, L., on
interdisciplinary
knowledge, 356
Cronin, P., on concept analysis,
378
Crowley, D.M.
on disciple of nursing, 88
on Levine, 299
on nursing discipline, abstract,
453
on perspective, 132
on prescriptive theory, 35
on theory development, 75
Cudney, S., on Roy, 338
Cullen, J.A., on caring, 91
Cullum, N., on United Kingdom
acute care settings, 78
Cunningham, D.A., on Roy, 335
Cutcliffe, J.R., on theory
development, 393
Cypress, B.S., on modeling, 385
D
Dachelet, C.Z., on women in
nursing, 45
Dagenais, F., on sex roles, 52
Dale, M.L., on Neuman, 309
Dallafar, A., on immigrants’
transitions, 416
Dalton, J.M., on Kim’s theory of
collaborative decision
making, 396
Daly, J.M., on knowledge
development, 17
Damus, K., on Johnson, 288
Daniel, J.M., on King, 240
Daniels, A., on Orem, 220
D’Antonio, P., on nursing
education, 42
Dariel, O.P.D., on learning
experiences, 257
Dashiff, C., on theory in
administration, 366
Dashiff, C.J., on Orem, 222
Dassen, T., on Wilson, 378
Daubenmire, M.J., on King, 239
Davies, B., on rethinking
theories, 358
Davis, B., on caring for aged, 308
Davis, F., on women’s roles, 46
Davis, G.C., on concept analysis,
376, 378
Davis-Sharts, J., on Maslow
theory testing, 201
de Joseph, J., on mothering, 392
de Munck, R., on Neuman, 309
De Valde, S., on life-threatening
disease, 392
de Vries, K., on hybrid strategy,
379
Dean, J.M., on theory evaluation,
203
Dean, P.R., on King, 237
Dearing, K.S., on communication
styles, 102
Decker, S.D., on feminism in
nursing, 52
Dee, U.
on extension of Johnson
theory, 287
on Johnson, 289
on psychiatric nursing, 289
Dee, V.
on Johnson, abstract, 469–470
on patient classification,
abstract, 469–471
DeGroot, H.A., on theory in
administration, 366
Delmore, B.A., on Levine, 300
Delunas, L.R., on Neuman, 308
DeMaio, D.J., on theory
development, 51
Dennis, C.L., on concept
development, 372
Dennison, P.D., on nursing
diagnosis, 360
DeNuccio, G., on concept
analysis, 379
Denyes, M.J., on Orem, 207,
209, 213, 221
Derdiarian, A.K.
behavioral system model of,
287, 289
on Johnson, abstract, 472, 473
on theory testing, 201
DeSanto-Madeya, S.A., on Roy,
337
Despins, L., on discipline of
nursing, 88
Dewey, J.
on critical thinking, 19, 354
on problematic method, 103
Dickelman, N.K.
on critical theory, 149
on knowing patterns, 138
Dickoff, J.
on borrowed theory, 128, 129,
395
on conceptual models, 120, 126
on humility, 53
on Johnson, 284
on nursing concepts, 126
on practice oriented research,
abstract, 443
on practice theory, 130
on prescriptive theory, 30
on propositions, 386
on situation-producing theory,
130
on theory, abstract, 451–453
on theory definition, 30
on theory development, 71, 74,
154, 461
abstract, 451
on theory evaluation, 189
on theory in practice, abstract,
451–453
Dickson, G.L.
on Orem, abstract, 485
on theory advocate, 76
642 AUTHOR INDEX
LWBK821-Au-index_637-662 07/01/11 8:01 PM Page 642
Dickson, V.V., on self-care, 224
Diekelman, N.K.
on knowledge development
approaches, 64
on knowledge-research
congruency, 149
Diekelman, N.L., on theory
development, 393
Diers, D.
on Orlando, 247, 250
on scholarliness, 9, 18
on theory testing, 201
on Wiedenbach, 250
Diers, D.K., of nurse–patient
interactions, 250
DiGerolamo, L., on Neuman,
303
Dijkstra, A., on interruption, 378
DiMattio, M.J., on Roy, 334
Dirkensen, M., on Orem,
abstract, 484
Dirksen, M., on Orem, 218
DiVincenti, M., on theory in
administration, 366
Dluhy, N.M., on theory
development, 402
Doane, G.H., on research
enterprise barrier, 50
Dobal, M.T., on theory in
administration, 367
Dobratz, M.C., on Roy, 333, 334
Doering, L., on gender
orientation, 146
Dominiak, M.C., on concept
exploration, 373
Donaldson, S.K.
on Levine, 299
on nursing discipline, 88, 256
abstract, 453
on Paterson-Zderad theory, 256
on perspective, 132
on theory development,
commitment to, 73t, 75
Donovan, M.J., on Rogers, 320
Doona, M.E., on Travelbee, 264
Doornbos, M.M., on King, 232,
236, 240
Dougherty, C.M., on nursing
diagnosis, 120
Dowd, M.W., on feminism in
nursing, 52
Downey, C., on Roy, 335
Downs, F., on theory
development, 77
Downs, F.S., on theory-research
links, 11, 75
Doyle, N., on concept
development, 380
Dracup, K., on role
supplementation, 414
Dracup, K.A., on Orlando, 250
Dramiga, S.A., on Roy, 337
Draper, P., on post modernism, 149
Drevdahl, D., on
poststructuralism, 149
Drew, L.L., on Neuman, 309
Dreyfus, H.
on decision making, 15
on skill acquisition, 395
Dreyfus, S.
on decision making, 15
on skill acquisition, 395
Dropkin, M.J., on Orem, 218
Dubos, R.
on health, 464
as Levine influence, 297
Ducharme, F., on Roy, 336
Dufault, K., on theory issues, 75
Dufault, S.K., on theory
development, abstract, 450
Duffey, M.
on feminist perspective, 147
on theory analysis, 193
on theory evaluation, 182
on Travelbee, 263
Duffy, M.E., on feminist
perspective, 147
Dufour, L.T., on King, 238, 239
Duke, J.
on community of scholars, 435
on scholarliness, 9
Duldt, B.W.
on decision making process,
119
on nursing process, 104, 119
on Orem, 223
Dumas, R.G.
on Orlando, 250
on preoperative anxiety, 202
Duncan, C., on concept
development, 372
Dunn, K.S., on Roy, 337
Dunn, S.I.
on health, 464
on Neuman, 308
Duquette, A., on Roy, 336
Durán, M.M., on nursing
curriculum, 338
Durand, M., on nursing
diagnosis, 120
Durant, W.
on knowledge development,
113
on wisdom, 436
Dzau, V., on interdisciplinary
knowledge, 356
Dzurec, L.C.
on empirical theory, 140
on poststructuralism, 150
E
Eakes, G.G., on theory
development, 398
Easton, K.L., on Orem, 217
Edelson, M., as Neuman
influence, 306
Edlefsen, P., on research
program, 414
Edwards, C.N., on passivity, 42
Effken, J.A., on intuition, 53
Egan, C., on nursing practice,
248
Egbert, E., on Rogers, abstract,
489
Ehrenberger, H.E., on King, 241
Ehrenreich, B., on women’s role,
46
Eisenhauer, L.A., on nursing
diagnosis, 120
Eisler, J.
on Orlando, 250
on Weidenbach, 271
Ek, A-C, on self-care, 221
Ekman, S.L.
memory loss, 417
on transition in elderly, 416
El-Masri, M.M., on nursing care,
15
Elberson, K., on King, 239
Ellis, R.
on personal values, 199
on philosophical inquiry, 64
on theory, abstract, 453–454
on theory characteristics, 454
on theory complexity, 195
on theory definition, 30
on theory development, man’s
uniqueness, 409
on theory evaluation, 181, 182
on theory meaning, 75
on theory scope, 193
on theory types, 74
on theory usefulness, 198
Elms, R.R.
on Orlando, 250
on Weidenbach, 271
Engalla, M., on Orem, 218
Engally, M., on Orem, abstract,
484
Engel, G.L., on biomedical
model, 355
Engholm, R., on hope, 264
England, M., on nurse–client
interactions, 248
AUTHOR INDEX 643
LWBK821-Au-index_637-662 07/01/11 8:01 PM Page 643
Epshtein, A., on clinical scholars,
15
Erickson, E., on stages of
development, 162
Ericson, D., on Orem theory, 222
Erikson, E.
as Levine influence, 297
theory of, 161
Ervin, N.E., on evidence-based
practice, 26
Esposito, C.H.
on Levine, 296
abstract, 478
Estabrooks, C.A., on taxonomy of
knowledge, 116, 361
Ettipio, A.M., on King, 237
Eubank, E.E., on labeling, 384
Evans, J., on nursing role for
men, 45
Evers, G., on research theory,
122
Evers, G.C.M., on Orem, 221
F
Facione, N.C., on critical
thinking, 354
Facione, P.A., on critical
thinking, 354
Fagerhaugh, S.Y., grounded
theory approach of, 399
Fagerstrom, L., on nursing
diagnosis, 121
Fagin, C., on scholarliness, 11, 13
Fahlström, G., on interpersonal
relationships, 264
Fahlström, J., on medications for
older people, 218, 219
Fairman, J., on theory
development, 51
Falco, S.M., on Rogers, abstract,
489
Falk-Rafael, A., on nursing
interventions, 356
Falk-Rafael, A.R., on
empowerment, 421
Falls, C.E., on paradigmatic
origins, 269
Fan, L., on self-care behaviors of
school children, 220
Fangary, A.S., on Al-Islamiah, 60
Farkas, L.
on Roy, 335
abstract, 494
Farquhar, C.M., on research
enterprise barrier, 50
Farren, A.T., on Rogers’ theory,
319, 320
Faust, C., on Orlando, 249
Fawcett, J.
on borrowed theory, 128
on conceptual models, 30, 126,
127, 182
abstract, 454
on empirical theory, 140
on evidence-based practice, 26,
232
on health orientation of
discipline, 93
on King, 234, 235, 239, 240,
241
on Levine, 296
on Neuman, 305, 307, 308
on Orem, 213, 216, 217
on research and theory, 11, 75,
122
on Rogers, 312, 314, 316
on Roy, 334, 337
on theory analysis, 30, 76
on theory definition, 29
on theory evaluation, 182, 183
on theory in nursing education,
122, 366
as theory synthesizer, 76
Fawdry, K., on King, 236
Feldman, M.E., on caring, 93
Felton, G., on Travelbee, 265
Fenerty, A., on Neuman, 310
Fenner, K., on Orem, 219
Fenton, M.V., on concept
exploration, 373
Ference, H., on Rogers, 321
Ferguson, S., on Orem, 222
Ferketich, S.L.
on mothering, 392
on theory in administration,
366
Feshback, S., on aggression, 285
Fewster-Thuente, L., on
collaboration, 239
Feynman, R., on Levine, 290
Field, L., on nursing, 107
Fielder, J.H., on practice theory,
abstract, 450
Finfgeld-Connett, D., on nursing
presence and caring, 379
Firsich, S.C.
on cancer patients, 334
on Roy, 334
Fisher, E., on theory
development, 398
Fitzgerald, S., on Orem, 218
Fitzpatrick, J.
on evidence-based practice, 26
on Rogers, 320, 321
on theory analysis, 76, 115
on theory synthesizer, 76
Fitzpatrick, J.J.
on conceptual models, 126
on empirical theory, 140
on health orientation of
discipline, 94
Flaskerud, J.H.
on domain definition, 97
on interaction, 102
on Levine, 299
Fleischer, B.J., On Orem, 221
Fleiss, J., On Orem, 221
Florczak, K.L., on concept
exploration, 373
Floyd, J.A., on Rogers, 320
Fogarty, C., on concept analysis,
378
Foli, K.J., on Levine, 296
Fonow, M.M., on gender-
sensitive research, 147
Fontana, J.S., on critical theory
thinking, 148
Foote, A.W., on Neuman, 308
Forbes, D.A., on “warrantable
evidence” criteria, 152
Forchuk, C.
on interaction, 102
on Orlando, 243, 247
Forsythe, A.B.
behavioral system model of,
289
on Johnson, abstract, 473
on theory testing, 201
Foster, P.C.
on Orem, 212
on Wiedenbach, 267
Foucault, M., on
poststructuralism, 149
Fox, M.A., on Orem, 223
Foxcroft, D.R., on organizational
infrastructure, 78
Fox-Wasylyshyn, S.M., on
scholarliness, 15
Frame, K., on Roy, 337
Franca, I.S.X., on King, 238, 240
Francis, B., on poststructuralism,
149
Frank, P., on human beings, 433
Frankel, V., as Travelbee
influence, 263
Fraser, N.
on decision making process,
120
on postmodernism, 149
Frazer, A.G., on marginalized
populations, 357
Frederickson, K., on Roy, 333,
334, 337
Freese, B.T., on Neuman, 309
644 AUTHOR INDEX
LWBK821-Au-index_637-662 07/01/11 8:01 PM Page 644
Freese, L., on cumulative
knowledge, 432
Freihofer, P., on Travelbee, 265
French, P., on evidence-based
nursing, 78
Frey, M.
care for ill infants, 237
on King, 238, 240, 241
on Orem, 223
Frickel, S., on interdisciplinary
knowledge, 355
Fridlund, B., on theoretical
model, 379
Friedman, M.M., on nursing as
human science, 89
Frisch, N.
on decision making process, 120
on nursing process, 103, 119
Froland, S.S., on self-infusion, 222
Fry, S.T.
on knowing patterns, 137
on philosophical inquiry, 64
Fullbrook, P., on organizational
infrastructure, 78
Fuller, S., on autonomy, 36
Fulton, J.S., on theory analysis,
191
Funk, S.G., on recovery, 77
G
Gadamer, H., on critical theory
perspective, 148
Gadow, S.
on caring, 93
on theory development, 398
Gaffney, K.F., on maternal role
insufficiency, 414
Gagliardi, B.A., on Roy, 333,
334
Gagner-Tjellesen, D., on Levine,
300
Galligan, A.C.
on Roy, 335
abstract, 495
Galvao, C.M., on Levine, 300
Gardulf, A., on Orem, 222
Garon, M., on Rogers, 319
Gast, H., on Orem, 217
Gastaldo, D., on nursing, 80
Gaston, J., on rewards, 43
Gauthier, T., on Orem, 218
Gavin, C., on Orland, 250
Gebbie, K.
on nursing diagnosis, 120, 194
abstract, 454
Gebbie, K.M., on nursing
diagnosis, 359
abstract, 454
Geden, E.A., on Orem, 213, 216,
223
Gehrling, K.R.
on adversity, 303
on Neuman, 307
Gelman, R., on domain of
knowledge, 94
Gendron, D., on caring, 92
George, A., on interpersonal
relationship, 264
George, J.B., on King, 235, 237,
238
Georges, J.M.
on critical theory thinking,
148, 149
on diversity in nursing, 79
on identity, 356
on postmodernism, 149
Gesse, T., on Wiedenbach, 266,
267
Giangrande, S.K., on Neuman,
307, 310, 311
Gibson, C.H., on critical
reflection, 152
Gift, A., on symptom
management, 106
Gift, A.G.
on collaboration, 410
on situation-specific theory,
367
on theory development, 31
Gigliotti, E., on Neuman, 303,
305, 307, 310
Gill, B.P., on Rogers, 320
Gilligan, C., in developmental
differences between sexes,
8, 46
Gilliss, L., on Orlando, 250
Glaser, B.G.
on dying, 193
on grounded theory, 399
on nursing as human science,
89, 97
on theory development, 397
Glassick, C.E.
on Boyer, 7
on teaching, 8
Gless, P.A., on Roy, 335
Gliss, P.A., on Roy, 331b
Gobet, F., on intuitive learning,
141, 410
Goldberg, P., on sex-role
stereotyping, 46
Goldberg, W.G., on Rogers,
320
Goldberger, N.R., on knowers,
8, 16
Gonot, P.J., on King, 237
Goode, C.J.
on evidence-based practice, 78
on research enterprise barrier,
50
Goodwin, J.O., on Orem, 221
Goodwin, Z., on King, 238
Goodykoontz, L., on Neuman,
308
Gordon, J., on Roy, 335
Gordon, M.
on decision making process,
120
on nursing diagnosis, 119, 120
Gordon, S.
on theory development,
environment for, 124
on women’s role, 46
Gortner, S.R.
on collaboration, 12
on nursing science and
research, abstract, 455
on research, 61
on scholarliness, 14
on source of ideas, 61, 114
Gottlieb, A., on truth, 154
Gottlieb, L.N., on integration,
435
Gowan, N.I., on Orlando, 250
Grace, P.J.
on human science, 89
on nursing discipline, 88, 101
Gracia, J., on ontology, 27
Gragert, M., on Levine, 300
Graham, K., on Orem, 218
Grant, J., on nursing diagnosis,
120
Gray, C.J., on nursing curricula,
51, 76
Green, J.A., on nursing science,
abstract, 455
Greenberg, E.A., on interactions,
319
Greenfield, E., on cancer
patients, 218
Grey, M., on interdisciplinary
knowledge, 355, 356
Griffiths, B., on nursing theory,
270
Grimm, P.M., on Levine, 300
Grimshaw, J., on evidence based
medicine, 78
Grindley, J., on Levine, 298
Grobe, S.J., on nursing diagnosis,
121
Groer, M.W., on Roy, 334
Grol, R., on evidence based
medicine, 78
Grossman, R., on ontology, 27
AUTHOR INDEX 645
LWBK821-Au-index_637-662 07/01/11 8:01 PM Page 645
Group, T., on women’s role, 45
Grubbs, J.
on domain concepts, 283t
on Johnson, 281b, 286, 287, 288
abstract, 473
Grummon, D.L., on Travelbee,
265
Gulitz, E.A., on King, 239
Gurland, B., on Orem, 221
Gustafson, D.L., on transcultural
nursing theory, 79
Guzzetta, C., on nursing
diagnosis, 120
H
Haase, J.E.
on collaborative theory of, 379
on concept analysis, 378
Habermann, B., on theory of
integration, 434, 435
Habermas, J.
on critical theory perspective,
148
on theory development, 398
on understanding, 145
Hadley, B.J.
on Johnson, 287
theory of, bibliography on, 550
Hage, J.
on Orlando, 244
on theory development, 454
on theory evaluation, 187
Hagell, E.I., on gender-sensitive
theories, 146
Hagell, R.I., on knowledge
development approaches,
77
Hagerty, B.M.
on human relatedness, 77, 409
on theory development, 419
Haggart, M., on Neuman, 307
Haggerty, L.A., on Orlando,
250–251
Hägglund, D., on Travelbee,
264
Hagopian, G.A., on Orem, 222
Hall, B., on biomedical model,
117
Hall, B.A.
on change paradigm, abstract,
456
on goal of nursing, 169
on knowing patterns, 141
on medical model as theory
source, 117
on medicalization, 79
on postmodernism, 149
theory of, bibliography on, 550
Hall, E.O.C.
on Paterson and Zderad, 256
on self-care, 223
Hall, J., on postmodernism, 149
Hall, J.M.
on concept clarification, 375
on marginalization, 19, 357
on postmodernism, 149
on scholarliness, 19
Hall, K.V., on Levine, 298
Hall, L.E., nursing concept of, 70
Hall, S., on Levine, 300
Hallett, C.E.
on Paterson and Zderad theory,
257
on phenomenological
philosophy, 399
Halloran, E.J.
on domain definition, 97
on interaction, 102
Hamer, B.A., on Roy, 335
Hammond, H., on Roy, 325, 327,
335
abstract, 496–497
Hampe, S.O., on Orlando, 250
Hampton, D.C., on King, 237
Hampton, M., on Orem, 218
Hanchett, E.
on Orlando, 249
on Rogers, 322
Hanchett, E.S.
on Rogers influence, 316
on Roy, 335
Hanestad, B.R., on Travelbee, 265
Hankerson, C., on Neuman, 308
Hanley, M.A., on concept
exploration, 373
Hanna, D.R.
on assumptions, 325
on Roy, 326, 328t, 330t
Hannon-Engel, S.L., on Roy, 327
Hansen, D.A., on concepts and
theory, 126
Hansen, M., on Neuman, 309
Hanson, B.R., on Orem, 221
Hanucharurnkui, S.
on King, 240
on Orem, 222
Harden, J., on language analysis,
393
Harder, I.
on King, 238
on Orlando, 248, 249
Hardin, S.R., on Rogers, 323
Harding, S.
on feminist perspective, 147
on housework, 137
on scholarship, 15
Hardy, M.E.
on nursing theory, abstract,
456
on revolutionary theory of
progress, 431
on theory development, 75
on theory evaluation, 182
Harms, M.T., theory of,
bibliography on, 551
Harris, R.B., on Johnson, 287
Harris, S.M., on Neuman, 310
Harrison, L.L., on Roy, 334
Harrison-Raines, K., on Orem,
218
Hart, M.A., on Orem, 211b, 213,
213b, 220, 222
Hartley, L.A., on Orem, 222
Hartmann, N., on ontology, 27
Hawks, J.H., on concept analysis,
378
Hawley, G., on Travelbee, 265
Hawthorne, D.L., on interaction,
102
Hayes, P., on discipline, 87
Hayman, L.L., on theory
development, 67
Hays, B.J., on technology
challenges, 359
Head, B., on nursing diagnosis,
120
Heaslip, P., on knowing patterns,
141
Hedin, B.A.
on environment, 104
on feminist perspective, 147
Hedly, V., on Orem, 220
Heffline, M.S., on Neuman,
308
Heide, W.S., on women in
nursing, 45
Heidt, P., on Rogers, 320
Heinrich, K.T., on global/local
theories, 356
Heitkemper, M.M., on domain of
knowledge, 95
Hektor, L.M., on Rogers, 315
Helson, H., on Roy influence,
327
Hemphill, L., on Rogers, 322
Henderson, D.J., on practice
situation, 397
Henderson, V.
on education, 61
on goal of nursing, 171
on interaction theories, 162
needs theory and, 162t, 163t,
164t
on Orem, 216
646 AUTHOR INDEX
LWBK821-Au-index_637-662 07/01/11 8:01 PM Page 646
on role nurses play, 176t
on Roy, 332
on theory evaluation, 194
on theory usefulness for
education, 198
theory of, 194
bibliography on, 551
Henklein, J., on Roy, 337
Hennrich, M., on Orem, 218
abstract, 484
Henry, B., on theory in
administration, 366
Herber, O.R., on Orem, 220
Herdtner, S., on Rogers, 318,
322
Herman, J., on concept of quality
of life, 122
Hermiz, M.E., on Neuman, 310
Hernandez, A., on Roy, 338
Herrick, C.A., on Neuman, 308
Hessian, M., on Neuman, 309
Heuther, S.E., on nursing
science, abstract, 457
Hicks, F., on postmodernism, 65
Hildingh, C., on concept
analysis, 379
Hill, R., on concepts versus
theory, 126
Hills, R.G.S., on Rogers, 322
Hinds, P., on Johnson, 289
Hines, S.H., on Orem, 217
Hinton-Walker, P.
on empirical theory, 140
on Neuman, 309
Hirschfeld, M.J., on Levine, 298,
299, 479
abstract, 479
Hisama, K.K., on Travelbee, 265
Hobbs, JL., on scholarliness in
nursing, 11
Hoch, C., on Roy, 333
Hochschild, A.R.,, on women’s
role, 46
Hoeffer, B., on specialization,
abstract, 462
Hoeman, S., on Neuman, 308
Hoey, D., on postmodernism,
149
Hofmeyer, A.
on progress in discipline, 427
on scholarship, 18
Hofrocks, S., on scholarship, 18
Hohn, S.A., on Orem, 210, 211,
218
abstract, 482
Holaday, B.
on achievement, 288
on Johnson, 282, 286
abstract, 474
on material responses to ill
infants, 290
Holder, P., on Neuman, 308
Holmes, C.A.
on nursing as human science, 89
on theory development, 123
Holmes, D.
on nursing, 80
on Paterson and Zderad, 254
Holter, I.M., on critical theory
perspective, 148
Holton, G., on women in nursing,
45
Holzemer, W., on scholarliness, 15
Hopkinson, J.B.
on Paterson and Zderad, 257
on phenomenological
philosophy, 399
Horner, M., on achievement-
related conflicts, 45
Howland, D., theory of,
bibliography on, 551
Hoy, B., on self-care, 223
Hoyer, P.J., on King, 238
Hsieh, C.H., on Orem, 220
Huber, M.T., on scholarship, 7
Hudak, J., on Johnson, 289
Huether, S.E.
on concept definition, 385
on theoretical nursing, 365–366
theory-practice linkage,
abstract, 457
Hughes, A.M., on rethinking
theories, 358
Hunt, C.K., on concept
clarification, 121
Hunter, L.A., on Orlando, 248
Hunter, L.P., on Orlando, 248
Hurlock-Chorostecki, C., on
Orem, 218
Husband, A., on King, 237
Huss, K., on Orem, 223
Huss, R.W., on Orem, 223
Hussein, S.H.,, on al-Aslamiya, 60
Husting, P.M., on King, 239
Hutchings, P, on scholarship of
teaching, 8
Hutton, E., on Neuman, 309
I
Idle, B.A., on Roy, 333, 334
Idvall, E.
on concept analysis, 378
on Levine, 300
Im, E-O.
on gender-sensitive research,
147
on gender-sensitive theories,
79, 419
on situation-specific theories,
78, 420, 421, 422
Irvin, S.M., on Levine, 300
Irvine, F., on poststructuralism,
149
Isaramalai, S., on Orem, 216,
223
Isenberg, M., situation-specific
theories, 78, 368
Izumi, S., on concept
development, 380
J
Jackson, S., on Rogers, 319
Jacob, J.D., on Paterson and
Zderad, 254
Jacobs, B.B., on nursing client,
99
Jacobs, M.K.
on concepts definition, 385
on nursing theory, 29, 30
on phenomenon, 384
on propositions, 386
on theory development, 51,
393
on theory-practice linkage,
abstract, 457
Jacobs, S., on theory testing,
201
Jacobs-Kramer, M.K.
on knowing patterns, 137
on theoretical nursing,
365–366
Jacobson, S., on theoretical
nursing, 365
Jacobson, S.F.
on nursing theories, 76
on theory testing, 201
Jacoby, M.K., on nursing
diagnoses, 360
Jacono, B., on Rogers, 318
Jacono, J., on Rogers, 318
Jacox, A.
on middle-range theories, 193
on nursing diagnosis, 120
on practice theory, 128
on received view, 138, 139
on situation-specific theories,
419
on theory construction,
abstract, 457–458
on theoretical nursing, 75
on theory strategy, 398
Jacquette, D., on ontology, 27
Jagger, A.M., on feminist
perspective, 147
AUTHOR INDEX 647
LWBK821-Au-index_637-662 07/01/11 8:01 PM Page 647
James, P.
on conceptual models, 126
on Johnson, 284
on nursing concepts, 129
on nursing diagnosis, 120, 359
on nursing theory, 30
on practice oriented research,
abstract, 451–453
on practice theory, abstract,
451–453
on propositions, 386
on situation-producing theory,
128
on theory development, 71, 74,
154, 359
research in, abstract, 451
on theory evaluation, 189
on Wiedenbach, 266, 269
on women in nursing, 53
Jan, R., on Al-Islamiah, 45
Janelli, L.M., on Roy, 335
abstract, 496
Jankin, J.K., on nursing
diagnosis, 120
Janson-Bjerklie, S.J.
on theory development, 393
on theory testing, 201
Janssens, N.P., on Orem, 212
Jasper, M., on knowing patterns,
138
Jaspers, K., on understanding, 145
Jennings, B.
environment for, 124
on supportive environments,
55, 124
Jennings, B.M.
on supportive environments,
55, 124
theoretical aspects of nursing
domain, 367
Jennings, B.W., on evidence-
based practice, 26
Jenny, J.
on knowing patients, 91, 142
on knowing patterns, 142
on nursing diagnosis, 360
Johansson, I., on concept
analysis, 379
Johnson, D.E.
on behavioral patterns, 188
on behavioral systems,
abstract, 475
bibliography on, 340–341
on borrowed theory, 128, 131,
132
abstract, 458–459
on concepts versus theory, 126
on domain concepts, 189
on functional requirements, 188
on knowledge of control, 194
literature abstracts on, 469–478
on nursing concepts, 169, 174
on nursing perspective, 174
on nursing philosophy,
abstract, 474
on nursing theory, 122
abstract, 458–459
on nursing significance,
abstract, 475
on nursing therapeutics, 171
on Parsons’ behavioral system
concept, 285
on role nurses play, 176t
on social behavior system, 153,
154
on theory context, 194
on theory evaluation, 181, 191,
199
theory of, 280–290
abstracts on, 469–478
bibliography on, 551–554
Johnson, J., on caring, 92
Johnson, J.E., on research and
theory, 122
Johnson, J.L., on caring, 93
Johnson, M., on nursing
diagnosis, 120
Johnson, M.A., on situation-
specific theories, 420
Johnson, M.J., on interactions,
102
Johnson, R.A., on scholarship in
nursing, 17
Johnson, S.E., on Neuman, 309
Johnson, T.R., on concept
analysis, 378
Johnston, C., on concept
analysis, 378
Johnston, L., on organizational
infrastructures, 78
Johnston, R.L.
on Orem, 217
on Rogers, 320
Jones, A., on cultural factors, 239
Jones, D., on role
supplementation, 194
Jones M., on Orem, 219
Jones, P., on nursing
therapeutics, 106
Jones, P.S., on health, 106
on Roy, abstract, 496
Jones-Cannon, S., on Neuman,
308
Jonsdottir, H.
on caring, 171
on discipline, 90
Jonsdottir, H.
Jopp, M.C., on Neuman, 309
K
Kameoka, T., on King, 238
Kant, I., on Paterson–Zderad
influence, 254
Kantorski, L.P., on Paterson–
Zderad influence, 258
Kaplan, A.
on abstractness, 194
on coherence theory, 152
on concepts in theory, 125, 126
on pragmatism theory, 153
on theories of truth, 150
on theory analysis, 192, 193
Karl, C.A., on Orem, abstract,
485
Karmels, P., on theory in nursing
education, 366
Kasch, C., on theoretical
exemplars, 435
Kass, M.J., on role
supplementation, 414
Katajisto, J., on Levine, 300
Katz, V., on Rogers, 320
abstract, 490
Kearney, B.Y., on Orem, 221
Keeling, A.W., on nursing
diagnosis, 360
Kehoe, C.F., on Roy, 335
Keller, E., on theory
development, 44, 46
Keller, K.B., on Neuman, 307
Kelley, J.A., on Neuman, 309
Kelley, J.H., on nursing
diagnosis, 120
Kelly, A.E., on Rogers, 322
Kelly, J., on Travelbee, 264
Kelly, L., on Roy, 337
Kelly, L.S., on role
supplementation, 414
Kelly, R., on Neuman, 310
Kemp, J., on Rogers, 322
Keough, V., on Roy, 334, 338
Kerfoot, K.M., on Orem, 218
abstract, 483
Kershaw, T., on Orem, 222
Kiehl, E.M., on King, 238
Killeen, M.B, on King, 231, 234
Kim, C., on Rogers, 321
Kim, H.S.
on interactions, 102
on nursing diagnosis, 129
on nursing process, 104
on nursing:a human science,
89
on Rogers, 320
648 AUTHOR INDEX
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Kim, M.A., on Rogers, 318
Kim, M.J.
on nursing diagnosis, 120
on Rogers, 318
on theory testing, 201
Kim, T.S., on Rogers, 318, 320
King, I.M.
assumptions, 229–230, 230b
bibliography on, 272–275
conceptual framework for
nursing, 229–232, 231b
domain concepts, 233–234t
on interaction theories, 165,
165t–168t, 229
on labeled theory, 127
on nurse–patient interactions,
174
on role nurses play, 176t
on theory evaluation, 189
on theory testing, 240–241
theory of, 229–241
bibliography on, 554–559
King, K.M., on “warrantable
evidence” criteria, 152
Kinlein, M.L., on Orem, 218
Kinney, A.Y., on concept
analysis, 379
Kinney, M., on nursing
diagnosis, 120
Kintzel, K.C., on concept
clarification, 121
Kirkevold, M.
on King, 238
on Orlando, 248, 249
Kirkham S., on philosophical
stage, 65
Kirkham, S.R., on
postcolonialism, 150, 155
Kitchell, R., on nursing concepts,
129
Kleffel, D., on environment,
105
Kleiman, S., on Paterson–Zderad
theory, 255, 257
Klein, J.F., on concept versus
theory, 126
Klein, J.T., on nursing discipline,
87
Kleinbeck, S.V.M., on Roy,
337
Knafl, K.A., on concept
development, 371, 372
Knapp, T.R., on praxis, 28
Knight, J.R., on Neuman, 305
Knox, S.M., situation-specific
theories, 420
Kochinda, C., on Roy, 337
Koehler, J., on Roy, 337
Koerner, J.E.
on Middle Eastern immigrant
population, 78
on situation-specific theories,
368
Koertvelyessy, A., on Neuman,
305, 308, 310
Kolcaba, K.
on practice situation, 397
on practice to theory strategy,
397
Kolcaba, K.Y.
on Paterson and Zderad, 257
on Wiedenbach, 269
Kolcaba, R.J., on Paterson and
Zderad, 257
Korhonen, T., on hybrid strategy,
379
Koto, E.M., on Orem, 221
Kottwitz, D., on Neuman, 311
Kramer, M., on concept
definition, 25
Kramer, M.K.
on classical analysis, 137
on concept analysis, 376
on concept clarification, 374,
375
on concept development, 380
on empirical theory, 140
on knowing patterns, 138
on post epistemologies, 150
on theory clarity, 195–196
on theory definitions, 29, 30,
182
on theory evaluation, 182, 184t
Kramer, S. on behavioral science,
abstract, 459
Krekeler, K., on Rogers, 318, 319
Krieger, D.
on Levine, 299
on nursing therapeutics, 106
on Rogers, 318
Kristoffersen, K., on Travelbee,
264
Kritek, P.
on definition of nursing, 107
on nursing diagnosis, 120
on nursing theories, 34
Kritek, P.B., on nursing
diagnosis, 359, 360
abstract, 460
Kroll, T., on Orem, 219
Ku, Y-C., on Orem, 220
Kubricht, D., on Orem, 220
Kubsch, S., on Neuman, 308
Kuhn, T.S.
on competing theories, 203
on domains, 95
on paradigm, 27
on scholarliness, 12
on science, 28
on scientific discipline, 430–431
on stage of research, 62
on theory development, 392
on theory of revolution, 428–429
on theory scope, 193
Kulig, J.C., on theory
development, 393
Kumar, C.P., on Orem, 216
Kurek-Ovshinsky, C., on Roy, 335
Kuriansky, J., on Orem, 221
Kurtz, R.R., on Travelbee, 265
Kushner, K.E.
on critical theory, 148
on “warrantable evidence”
criteria, 152
Kyle, L., on Rogers, 318
Kylmä, J., on hybrid strategy,
379
Kyngäs, H., on research program,
414
L
Laborde, J.M., on concept
exploration, 373
Lacey, B.
on Middle Eastern immigrant
population, 78
on situation-specific theories,
368
Lachicotte, J.L., on Johnson, 288
Lackey, N.R., on concept
clarification, 375
LaCoursiere, S.P., on theory
selection, 421
Lakin, J.A., on research program,
414
Lamb, K.A., on Neuman, 305
Lancaster, D.R., on Neuman, 307
Landis, C., on description of
phenomenon, 383
Landmark, B.T., on theory
testing, 265
Lange, M.P., on Orem, 213
Langemo, D.K., on Levine, 300
Langford, A.M., on theoretical
nursing, 366
Langstaff, D.
on concept clarification, 376
on theory critique, 264
Lanigan, T.L., on theory critique,
219
Laros, J., on Roy, 335
Larson, P., on scholarliness, 11
Larson, P.A., on theory testing,
371
AUTHOR INDEX 649
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Larson, P.J., on theory
development, 393
Larsson, I.E., on concept
clarification, 376
Lasome, C.E.M., on King, 237
Lasus, H., on Orem, 211b, 221
Lathlean, J.
on concept analysis, 377
on theoretical thinking, 366
Laudan, L.
on integrative theory, 153
on knowledge development, 90
on Kuhn’s view of scientific
discipline, 430
on scholarliness, 13
on theoretical discourses, 367
on theory development, 185
on theory of integration, 434
on world view of truth, 155
Lauder, W.
on Orem, 211b, 219, 223
on theory of integration, 435
Laurent, C.L., on interactions, 249
Lavin, M.A., on nursing
diagnosis, 359
abstract, 454
Leddy, S.K., on Rogers, 319, 321
Lee, B.T., on King, 239
Leenerts, M.H., on Orlando, 248,
250
Leeper, J.D., on Roy, 334
Lee-Villasenor, H., on theory
advocates, 76
on Orem, abstract, 485
Lefaiver, C.A., on Roy, 334
Legwand, C., on Orem, 218
Leidy, N.K.
on collaboration, 410
on concept analysis, 378–379
bibliography on, 559–560
Leino-Kilpi, H., on Levine, 300
Leininger, M.M.
on caring, 92, 93
on nursing science, abstract, 460
on stage of research, 61
theory of, bibliography on,
559–560
Lejewski, C., on ontology, 26
Lenz, E., on nursing theories, 31
Lenz, E.R.
on collaboration, 410
on knowledge integration, 402
on theory testing, 201
Leonard, M.K., on Levine, 296
abstract, 478
Leonard, R.C.
on practice theory, 128
abstract, 468
on preoperative anxiety, 202
on theory testing, 250, 271
Leonard, V.E.
on concept development, 380
on differentiating, 385
on theory development, 393
on theory strategy, 398
Leonard, V.W., on knowledge
development approaches, 77
Lerner, B., on Travelbee, 265
Letourneau, N.L., on “warrantable
evidence” criteria, 152
Levesque, L., on Roy, 336
Levett-Jones, T., on Wilson’s
method of concept
analysis, 378
Levin, H., on Johnson, 285
Levine, M.E.
bibliography on, 341–343
on adaptation and assessment,
abstract, 479
on assessment guidelines,
560–562, 291–292
on conservation principles,
290, 296
abstract, 480
on domain concepts, 295t–296t
on Erikson, 297
on holistic nursing, 292
abstract, 480–481
on humanistic purpose of
nursing, 297
literature abstracts on, 478–482
on pursuit of wholeness,
abstract, 480–481
on research and theory, 122
on role nurses play, 176t
on Roy, 332
on scientific method, 291, 297
on technological change,
abstract, 481–482
on theory development, 63
on trophicognosis, 291
propositions, 294b
theory of, 63, 169, 290–300
abstracts on, 478–482
bibliography on, 560–562
Lewandowski, W.A., on Rogers,
323
Lewin, K., on Rogers, 316
Lewis, F., on Roy, 334
Lewis, F.M., on Roy, 334, 337
Lewis, S.M., on concept
clarification, 375
Licavoli, C.M., on King, 241
Liehr, P.R.
on middle-range theory, 410, 411
on theory development, 393
Lindeman, C.A.
on research and theory, 122
on theory strategy, 399
Lindencrona, C.S.C., on concept
clarification, 376
Lindsey, A.M., on concept
analysis, 189
Linton, S.M., on Neuman, 308
Lipson, J., on Orlando, 249
Lipson, J.G., on middle-range
theory, 416
Litchfield, M., on practice-
oriented discipline, 90
Litchfield, M.C., on nature of
practice, 359
Loan, L.A., on evidence-based
practice, 26
Lobo, M.L.
on Johnson, 287
on Rogers, abstract, 489
Loescher, L.J., on nature of
practice, 359
Logan, J.
on knowing patterns, 142
on practice-oriented discipline,
91
Logan, M., on Roy, 335
Logan, W., on theory usefulness,
196
Lohr, K.N., on evidence-based
practice, 78
Lohrmann, C., on concept
analysis, 378
Lookinland, S., on theoretical
nursing, 367
Loomis, M.E., on functional
orientation, 42
Louis, M., on Neuman, 308, 310
Lovejoy, N.
on projective test, 289
on theory testing, 201
on Johnson, abstract, 476
Lowenstein, A., on King, 236, 238
Lowry, L.W., on Neuman, 307,
309, 311
Lowry, R.C., on Rogers, 322
Luke, S., on Travelbee, 264
Luker, K.A., on theory
development, 399
Lundberg, G.A., on labeling, 384
Lunney, M.R., on nursing
diagnosis, 120
Lush, M.T., on theory testing, 201
Lutzen, K., on nursing
perspective, 88
Lynam, J., on scholarliness, 8
Lynam, M.J., on postcolonialism,
150
650 AUTHOR INDEX
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Lynch, M.P., on truth, 154
Lynch-Sauer, J.
on middle-range theories, 77
on theory development, 409
M
Maas, M., on nursing diagnosis,
120
Maas, M.L., practice-oriented
discipline, 90
Maccoby, E.E., on Johnson, 285
MacFarlane, J., on women in
nursing, 53
Machado, A., concept
development, 371
Machung, A., on women’s role, 46
MacLaren, A., on Wiedenbach,
267
MacPherson, K.I.
on caring, 93
on gender sensitive theories,
146
Macrae, J., on theory of
integration, 434
Madden, B.P., on hybrid strategy,
379
Madrid, M., on Rogers, 313t, 318
Maeroff, G.I., on scholarship, 7
Maeve, M.K., on theory strategy,
398
Magan, S., on King, 232
Magnan, M., on Orem, 213, 222
Maguire, J., on concept analysis,
379
Mahon, N.E., on Rogers, 321,
322, 323
Mairis, E., on concept
clarification, 375
Maislin, G., on nursing
therapeutics, 106
Majesky, S.J., on Johnson, 289
Makaroff, K.L.S., on nursing
discipline, 88
Malinski, V.M.
on nursing as human science,
89
on Rogers, 314, 321
on Roy, 336
Mantle, F., on Levine, 300
Mantzoukas, S.
on knowing pattern, 138
on knowledge in nursing
practice, 118
Mapanga, K.G., on practice-
oriented discipline, 90
Mapanga, M.B., on practice-
oriented discipline, 90
Marenbon, J., on parsimony, 27
Mariano, C., on nursing as
human science, 89
Marriner-Tomey, A.
on theoretical nursing, 366
on theory analysis, 191
on theory critique, 247
Martin, A.
on Orem, 216
on patient-centered nursing, 119
on theoretical nursing, 70
Martin, E.M., on Orem, 216,
218
Martin, J.P., on King, 240
Martin, K.S., on informatics and
theoretical nursing, 359
Maslow, A., on theory, 162, 192
Mason, T., on Rogers, 318
Massey, V.H., on Roy, 339
Masson, V., on practice-oriented
discipline, 91
Mastal, M.F., on Roy, 325, 327,
335
abstract, 496–497
Matheney, R.V.
on nursing process, 119
on Orem, 216
on patient-centered nursing,
70
Matthewman, S., on
postmodernism, 149
Matthiesen, S., on Rogers, 322
Maunz, E.R., on Orem, 220
Mautner, T., on tautology, 28
Maville, J.A., on Rogers, 318
May, B.A., on King, 231
May, K., on theory development,
392
May, K.M.
on mentorship, 55
on norms, 410
on theory development, 123
May, R., on Travelbee, 263
McBride, A.B., on future of
nursing theory, 436
McBride, L., on Orlando, 250
McBride, M.A., on Travelbee,
265
McBride, S., on Orem, 221
McBroom, L., on discipline, 88
McCann, T.V., on Travelbee,
265
McCarthy, R.T., on practice
theory, abstract, 460
McCaughan, D., on United
Kingdom acute care
settings, 78
McCauley, K.M., on nursing
therapeutics, 106
McCorkle, R., on Roy, 336
McCreedy, M., on Johnson, 288
McCubbin, M., on Orem, 220
McCullagh, M., on Neuman, 309
McDonald, C., on nursing client,
100
McDonald, F.J., theory of,
bibliography on, 551
McDowell, B.M., on Neuman,
307
McGillian, M., on theory
development, environment
for, 124
McGrath, B.B.
on theory development, 392
on transitions, 100
McGuire, S., on critical theory
thinking, 148
McIlveen, K.H., on concept
exploration, 373
McIntyre, M., on nursing client,
100
McKay, R.
on nursing theory, 29
abstract, 461
on taxonomy, abstract, 461
McKee, M., evidence-based
practice, 78
McKeehan, K., on nursing
diagnosis, 120
McKenna, H.P., on theory
development, 393
McKinney, N.L., on King, 237
McLaughlin, K., on Orem, 218
McLeod, D., on Roy, 325
McMahan, T., on Orem, 220
McManus, R.L., on
taxonomies/interpretations,
359
McMillan, M., on concept
analysis, 378
McPherson, K., on evidence-
based practice, 78
McPherson, K.I.
on knowledge, 53
on postmodernism view, 137
McTaggart, J.E., on
correspondence theory, 151
McWhinney, I.R., on nursing as
human science, 89
Mead, G.H.
on interactions, 102
on symbolic interactionism, 25
Medina, R.F., on Paterson and
Zderad, 258
Meeker, B.F., on sex-role
differentiation, 52
Meininger, M., on Neuman, 310
AUTHOR INDEX 651
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Meleis, A.I.
on analogizing, 386
on concept analysis, 189
on context of theory, 194
on critical theory, 148
on definitions, 107
on delineating consequences,
385
on delineating antecedents, 385
on derived concepts, 187
on differentiating, 385
on diversity, 79
on environment for, 124
on experience as theory source,
117
on gender-sensitive research,
147
on health, 106
on health-oriented discipline,
93, 94
on King, 238
on labeling, 384
on middle-range theory, 411,
413
on nurses as women, 45, 52
on nursing as human science,
89
on nursing education, 55
on Orlando, 249
on postmodernism, 149
on received view, 140t
on role supplementation, 129
on scholarliness, 14, 16, 17, 19
on situation-specific theories,
77–78, 368, 419, 420
on theoretically supportive
environment, 124
on theory development, 123,
366
on theory evaluation, 185
on theory support, 202
on theory testing, 200
on transitions, 100
theory of, bibliography on,
562–563
Melnyk, K.A.M., on Orem, 215,
218, 219
Meltzer, L.E., on nursing
concepts, 129
Memmott, R.J., on Neuman,
303
Menke, E.M.
on Paterson and Zderad, 257
on theory development,
abstract, 461
Mentzer, C.A., on Newman’s
situational control
proposition, 202
Mercer, R.
on mothering, 392
on nursing phenomena, 12
on theory development, 392
Merkle, C.J., on nursing practice,
358
Merton, R.
on middle-range theories, 193,
411
on norms, 410
on situation-specific theories,
419
Merton, R.K.
on domains, 95
on norms, 410
on stage of research, 61
Mertz, H., on Orlando, 250
Merwin, E., on Orem, 222
Messias, D.K., on middle-range
theory, 419
Messmer, P.R., on King, 231, 234
Meter, M.J., on role strain in
faculty, 201
Meyer, P.A., on theory testing,
201
Meyer, T., on Neuman, 308
Michael, M.M., on Orem, 218
Miller, J.B., on relational culture,
79
Miller, J.F., on Orem, 218, 220
abstract, 486
Miller M.W., on Neuman, 309
Milligan, R.A.
on changes in attitude toward
theory, 31
on collaboration, 410
on middle-range theory, 402
on nursing therapeutics, 106
on situation-specific theories,
368
Millor, G.K.
on nursing phenomena, 12
on paradigm, 395
Mills, D., on Orlando, 247
Mirenda, R.M., on Neuman, 309
Mischel, M.H., on pluralism, 12
Mishel, M.H., on situation-
specific theory, 77
Mitcham, C.
on concept development, 371,
380
on Travelbee, 264
Mitchell, G.J.
on domains, 95
on nursing as human science,
89
Mitchell, P.H., on nursing
concepts, 129
Moccia, P., on Rogers, 321
Moch, S.D.
on health, 93
on knowing patterns, 141
on nurses’ experience, 117
Mock, V., on Levine, 300
Modrcin-Talbott, M.A., on Roy,
334
Molzahn, A.E.
on King, 232
on Rogers, 314, 320
Montgomery, K.S., on Orem, 217
Mood, D.W., on Orem, 222
Moore, C., on Roy, 337
Moore, D., on Neuman, 310
Moore, D.S., on feminism in
nursing, 52
Moore, J.B., on Orem, 213, 218,
221
Moore, M.A., on nursing
discipline, abstract, 461
Moore, S., on nursing discipline,
88
Moore, S.M., on middle-range
theory, 414
Moorhead, S., on nursing
diagnosis, 120
Moorhead, S.A., on scholarship,
17
Morales-Mann, E.T., on Roy, 335
Moreira, T.M.M., on King, 237,
240
Moreno, M.E., on Roy, 338
Moritz, D.A.
on nursing diagnosis, 120
on Rogers, 317, 318
Morris, M., on Orlando, 250
Morrow, J.H., on Orem, 218
Morrow, R.
on critical theory thinking, 148
on theory, 66
Morse, J.
on concept development, 380
on Travelbee, 264
Morse, J.M.
on caring, 93
on concept clarification, 375
on concept exploration, 373
on scholarliness, 11
on Travelbee, 265
Morse, W., on Orem, 218
Morton, M.K., on situation-
specific theories, 420
Moscaritolo, L.M., on Neuman,
308
Moser, A., on Orem, 219
Moses, M.M., on Travelbee, 265
Mosher, R.B., on Orem, 218
652 AUTHOR INDEX
LWBK821-Au-index_637-662 07/01/11 8:01 PM Page 652
Moss, C., on scholarliness, 9
Moss, R., on health-oriented
discipline, 93
Mountford, B., on theory
evaluation, 203
Mrkonich, D.E., on Neuman, 309
Mu, P.F., on situation-specific
theory, 423
Mucha, A., on Johnson, 289
Muhlenkamp, A.F.
on theory analysis, 193
on theory evaluation, 182
on theory syntax, 75
on Travelbee, 263
Mullhall, A., on United Kingdom
acute care settings, 78
Mullin, V.I., on Orem, 218
Munhall, P.L.
on integrative theory, 153
on knowing patterns, 142
on Paterson and Zderad, 257
Muniz, R.M., on Paterson and
Zderad, 257
Munn, V.A., on Roy, 336
Murk, A., on Neuman, 309
Murphy, C.P., on nursing
process, 119
Murphy, P.P., on Orem, 218
abstract, 487
Murphy, S.A., on specialization,
abstract, 462
Murray, S., on evidence-based
practice, 78
Myrick, A.F., on “warrantable
evidence” criteria, 152
Myrick, F., on measuring
progress in a discipline, 427
N
Naden, D., on Travelbee, 264
Naguib, H.H., on Johnson, 290
Nahm, H., on stage of research,
61
Nakajima, H., on
marginalization, 357
Narayanasamy, A., on Travelbee,
265
Nayback, A.M., on Roy, 333
Naylor, M.D.,, on transitions, 100
Neander, W., on caring, 93
Neander, W.L.
on caring, 93
on concept clarification, 375
Nelson, A.M., on situation-
specific theories, 420, 422
Nelson, L.F., on Neuman, 309
Nelson, S., on supportive
environment, 124
Neuman, B.
assumptions, 301b
bibliography on, 343–345
client system of, 302
on domain concepts, 304t
on empirical theory, 140
on entropy, 304
on evidence-based practice, 26
on health, 106
on Neuman Systems
Management Tool, 310
on reconstitution, 305
on theoretical development,
115, 174
theory of, 300–311
bibliography on, 563–570
concepts of, 301b
Neuman, B.M., on Orem, 213
Neves-Arruda, E.N., on Rogers,
393
Newman, D.
on caring, 174
on Johnson, 288
Newman, D.M., on Neuman, 308
Newman, D.M.L., on Neuman, 308
Newman, M.
on health, 106
on health-oriented discipline,
93, 94
on nursing domain, 96, 97
on scholarliness, 11
Newman, M.A.
on caring, 93
on definitions of nursing, 107
on health-oriented discipline,
93
on nursing as human science, 89
on nursing client, 98
on nursing theory, 30
on practice-oriented discipline,
91
on relationships and
interactions, 101
on Rogers, 321, 322, 323
on scientific method, 139
on stage of philosophy, 64, 65
on theory analysis, 194
on theory development, 194
on theory evolution, abstract,
462
theory of, bibliography on,
570–571
Newport, M.A., on Levine, 299
Newton, M.
measuring progress in discipline,
427
on scholarship, 18
Nicholas, P.K., on Orem, 220
Nicholl, H., on nurses as women,
46
Nicholson, Jr. N.R., on Roy, 338
Nicholson, L.J., on
postmodernism, 149
Nickel, S., on Wiedenbach, 266
Nickitas, D.M., on Orem, 217
Nicoll, L.H., on theory testing,
201
Nield, M., on theory testing, 201
Nightingale, F.
on biomedical model, 116
on clinical theories, 362
on definition of nursing, 106
on environment, 104
on health, 106
on Johnson, 285
on Levine, 300
on nursing client, 98, 102
on nursing practice, 115
on Orem, 217, 223
on paradigmatic origins, 297
on Rogers, 314
on Roy, 332
on stage of practice, 60
on theory development, 51,
72t, 392
theory of, bibliography on,
571–573
Nilsson, U., on Levine, 300
Nishio, K.T., on Johnson, 289
Nojonen, K., on nursing
diagnosis, 121
Noone, J., on Orem, 218
Norbeck, J.
on nursing concepts, 129
on scholarliness, 12
on social concepts, 129
Norberg, A.
on King, 240
on Orem, 220
Nordstrom, C.K., on Orem, 218
Norgan, G.H., on King, 237
Norman, G.
on theory support, 181
on theory testing, 200
Noroian, E.L., on Roy, 334
Norris, C.M.
on biomedical model, 116
on concept analysis, 189
on concept clarification, 121,
129, 374
on concept exploration, 372
Norris, D.M., on King, 237, 238,
239
Norris, J., on nursing/medical
informatics, 359
Norris, M.K., on Orem, 218
AUTHOR INDEX 653
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Northrop, F.S.C., on Rogers, 316
Northrup, D.T.,
on discipline of nursing, 88
on health, 106
Notter, L.E., on research,
abstract, 463
Nowak, K.B., on Travelbee, 265
Nuamah, I.F., on Roy, 336
Nye, F., on concepts and theory,
126, 128
O
Oakley, D., on Orem, 222
O’Baugh, J., on Travelbee, 264
O’Brien, B.
on concept exploration, 373
on knowing patterns, 142
O’Brien, C., on Neuman, 310
O’Connell, R.K., on Neuman, 308
O’Connor, N.A., on Orem, 222
Oiler, C.
on Paterson and Zderad, 257
on phenomenology, 71
on theory development, 382
on world view of truth, 155
O’Leary, K.A., on nurses’
experience, 117
Olesen, V.
on labeling, 384
on women’s roles, 46
Olshansky, E., on “identity as
infertile”, 79
Olshansky, S., on theory
development, 397
Olson, B., on Levine, 300
Olson, J., on Orlando, 249
Olson, J.K., on integrative theory,
153
Olson, T.C., on caring, 93
Olynyk, V.G., on discipline, 88
O’Mathuna, D.P., on Rogers, 322
Omery, A., on phenomenology,
71
Ord, L., on Orem, 210, 211, 218
abstract, 482
Orem, D.E.
on abstractness, 194
assumptions, 211b
on conceptualization, 213
on content of theory, 192
on domain concepts, 214t
on health, 106
literature abstracts on, 482–489
needs theory and, 162t, 163t,
164t
on nursing client, 98
on nursing functions, 162
on nursing process, 103
on nursing therapeutics, 106
on propositions, 215b
on role nurses play, 176t
on scholarliness, 13
on self-care, 207–209, 215–217
on theory development, 63, 64
theory of, 207–224
abstracts on, 482–489
bibliography on, 573–585
Orlando, I.J.
bibliography on, 275–276
on domain concepts, 245t
on interaction theory, 165t–168t
on nurse–patient interactions,
174
on nursing process, 103, 119
on propositions, 247b
on role nurses play, 176t
on theory development, 154
theory of, 241–251
bibliography on, 585–588
Ornellas, C.P., on Paterson and
Zderad, 254
Osborne, T., on postmodernism,
149
Osen, L.M., on Hypatia, 7
O’Shea, H.S., on role strain
faculty, 201
Ossler, C.C., on King, 237
O’Toole, M.T.
on praxis, 28
theoretical frameworks, 28
Owen, M.J., on nursing as human
science, 89
Owen, T.R., on Johnson, 288
P
Pace, J., on Orem’s theory, 218
Pace, K., on Roy, 337
Padilha, M.I.C., on Paterson and
Zderad’s theory, 257
Pagels, A.A., Orem’s theory on
self-care, 220
Pagliuca, L.M., on Orlando, 249
Pagliuca, L.M.F., on King, 237,
238, 240
Palencia, I., on Roy, 337
Paley, J.
on concept development, 380
on perceived view, 141
Palmer, I.S., on scholarship, 18
Palmer, J.O., on Johnson, 289
Panniers, T., on self-care
practices, 67
Paradowski, M., on Levine, 298
Parahoo, K., on evidence-based
nursing, 365, 367
Park, J.S., on Rogers, 318
Park, K.M., on Rogers, 321
Park, Y. J., on concept analysis,
378
Parker, A., on interdisciplinarity,
356
Parker, B., on self-assurance, 53
Parker, M.E., on knowing
aesthetic patterns, 142
Parrish, E., on treating adults
with depression, 264
Parse, R.R.
on caring theories, 171, 172t,
173t, 175
on roles nurses play, 177t
on scholarliness, 17
on theory definition, 30
theory of, bibliography on,
588–590
Parsell, S., on Roy, 334
Parsons, T.
on domain definition, 95
on homeostasis of social
systems, 395
on Johnson’s theory, 285
on theory origin, 191
on theory scope, 193
Patel, M., on theory testing, 201
Paterson, J.G.
bibliography on, 276–277
on comfort, 257
on domain concepts, 254t
on empathy, 257
on environment, 104
on experience as knowledge
source, 251
on gender-sensitive theories, 147
on health, 106
on health orientation of
discipline, 94
on humanistic theory, 256, 257
on interaction, 102, 168, 229
on interaction theory, 162t,
165t–168t, 176t
on nurse–patient interactions,
174
on nursology, 255
on phenomenology, 255
on role nurses play, 176t
on tautological theory, 256
on theory context, 191, 194
theory of, 174, 251–258
assumptions of, 234, 251,
252b
bibliography on, 590–594
development of, 251, 253, 254
on theory origin, 191
Patterson, L.M., on Roy, 334
Patterson, R., on Rogers, 318
654 AUTHOR INDEX
LWBK821-Au-index_637-662 07/01/11 8:01 PM Page 654
Patusky, K.L.
on human relatedness, 409
on theory development, 77
Paul, R.W., on knowing patterns,
141
Paul-Simon, A., on Orem, 220
Payne, G.
on comparative sociology, 463
on health, abstract, 463
Payne, L., on concept of health,
abstract, 463
Pearson, A.
on knowing patterns, 142
on Orem, 216, 223
Peck, S., on concept
development, 380
Peden, A., on treating adults with
depression, 264
Penn, P.E.
collaborative theory of, 410
on simultaneous concept
analysis, 378, 379
Peplau, H.
conceptualization of nursing,
163
on developmental theories, 161
on interaction theory, 165,
165t–168t
on psychiatric nursing, 162, 165
on role nurses play, 176t
Peplau, H.E.
on grand theories, 408t, 419
on interpersonal theory, 70, 118
on nursing theory, 69, 71,
394t
as Orlando influence, 246
on theory definition, 30
theory of
bibliography on, 594–595
interpersonal relations, 70
Perrett, S.E., on Roy, 333
Perron, A., on colonial
patronage, 44
Perry, J., on postcolonialism, 79
Peterson, C.J., on theory and
conceptual frameworks,
abstract, 464
Peterson, S.J., on middle-range
theory, 410–411
Peterson, J.Z., on King, 238
Petrlik, J.C., on self-care in
diabetic neuropathy,
abstract, 487
Pharris, M.D.
on caring discipline, 93
on practice-oriented discipline,
91
Phillips, J.R.
on borrowed theory, 132
on nursing models, abstract,
464
on Rogers, 321, 323
Phillips, K.D., on Orem, 218
Piaget, H., cognitive abilities,
118
Piazza, D., on Neuman, 308
Piccoli, M., on Levine, 300
Pichler, V.H., on Orem, 213, 221
Pickens, J.M., on Orem, 221
Pickett, M., on Levine, 300
Pienschke, D., nurse–patient
interactions, 250
Pierce, J.D., on pragmatism
theory, 152
Pilkington, F.B., on nursing as
human science, 89
Piper, B., on cachexia, 393
Piper, B.F., on concept analysis,
189
Pitre, N.Y., reciprocal
interdependence, 427
Plos, K.A.E., on concept
clarification, 376
Plummer, M.
on Rogers, 314, 320
theory of goal attainment, 232
Poat, M.C., on Levine, 341
Polanyi, M.
on knowing patterns, 141
on Rogers, 316
Polit, D.F., nurses as women, 47
Pollock, S.E., on Roy, 337
Pond, J.B., on Levine, 298
Ponte, P.R., on clinical scholars,
15
Popkess-Vawter, S., On Roy, 337
Poppa, L.D., on Levine, 341
Popper, K., on demarcation
criteria, 151
Porter D., on Orem, abstract, 487
Porter, L., on premature infants,
289
Porter, L.S.
on infant growth, 491
abstract, 491
on Rogers, abstract, 491
Porter, S.
on empirical theory, 140
on knowing patterns, 427
Poss, J.E., health belief model,
421
Poster, E.C.
on Johnson, 289
on psychiatric nursing, 287
Pothiban, L., on Neuman, 307
Potter, M.
on Neuman, 311
on Orlando, 249
Poush-Tedrow, M., on Roy, 333
Powers, B.A., on praxis, 28
Preview, on national conference,
75
Price, M.
on theory development
enhancement strategies, 55
environment for, 124
Price, M.J., on theory in nursing
education, 366
Primomo, J., on environment, 105
Prince, R., on nursing diagnosis,
120
Profetto-McGrath, J.
on nurses’ experiences, 118
on “warrantable evidence”
criteria, 152
Pryjmachuk, S., on Rogers, 322
Przylebski, A., on epistemology,
26
Ptak, H.F.
on nursing curricula, 76
on nursing theory, 51
Pugh, L.C.
on changes in attitudes toward
theory, 31
on collaborative theory, 410
on situation-specific theory, 368
on theory development, 402
Pullen, L., on Travelbee, 265
Purkis, M.E., on health, 106
Putnam, P., on nursing concepts,
abstract, 465
Putt, A., as Neuman influence,
306, 345
Q
Quinn, J.F.
on Rogers, 321
on theoretical thinking, 24
Quinn, R.M.
Neuman Systems Management
Tool, 310
on Neuman, 308
Quint, J.C., on theory and
empiricism, abstract, 465
R
Raborn, M., on Neuman, 309
Rafferty, A.M., on theory in
nursing education, 366
Rail, G., on nursing practice, 78
Rainio, A.K., on nursing
diagnosis, 121
Ramini, S.K., on Roy, 334
Ramos, M.C., on Orem, 228
AUTHOR INDEX 655
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Randall, B., on Roy, 333
Randell, B.P., on Johnson, 287,
289
Rapaport, A., on Johnson, 285
Rappaport, J., on Travelbee, 265
Räsänen, P., on research
programs, 414
Rauhala, A., on nursing
diagnosis, 121
Ravelin, T., dance in mental
health nursing, 379
Ravetz, J., on social significance,
199
Rawls, A.C., on Johnson,
abstract, 477
Rawls, A.G., on Johnson, 287
Rawnsley, M.M.
on nursing as human science,
89
on ontology, 27
Reed, K.S., on Neuman, 307, 309
Reed, P., self-management, 414
Reed, P.G.
on concept development, 380
on nursing client, 98
on nursing concepts, 197, 385
on ontology, 27
on self-neglect, 393, 398
Reeder, F., on domain concepts,
76
Reemtsma, J., on knowledge and
practice, 14
Register, M.E., on concepts
clarification, 122
Rehwaldt, M., on self-help
strategies, 220
Reichenback, H., on logical
empiricism, 139
Reid, B., on Orem, 218
Reimer, A.P., integrative
literature review, 414
Reimer–Kirkham, S., on
women’s history, 8
Reiz, J.A., on theory in
administration, 366
Renpenning, K.E., on Orem,
211b, 213, 213b
Renpenning, K.M., on Orem, 218
Reverby, S.M., on productivity,
46
Rew, L., on knowing patterns, 141
Reynolds, A., on Roy, 338
Reynolds, C., on health-oriented
discipline, 93
Reynolds, P.D.
on Baconian approach, 398,
399
on propositions, 386
on theory development, 123
Reynolds, W.
on criteria-based language, 24
on Johnson, 287
Rhinehart, E., on nursing as
human science, abstract, 89
Rhoten, D., on interdisciplinarity,
356
Rhymes, J., on nurse–patient
interactions, 250
Ricard, N., on Roy, 336
Rice, V.H., on truth in theory
development, 399
Ricka, R., on Orem, 221
Rickleman, B.L., on
Wiedenbach, 270
Riegel, B.
middle-range theory, 421
situation-specific theory, 224
Riehl, J.P.
on conceptual models, 126
on Levine, 298
on Orem, 213
on theory origin, 191
Riehl-Sisca, J.P., on Orem, 213
Ring, M.E., on Rogers, 314
Risk, J., on Orem, 222
Roberts, C.S., on Orem, 223
Roberts, F.B., on conceptual
models, 127
Roberts, J., critical thinking, 45
Roberts, M.P., on Roy, abstract,
497
Roberts, S.L.
on domain concepts, 330t, 331t
on internal dimensions, 332
on theory evaluation, 186
Robinson, D.J., on Wilson’s
method, 378
Robinson, P.R., on conceptual
framework, 417
Rodgers, B.L., on concept
development, 371, 372
Rodman, H., on concepts versus
theory, 126, 127
Rodney, P., on nursing clients,
357
Rodwell, C.M., on concept
development, 380
Roe, A., on theory development,
123
Roe, L., on scholarliness, 17
Rogers, M.E.
analysis of, 314, 315, 316
on assumptions, 312b
bibliography on, 345–348
on creativity, 13
deductive theory, 193, 316
on domain concepts, 313t
on environment, 63, 104
on euphemisms in nursing,
abstract, 492
on field patterns, 315
focus of nursing, 170t
on general systems theory,
315
goals of nursing, 170t
on health, 106
on health orientation of
discipline, 93
on holism, 316
on hyperactivity, 318
on integrative theory, 102, 153,
154
as Levine influence, 297, 300
literature abstracts on, 489–494
on macrotheory, 192
on nursing problems, 171t
on nursing therapeutics, 104,
171t
origin of, 315
outcomes, 169
on roles nurses play, 126t, 176t
on theoretical basis of nursing,
169, 174
abstract, 465, 491
theory of, 174, 279, 311–323
abstractness of, 193, 194
analysis of, 192
bibliography on, 595–603
on euphemisms in nursing, 492
on scholarliness, 13
on unitary man, 311, 314, 317t
abstract, 493
view of nursing, 170t
Rooda, L.A., on King, 240
Rooke, L., on King, 238–240
Roper, N., on theory usefulness,
196
Ropka, M.E., on Levine, 299
Rose, H., on feminist theories,
147
Rosendahl, P.B., on King, 240
Ross, M.M., on Neuman, 308,
309
Ross, V., on King, 240
Rossi, L.
on King, 237
on Rogers, 318
Rothbart, D.
on phenomenology, 71
on problem solving, 12
on theory analysis, 191
on theory development
changes, abstract, 466
Rothlis, J., on Orem, 222
656 AUTHOR INDEX
LWBK821-Au-index_637-662 07/01/11 8:01 PM Page 656
Rousseau, G.K., on research
program, 413
Roy, C.
abstracts on, 494–501
on adaptation, 324, 331
abstract, 498–499
assumptions of, 324b
bibliography on, 348–351
on Brown and Bacon article,
abstract, 499
concepts, 328b
on conceptual framework,
abstract, 498–499
on conceptual models, 125,
126, 327, 329b
on domain concepts, 330t–331t
focus of nursing, 170t
goals of nursing, 170t
on health, 106
on humanistic values, 325
on interaction, 101
on Johnson influence, 169
literature abstracts on, 501
on nursing concepts, 174
on nursing therapeutics, 171
on Orem, 123
on philosophical base of
nursing, 65
on propositions, 333b
on response to stimuli, 106
on role nurses play, 176t
on theory and education,
abstract, 499
on theoretical propositions, 186
on theoretical thinking, 191
on theory development, 75,
186, 332
theory of, 324–338
bibliography on, 603–610
view of nursing, 170t
on Wolfer article, abstract,
499
Rubin, R., on clinical nursing
theory, abstract, 466
Rudy, E.
on theory–research gaps, 75
on theory development,
abstract, 450
Runggaldier, E., on Carnap
philosophy, 138
Russell, B., correspondence
theory, 151
Rustoen, T., on Travelbee, 265
Rutakumwa, W., on nurses’
experiences, 117
Ryan, P., on middle-range
theories, 414
Ryan, W., “blaming the victim”, 47
Ryle, S., on King, 238
Ryu, H., on concept analysis, 378
S
Sachse, D., on concept
clarification, 376
Sahlsten, M.J.M., on concept
clarification, 376
Said, E.W., on postcolonialism,
150
Sakraida, T.J., on situation-
specific theory, 422
Salas, A.S., on dialogues, 79,
357
Salazar, M.K., on environment,
105
Salerno, M., on Orem, 223
Samarel, N.
on Rogers, 322
on Roy, 337
Sambrook, S., on
poststructuralism, 149
Sampselle, C.M.
on feminist perspective, 146
on gender-sensitive theories,
146, 147
Sanchez, C.A., on theoretical
thinking, 354
Sandelowski, M., on women in
nursing, 45
Sanders, N.F., on Neuman, 309
Sanderson, C., on evidence-based
practice, 78
Sandman, P.O., on Orem, 220
Sanford, R.C., on caring, 93
Santana, M.G., on Paterson-
Zderad theory, 257
Sarlore, J.P., on Travelbee, 263
Sarter, B., on philosophical base
of nursing, 64
Sarvimaki, A.
on knowing patterns, 141
on nursing perspective, 88
theory–research–theory
strategy, 404
Sauter, M., on Orlando, 247
Savala, S.M., on Neuman, 309
Sawin, K.J., on self-management
theory, 414
Sawyer, L.M., on conceptual
framework, 416, 417
Sayers, K.L., on hybrid strategy,
379
Schatzman, L.
on concept analysis, 379
theory development and, 397
Scheffler, I., on labeling, 384
Schensul, S.L., on theory
development, 391
Schlotfeldt, R.M.
on pluralism in theory, 12
on stages of integration, 65
on theory and practice, 14
Schmieding, N.J., on Orlando, 71
Schmitt, M.H., on concept
clarification, 376
Schmitz, M., on Roy, 335
abstract, 500
Schneider, P.E., on Rogers, 322
Schnepp, W., on self-care, 220
Schodt, C.M., on Rogers, 321
Schoenhofer, S.O., on knowing
patterns, 142
Schorr, J.A., on Newman’s
situational control
proposition, 202
Schrag, C., on theory usefulness,
197, 198
Schreiber, R., on King, 239
Schultz, A.S.H., on integrative
theory, 155
Schultz, M., on Neuman, 308
Schultz, P.
on client definition, 97
on Orem, 218
Schultz, P.R., on practice
knowledge, 361
Schumacher, K., on transition,
100, 406, 415
Schumacher, K.L., on literature
reviews, 415
Schutz, A., on interpretive view,
145
Schwartz, G.E.
on nursing therapeutics, 106
on scholarliness, 11
Schwartz, M.A., interpretive
view, 145
Schwartz, M.D., on nursing
therapeutics, 106
Schwartz-Barcott, D.
on concept development, 372
on hybrid strategy, 379
Scott, C., on scholarliness, 18
Sears, R.R., on psychology, 285
Seers, K., on Paterson-Zderad
theory, 257
Sellers, S.C., on Orlando, 243
Sellman, D., on marginalized or
privileged populations, 357
Selye, H., as Levine influence,
297, 298
Semeniuk, P., on
postcolonialism, 79
AUTHOR INDEX 657
LWBK821-Au-index_637-662 07/01/11 8:01 PM Page 657
Seomun, G.A., on concept
analysis, 378
Serqueira, H.C., on Paterson-
Zderad theory, 257
Severinsson, E.I., on Travelbee,
265
Sewall, K.S., on Orem, 218
Shamansky, S.L., on nursing
diagnosis, 120
Shanley, D.A., on Roy, 333
Shamian, J., on Orem, abstract,
487
Shannahan, M., on Roy, 337
Shapere, D., on Kuhn, 430
Shapiro, E.D., on scholarship of
application, 8
Sharp, E.S., on Wiedenbach, 270
Shattell, M., on integration, 434,
435
Shaul, M.P., on transitions
framework, 416
Shaver, J., on biomedical model,
355
Shea, N., on Orlando, 250
Sheafor, M., on Orlando, 249, 250
Shearer, N.B.C., on nurse–patient
participation model, 319
Shelton, K., on nursing
diagnosis, 120
Shelton, T.A.
nursing diagnosis, 120
on research-based knowledge,
78
Sherwin, S., on gender-sensitive
theories, 146
Shields, D.
on Neuman, 303
on Orem, 212
on Orlando, 270
Shih, F.J., transitions framework,
416
Shin, H., on concept analysis, 378
Shuldham, C., on Orem, 221
Shulman, L., on scholarship of
teaching, 8
Shuster, G.F., on Orem, 222
Shyu, Y., on Roy, 327
Sieloff, C., on King, 231
Sieloff, C.L., on King, 241
Sills, G.M., on Columbia
University impacts, 70
Silva, F.J., concept development,
371
Silva, M., nursing definition, 107
Silva, M.C.
on concept development, 371
on epistemology, 136
on introspection, 410
on intuition, 52
on knowledge consequences, 65
on Orem, 223
on phenomenology, 71
on philosophy and research,
abstract, 466
on philosophy and theory, 64
on problem solving, 13
on Roy, 336
on single theory, 75
on theory analysis, 191
on theory development
changes, abstract, 466
on theory testing, 200
Sime, A.M.
on caring, 93
on nursing definition, 107
Simmons, L., on Orem, 218
Simmons, S., on Roy, 334
Sinclair, M., integration, 365
Sinnott, M., on Neuman, 308
Sipple, J.A., on Neuman, 309
Sjöstrom, B., on patients’
involvement, 376
Skalski, C.A., on Neuman, 303
Skipper, J.K., on Wiedenbach, 271
Sloan, M., on Orem, 213
Sloane, A., on Travelbee, 264
Slusher, I.L., on Orem, 218
Slutsky, J., on research enterprise
barrier, 50
Small, B., on Johnson, 287
abstract, 478
Smith, B., ontology, 27
Smith, D., on conceptual
imperialism, 48
Smith, D.W., on Rogers, 322
Smith, F., on nurses’ experience,
117
Smith, J.A.
grounded theory approach of,
399
on health, 106
on health orientation of
discipline, 93
Smith, M.C.
on caring, 93, 172
on interactions, 101, 103
on King, 237
on Neuman, 307
on nursing client, 98
on Orem, 210, 211
abstract, 488
on Rogers, 312, 321, 322
Smith, M.J.
middle-range theory, 410
on Rogers, 202
on theory development, 202
Söderhamn, O., on Orem, 221
Söderhamn, U., on Orem, 221
Sohier, R.
on feminist perspective, 147
on Neuman, 308
Solberg, S., on caring, 93
Solberg, S.M.
on concept clarification, 375
on concept exploration, 373
Sollid, D., on mothering, 392
Sonnert, G.
on women as nurses, 45
on women’s role, 53
Sorokin, P., on theory
development, 409
Sorrell, D.S., on knowledge
consequences, 65
Sorrell, J.M.
on knowing patterns, 142
on knowledge consequences, 65
on theory testing, 200
Sousa, V.D., on Orem, 221
Souza, L.N.A., on Paterson-
Zderad theory, 257
Sowell, R.L., on King, 236, 238
SozWiss, G.B., on Orem, 207
Spangler, W.D., on theory
comparisons, 76
Spangler, Z.S., on theory
comparisons, 76
Spear, H., on nursing research
and theory, 122
Spear, H.J., on knowledge
barriers, 49
Spearman, S.A., on Orem, 223
Spencer, W., on Rogers, 322
Spreeuwenberg, C., on Orem, 219
Spring, A., on Roy, 338
Sproles, J.B., on Neuman, 308
St. Ours, C., on Levine, 300
Stacy, J., on gender-sensitive
theories, 146
Stainton, M.C., on nursing
science, abstract, 467
Stamler, C., on Johnson, 289
Stanwick, M., on Rogers, 322
Staten, R.T., on Travelbee, 264
Starr, S.L., on Roy, abstract, 500
Stein, L.I.
on barriers to professional
status, 47
on feminism in nursing, 52
Steinkeler, S.E., on Neuman,
310
Stepans, M.B., on Neuman, 305
Stern, P.
grounded theory approach of,
399
658 AUTHOR INDEX
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on Middle Eastern immigrant
population, 78
on Paterson-Zderad theory, 257
on situation-specific theory, 368
Stern, P.N.
grounded theory approach of,
399
on theory testing, 257
Stetler, C., on Travelbee, 265
Stevens, B., on environment, 104
Stevens, B.J.S., on Paterson-
Zderad theory, 255
Stevens, K., on organizational
infrastructure, 78
Stevens, K.R., on theory
analysis, 234
Stevens, P.
on concept development, 77
on postmodernism, 149
Stevens, P.E.
on concept clarification, 375
on concept marginalization, 357
on scholarliness, 19
on theory development, 393
Stevenson, J.S.
on knowing patterns, 138
on nursing phenomenon, 64
Steward, K.J., on Levine, 300
Stewart, B., on nursing diagnosis,
120
Storm, D.S., on Orem, 220
Story, E.L., on Neuman, 309
Stotts, N., on cachexia, 393
Stotts, N.A., on concept analysis,
189
Strandmark, M., on Travelbee, 265
Strauss, A., on grounded theory,
399
Strauss, A.L.
on data analysis, 485
on dying, 193
on grounded theory, 97, 379
on nursing as human science, 89
on theory development, 397
Street, A.F.
on critical questioning of rules,
43
on critical thinking, 45
Strober, M.H.
interdisciplinarity, 356
on scholarship of integration, 8
Strohmyer, L.L., on Roy, 334
Stromborg, M.F., on
professionalism, 52
Stryer, D., on research enterprise
barrier, 50
Stuifbergen, A.K., on situation-
specific theories, 422
Sullivan, H., on interaction, 102
Sullivan, J., on Neuman, 308
Sullivan, P., on Rogers, 322
Sullivan, T.J., on Orem, abstract,
488
Suppe, F.
on logical empiricism, 139
on “received view”, 138, 139
on situation-specific theory, 368
on symptom management, 106
on theory development, 410
on “Weltanschauung”, 154
Swan, J., on chronically ill
children, 289
Sweeny, M.A., on nursing
diagnosis, 120
Swendsen, L.
on nursing therapeutics, 106
on research program, 414
on role supplementation, 194
Swimme, B., on domain concept,
331t
Swoboda, W., on nursing
discipline, 87
Szabao, J., on nursing discipline,
88
T
Tak, S., on Roy, 337
Takase, M., concept
development, 380
Tandy, L., on nursing discipline,
88
Taney, S.G., on Levine, 298
Tanner, C.
on intuition, 15
on knowers, 16
on perceived view, 141
Tanyi, R.A., on Roy, 336
Tariman, J., on self-care
practices, 220
Tarule, J.M., on knowers, 8, 16
Tate, B., on scholarliness, 13
Taylor, J.W.
on Levine, 291
on self-care, 208, 216
Taylor, M.C., on Johnson, 289
Taylor, S.G., on Orem, 207
Teel, C.S., on Orlando, 248
Teeri, S., on Levine, 300
Temple, A., on King, 236
Ternestedt, B.M., on concept
development, 393
Tettero, I., on Rogers, 319
Theaker, C., on Orem, 221
Thibodeau, J.A., on process
theory, 103
Thomas, S.P., on King, 241
Thompson, C., on nursing
advancement, 48
Thompson, C.E.
on decision making, 121
on epistemology, 136
on science in nursing, abstract,
441
Thompson, C.R., on Johnson,
289
Thompson, J.L., on scholarliness,
19
Thompson, L.F., on concept
clarification, 121
Thorne, B., on gender-sensitive
theories, 146
Tichy, A.M., on Roy, 336
Tiedeman, M.E., on Roy, 327
Tierney, A., on theory usefulness,
196
Tilden, V., on nursing
phenomena, 12
Tillery, M., on Levine, 300
Tillich, P., as Levine influence,
297
Timmins, F.
on Orem, 216
treating adults with depression,
264
Timpson, J., on knowing
patterns, 142
Tinker, S., on Orlando, 249
Tinkle, M.B., on nursing science
and research, abstract, 467
Tinley, S.T., on concept analysis,
379
Titler, M.G., on clinical skills
deemphasis, 90
Todaro-Franceschi, V.
on Levine, 300
on Rogers, 318, 322, 323
Tokem, Y., on Orem, 220
Tompkins, E.S., on Levine, 299
Toniolli, A.C., on Orlando, 249
Tornberg, M.J., on life-
threatening disease, 392
Tornquist, E.M., on recovery, 77
Torres, G.
on curricula, 97
on nursing process, 103
Toth, J.C., on Orem, 222
Toulmin, S.
on domain definition, 95
on nursing discipline, 87
Tracey, C., on career advancement
for women, 46
Trangenstein, P.A.
on nursing definition, 107
on transition, 100, 415
AUTHOR INDEX 659
LWBK821-Au-index_637-662 07/01/11 8:01 PM Page 659
Tranvag, O., on nurse’s role, 264
Travelbee, J.
assumptions of, 259, 260b
bibliography on, 277–278
on concepts, 260b
on domain concepts, 261t
on gender-sensitive theories,
147
on health, 106
on health orientation of
discipline, 94
on interaction theory, 165t–168t,
174
on nursing process, 103
propositions of, 262b
on rapport, abstract, 501
on relationship development,
259
on role nurses play, 176t
on spirituality, 13
on suffering, 13
theory of, 258–265
abstracts, 501
bibliography on, 610–613
Trepanier, M., on Neuman,
276–277, 308
Tripp-Reimer, T.
on health, 106
on health orientation of
discipline, 93
on taxonomy development, 393
Truax, C., on Travelbee, 265
Tryon, P.A., on Orlando, 250
Tsai, P., on Roy, 337
Tsai, P.F., on Roy, 337
Tsai, Y.-F., on Orem, 220
Tsay, S.L., on situation-specific
theory, 423
Tschanz, C.L., on nursing
discipline, 88
Tuck, I., on Travelbee, 265
Tucker, R.W., on value decisions,
abstract, 468
Tulman, L.
on post-delivery function, 334
on Roy, 334, 336, 337
Turley, J.P., on Wilson, 378
Turner, B.S., on preliminary
research, 413
Turner, R., as Roy influence,
327, 331
Turner-Henson, A.
on chronically ill children, 288
on Johnson, 286, 289
Tutton, E.
interpersonal relationships, 264
on Paterson-Zderad theory, 257
on patient participation
concept, 376
U
Ugarriza, D.N., on Rogers, 322
Underwood, P.R., on Orem, 218
Underwood, P.W., on Orem, 218
Urry, J., on integration theory, 434
Uys, L.R., on King, 232, 240
V
Vaillancourt, V.H., on King, 239
Valian, V.
on women as nurses, 53
on women’s role, 45
Välimäki, M., on Levine, 300
Van Aernam, B., on theory
development, 399
van der Bruggen, H., on Orem,
219
Van Landingham, U.J., on Roy,
333
van Servellen, G., on behavioral
health, 287
VandeVusse, L., on Wiedenbach,
267
Vanrenterghem, Y., on Orem, 221
Varcoe, C., on research enterprise
as barrier, 50
Vardiman, E.M., on Orem, 221
Velsor-Friedrich, B., on King,
239
Viera, C.S., on King, 237
Villareal, E., on Roy, 334
Vinya-nguag, P.
on King, 240
on Orem, 222
Visintainer, M.
on nursing perspective, 355
on Orlando, 250
on Wiedenbach, 271
Visintainer, M.A., on nurse–
patient interactions, 250
Vojir, C.P., on Rogers, 322
von Krogh, G., on Travelbee, 264
W
Wadensten, B.
on Roy, 335
on Travelbee, 264, 265
Wagner, A.L., on Orem, 223
Wagner, L., on Orem, 223
Wagner, P.
on Roy, 335
abstract, 501
Wahl, A.K., on Travelbee, 265
Wahlund, L.O., on conceptual
framework, 416
Walborn, K.A., on Orem, 218
Wald, F.S.
on practice theory, 128
abstract, 468
Walker, D.M., on Orem, 218
Walker, K.M.
on borrowed theory, 132
on King, 240
on theory development, 393
Walker, L., on situation-specific
theory, 422
Walker, L.O.
on concept analysis, 189
on concept development, 371
on nursing process, 103
Walker, P., on evidence-based
practice, 26
Wall, L.M., on Rogers, 323
Wallace, C.L., on Roy, 335
Wallace, D., on Travelbee, 265
Wallace, D.C., on King, 241
Wallace, W.A., on Orem, 216
Wallen, A.J., on Neuman, 309
Walsh, M.B.,on nursing process,
103
Wandel, J.C., on Travelbee, 265
Wang, C.Y., on Orem, 219
Wang, H.H., Orem, 219
Wang, M., on theory testing, 220
Watkins, G.R., on Orem, 222
Watson, C.A., on King, 239
Watson, J.
on caring, 171, 172, 172t, 173t,
175
on empirical theory, 140
on evidence-based practice, 26
on Rogers, 312, 312b
on roles nurses play, 177t
on scientific method, 139
on theory definition, 30
theory of
bibliography on, 613–615
Waweru, S.M., on Roy, 334
Weatherston, L., on nursing
theory, abstract, 469
Weaver, K.
on concept development, 371,
380
on integrative theory, 153
on nurse’s role, 264
Weaver, M.T., on Orem, 221
Weber, N., on Orem, 222
Webster, G., on scientific
method, 139
Weed, L.L., on King, 237
Weedon, C., on sex roles, 52
Weinberg, D.D., on practice-
oriented discipline, 90
660 AUTHOR INDEX
LWBK821-Au-index_637-662 07/01/11 8:01 PM Page 660
Weinert, C., on Roy 338
Weiss, M., on Roy, 334
Weiss, S.
on nursing concepts, 129
on nursing phenomena, 12
Weiss, S.J., on nursing concepts,
129
Weitzel-O’Neill., on sex-role
stereotyping, 52
Wells, E., on Hatshepsut, 7
Wells, S.R., on Orem, 210, 211
abstract, 482
Wendler, M.C., on Roy, 334
Wengström, Y., on self-care, 220
Wenneberg, S., on simultaneous
concept analysis, 379
Werner, J.S.
on Orem, 218
on Roy, 336
Westcott, M.R., on intuition, 410
Westerbotn, M., on Orem, 218
Wewers, M.E., on theory testing,
201
Whall, A.
on conceptual models, 74t, 126
on nursing perspective, 88
on postmodernism, 65
on theory analysis
on theory evaluation, 183, 184t
on theory synthesizer, 76
Whall, A.F., on postmodernism, 65
Whall, A.L.
on concepts of theory, 126
on theory evaluation, 183
Whelton, B.J.
on Rogers, 318, 490
abstract, 493
Whelton, B.J.B., on King, 235
Whetsell, M.V., on Roy, 338
White, A., on epistemology, 26
White, C., nursing definition, 107
White, J., on knowing patterns,
138, 139
Whitehead, L., on Orem, 211
Whitley, G.G., on nursing
diagnosis, 120
Whittemore, R., on Roy, 338
Whittemore, T., on Roy, 324b, 329
Whittman-Price, R.A., on critical
theory thinking, 148
Wichowski, H., on Neuman, 307
Wickham, R., self-care practices,
220
Widdershoven, G., on Orem, 219
Wiedenbach, E.
assumptions of, 266, 266b
bibliography on, 278
on concepts, 267b
on domain concepts, 189, 268t
on interaction theory, 154,
165t–168t, 174
on Johnson, 284
on nursing diagnosis, 120
on nursing process, 103
on practice oriented research,
abstract, 451–453
on practice theory, abstract,
451–453
on propositions, 269b, 386
on roles nurses play, 176t
on theory analysis, 267
on theory development, 71
on theory evaluation, 189
theory of, 258–265
bibliography on, 615–616
testing of, 270
Wiese, R.A., on recovery, 77
Wiggins, O.P., on understanding,
145, 146
Wiklund, L.,on nurse’s role, 264
Wilkes, L.M., on nurse’s role,
264
Wilkie, D., on Johnson, 288
Wilkie, D.J., on Johnson, 288
Wilkie, G., on Johnson, 288
Wilkinson, A., on Orem, 211
Williams, B., on Orem, 222
Williams, D.L., on Orlando,
270
Williams S., on Orem, 223
Williamson, K.M., on Orlando,
248
Williamson, Y., Orlando, 251
Willis, D.G., on nursing
discipline, 88
Wilson, F.L., on Orem, 222
Wilson, H.S.
on Paterson-Zderad theory, 257
on scholarliness, 17
on theory in nursing education,
257
Wilson, J.
on concept analysis, 189
on concept development, 372
on theory development, 189,
372
Wilson, L.C., on Neuman, 311
Wilson, S., on Rogers, 319
Winbald, L.O., on conceptual
framework, 416
Winstead-Fry, P.
on health, 313t
on Rogers, 312b, 315, 319
on scientific method, 139
on theory analysis, 141
on women’s role, 45
Winters, D.M., on Neuman,
308
Wiseman, T., on concept
development, 380
Woeste, R., on Levine, 296
Wolfer, J., on Orlando, 271
Wolfer, J.A.
on Orlando, 250
on Wiedenbach, 271
Wolff, I.S., on Travelbee, 264
Wong, TKS, on self-care, 220
Wongvatunyu, S., on Orem,
211b, 216, 223
Woodgate, R.L., on situation-
specific theory, 423
Woods, E.C., on King, 238, 239
Woods, N.F.
on knowing patterns, 138
on nursing phenomenon, 64
on Orem, 220
on role strain in woman, 201
on theory development, 77
Woolridge, P.J., on Wiedenbach,
271
Wren, G.R., on women in
nursing, 45
Wright, B.W., on Rogers, 323
Wrubel, J.
on caring, 141
on experience as knowledge
source, 52
on knowing patterns, 141
Wu, C., on Johnson, 287
Wu, L.H, Li, P., on
phenomenological
nursology, 256
Wu, R., on extension of Johnson
theory, 287
Wuest, J.
in feminist perspective, 148
on concept development, 372
Wynn, J., on Neuman, 308
X
Xu, Y., on Neuman, 30, 87
Y
Yanni, C.R., on nursing
diagnosis, 120, 360
Yarcheski, A., on Rogers, 321
Yarcheski, T.J., on Rogers, 323
Yeaworth, R., on knowledge
barriers, 48
Yeh, C., on Roy, 327, 338
Yonge, O., on concept
exploration, 373
Yoon, M., on Roy, 334
Young, R.J., on stress, 301
AUTHOR INDEX 661
LWBK821-Au-index_637-662 07/01/11 8:01 PM Page 661
Young-McCaughan, S., on Roy,
335, 337
Younger, J.B., on knowing
patterns, 142
Yura, H.
on curricula, 97
on nursing process, 103
Yurkovich, E.E., on Levine, 300
Yurkovich, N.J., on interaction,
102
Z
Zauszniewski, J.A.
on Neuman, 311
on Orem, 221
Zderad, L.T.
bibliography on, 276–277
on concepts, 253b
on concept clarification, 121
on domain concepts, 254t
on environment, 104
on experience as knowledge
source, 251
on gender-sensitive theories,
147
on health, 106
on health orientation of
discipline, 94
on interaction theory, 102,
165t–168t
on nurse–patient interactions,
174
on nursing concepts, 386
on nursology, 252
on observation, 381
on phenomenology, 253
on phenomenon description,
381
on propositions, 252b
on role nurses play, 176t
on theory context, 191
theory development, 257
theory of, 251–258
assumptions of, 252b
bibliography on, 590–594
Zetterberg, H.L.
on existence propositions, 232,
284, 386
on prepositions, 188
Ziemer, M.M., on Neuman,
310
Zoffmann, V., on Orlando, 248
Zoretich, S.T., on Levine,
296
662 AUTHOR INDEX
LWBK821-Au-index_637-662 07/01/11 8:01 PM Page 662
SUBJECT INDEX 663
A
Abdellah, F.G., theory of
bibliography on, 548–550
nursing process, 103
nursing theory of, 70, 198
Abstract concepts, 393, 454
Abstractness, in theory analysis,
194
Academics, tangible goal for,
71–74
Achievement subsy tem, in
Johnson theory, 281b
Action research. See Action theory
Action, course of, determination
of, 92
Action theory, 28
Aadaptation, stress and
bibliography on, 622–624
Aadaptation theory. See Roy, C.,
theory of
Adaptive modes, 395
Administration
nursing, 239, 366
stage of education, 60
stage of theory, 62
theory use in
King, 239
Orem, 217
theory and, bibliography on,
538–542
Advanced Directive Decision
Making Model (ADDM),
238
Advances in Nursing Science,
15, 75, 76, 80, 440
Advancing knowledge, 371
Advocates versus synthesizers, 76
Aesthetics pattern, of knowing,
447
Affiliative subsystem, in Johnson
theory, 281b
Aggressive subsystem, in
Johnson theory, 281b
al-Aslamiya, Rufaida Bent Saad,
60
Al-Islamiah, Rofaida
mother of nursing, in Middle
East, 45
American Journal of Nursing, 76
American Nurses Association
(ANA), 10, 71, 107, 462
Analogizing, 386
example of, 386
Analysis, 376
of concept, 376–379
of theory. See Theory analysis
Antecedents
delineating, 385
Application, scholarship, 8
Art of nursing. See Nursing art
Association of Operating Room
Nurses (AORN), 481
Assumptions
definition of, 25
on Johnson theory, 280, 282b
of King’s theory, 229–230,
230b
of Levine theory, 290, 293b
of Neuman theory, 300, 301b
of Orlando theory, 241, 243b
of Paterson, 251, 252b
of Rogers theory, 311, 312b
of Roy theory, 324, 324b
of Travelbee theory, 258, 260b
of Wiedenbach, 265, 266b
on Zderad theory, 251, 252b
Attention giving, 382
Attention grabbing, 381, 382
Automatic nursing care, 242
Autonomy, 51
B
Bacon, 62
Barriers, to theory development
conceptual barriers, 49–50
knowledge barriers, 48–49
nurses
as nurses, 41–44
as theorists, 47–48
as women, 44–47
research enterprise, as barrier,
50
Basic science, 118–119
Behavior, 280
Behavioral systems. See Johnson,
D., theory of
Benner, P. theory of,
bibliography on, 550
Biomedical communication style,
102
Biomedical model, 116–117
Biophysiologic transition, 100
Biopsychosocial communication
style, 102
“Blaming the victim”, 47
Borrowed theory, 131, 132, 458
versus nursing theory,
128–132
Boston Based Adaptation
Research in Nursing
Society (BBARNS), 337
Boyer
scholarship of practice,
definition of, 10
Boyer, Ernest, 7
Brahe, Tycho, 12
Bush describers, 17
C
Caring discipline, nursing as,
91–93
Caring, for clients, 93
Caring/human becoming
theories, 171, 172, 172t,
173t, 174t, 177t
Carnegie Foundation, 7, 18
Cartesian concept, 62
Case Western Reserve
University, 71
Category-formulating theory. See
Factor-isolating theory
Center for Health Outcomes and
Policy, 12
Center for Integrative Science in
Aging, 12
S U B J E C T I N D E X
663
Note: Page numbers followed by b, f and t indicate boxes, figures and tables respectively
LWBK821-Sub-index_663-674 07/01/11 6:20 PM Page 663
Center for Research in Health
Equities, 12
Centers of research, development
of, 15
Channel of communication, 141
Choices, in Johnson theory, 280
Chronology of nursing theories,
161f
Circle of contagiousness, in theory
critique, 195t, 196, 270
Clarification, concept, 374–376
Client/client system, 301–302
Clinical nurse specialists (CNS),
471
Clinical Nurse Specialists
Conference, 54–55
Clinical scholars, 15
definition of, 18
Clinical theories, 362, 396t
Clinicians and scholars in
nursing, perspective of,
88–89
Cochrane Collaboration, 26
Cochrane Database of Systematic
Review, 78
Cognitive style, of woman, 53
Coherence theory, 152
Collaboration
essence of, 12
in nursing practice, 46
tool, 410
Collaborative efforts, in nursing,
19
Colonial patronage, 44
Columbia University Teachers
College Approach. See
Nursing theory, birth of
Communality, in theory
development, 410
Communication, 51
styles, 102
in Travelbee theory, 259
Community development
approach, 13
Community health nurses, 94
Comparative sociology, 463
“Compassion trap”, 53
Complexity, theory critique, 263
Concatenation, in scholarliness, 14
Concepts, 457
analysis, 376
simultaneous, 378–379
Wilson’s method of, 376–378
clarification, 374–376
example of, 376
processes of, 375
significant aspect of, 375
definition of, 25–26
development, 372, 384–386
examples of, 373
integrated approach to,
380–381
metatheory to, 77
strategies for, 372
exploration, 372–374
of Johnson theory, 283b
on King’s theory, 229–232,
231b
of Levine theory, 294b
of Neuman theory, 301b
on Orlando theory, 243–244,
244b
on Paterson theory, 253b
of Rogers theory, 312b
of Roy theory, 328–329b
on Travelbee theory, 260b
on Wiedenbach theory, 267b
on Zderad theory, 253b
Conceptual analogue, 126
Conceptual barriers, 48, 49–50
Conceptual blocks, 49
Conceptual environment, 291
Conceptual frameworks, 445,
447. See also Theoretical
frameworks
Conceptual models, 454. See
also Theoretical
frameworks
versus theory, 125–128
Conceptual phase, 442
Conceptual resources, for theory
development, 54
Conceptual theories, 362
Conceptualizers, 17
Conference, video/audio tapes
634–635
Connecting, with patients, 92
Constructed knowers, 16
Continuity, in scholarliness, 14
Contrary model, 385
Convergent process, 428
Correspondence theory, 150–152
Creativity
in caring, 92
in nursing, 13
in women, 52
Crimean War, 45, 51, 59, 60
Critical knowing, 148–149
Critical nursing theory, 148
Critical theory, 148
and hermeneutics
bibliography on, 625–626
Critical thinking
definition of, 19
in scholarliness, 3, 354
Cultural blocks, 49
Curricula
theory in
King, 239
Cyclical integration of theory,
research, and practice, 23
D
Darwinian theory, 431–432
Decision making
classifications of, 120–121
Deductive theory, 193, 216
Delineating consequences, 385
Delineating antecedents, 385
Dependence subsystem, in
Johnson theory, 281b
Derdiarian behavioral system
model (DBSM), 289, 473
Derived concept, 187, 232
Descartes, 53, 62
Descriptive theories, 34, 100
structural components of, 35
Deterministic propositions, 188
Developing theory
versus tested theory, 127
Developmental self-care
requisites, 209, 210b
Developmental theory
bibliography on, 619–622
Diagramming, in theory critique,
195, 195b
Differentiating process, 385
Disciplinary matrix, 27
Disciplinary/interdisciplinary
knowledge, 355–356
Disciplined process, in nursing,
242
Disciplines, 136
definition of, 87–88
definition of nursing, 106–108
domain, of nursing knowledge,
94
definition, 95–96
nursing domain, 96–106
epistemology of, 136
knowing from
postmodernism view,
136–138
of nursing, 8, 87, 95, 431, 453
of nursing perspective, 88
caring discipline, 91–93
health-oriented discipline,
93–94
human science, 89–90
practice-oriented discipline,
90–91
Diverse theories versus unified
theories, 450
Diversity, 79
664 SUBJECT INDEX
LWBK821-Sub-index_663-674 07/01/11 6:20 PM Page 664
Division of Nursing Resources,
61
Domain. See also Nursing
domain
definition, 26, 95–96
of Johnson theory, 283t
on King theory, 233–234t
of Levine theory, 295–296t
meaning of, 94
of Neuman theory, 304t
of nursing, 94, 96–106
on Orlando theory, 245t
on Paterson theory, 254t
of Rogers theory, 313t
of Roy theory, 330–331t
on Travelbee theory, 261t
on Wiedenbach theory, 268t
on Zderad theory, 254t
Domain concepts, emergence of.
See Nursing theories’
revival
Domain paradoxes
identifying, 124–125
Dualism, 64
Dutch philosopher, 113
Dynamics of theory, 130
E
Education
as nursing progress stage,
theory development and,
59–66
scholarly productivity
programs, 55
sex-role identities, 52
theory, and bibliography on,
532–538
Einstein, 13
Eliminative subsystem, in
Johnson theory, 281b
Ellis, Rosemary, 88
Empirical phase, 442
Empirical theories, 139, 362
Empirical understanding, 145
Energy fields, Roger’s theory of,
33
Entropy, 304
Environment, 15. See also
Rogers, M.E., theory of
of nursing domain, 104–105
Environmental blocks, 49
Epistemic diversity, 138
Epistemology, definition of, 26
Evidence-based practice, 23, 50,
78
definition of, 26
Ex post facto design, 495
Exemplar paradigms, 456
Exemplars, research-theory
method, 400–403
Existence propositions, 386
Existentialism, 255
Experiential knowing, 141
Expert knowledge, 16
Explanatory theory, 100
Explicating assumptions, 387
Exploration, concept of, 372–374
Extant nursing practice, 115–116
F
Factor-isolating theories, 34, 129,
451, 452
Family Relations (FR) test, 476
Feminist knowing, 146–148
Feminist movement, 52, 53
Feminist perspectives
bibliography on, 626–631
Feminist praxis, 28
FITNE, video and audio tapes
from, 633–634
Formal models, 126
Formalized ontology, 27
Fourth-level theory, 128, 129
Functional orientation of nursing,
42
Fundamental nursing sciences,
209
G
Gebbie, Kristine, 103
Gender influence, in nursing, 47
Gender-sensitive theories, 146,
147
General ontology, 27
Global/local theories, 356–357
Goal attainment theory, 229–241
Goal orientation, theories by,
34–35
descriptive theories, 34
prescriptive theories, 34–35
Goal-oriented nursing record
(GONR), 237, 238, 239
Grand theories, 33
Grasping meaning, 92
Grounded theory approach, 397,
399
Group identity, 326
H
Hadley, B. J., theory of
bibliography on, 550
Hall, B., theory of
bibliography on, 550
Harmer, Bershan, 70
Harms M., theory of
bibliography on, 551
Hatshepsut, 7
Health, models of, 106
Health, of nursing domain, 106
Health-deviation self-care
requisites, 209, 210b
Health/illness transition, 100
Health-oriented discipline,
nursing as, 93–94
Health Research Act (1985), 14
Health Sciences Consortium,
videotapes/audiotapes
from, 634–635
Hearsay knowledge, 113
Henderson, V., theory of
bibliography on, 551
nurse roles and images in,
176t
nursing focus in, 163t
nursing goals in, 164t
nursing problems in, 164t
nursing process, 103
nursing, role of, 107
nursing therapeutics, 164t
nursing view in, 163t
Hermeneutics, and critical theory
bibliography on, 625–626
Holism
bibliography on, 618–619
Holistic nursing challenge, 292
Howland, D., theory of,
bibliography on, 551
Human relatedness, theory of,
409
Human resources, in theory
development, 50–53
Human science
nursing as, 89–90
theoretical thinking in, 24
Human-made disasters, 105
Hybrid strategy, for concept
analysis, 379–380
Hypatia, 7, 8
I
Ideal nursing practice, 119
Ideas
sources for, 114
Images of nursing, 162
Immersion, as barrier to theory
development, 50
Indicators, of scholarliness,
14–15
Inductive reasoning, 23
Ingestive subsystem, in Johnson
theory, 281b
Integrality, 314
Integrated theorizers, 17
Integration of knowledge, 18
SUBJECT INDEX 665
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Integration, stage of, 65–66
Integration/isolation of
theoretical discourses,
365–367
Integrative process
for developing middle-range
and situation-specific
theories, 407–409, 408t
Integrative theory, 153–155
Integrity, 292
Intensive care unit (ICU), 94
Interaction theorists, 163–169,
165t, 166t, 167t, 168t, 176t
Interaction, symbolic,
bibliography on, 617–618
Interactions, of nursing domain,
101–103
Interdisciplinarity, 356
stage of, 66
technology and information
systems, stage of, 66–67
International Council of Nursing
(ICN), 70, 107
Interpersonal knowing, 141
Interpretative phase, 442
Interpretive model, 126
Interpretive view, 142
Introduction to Clinical Nursing,
479
Intuition, 52–53
Intuition tool, 410
Intuitive knowing, 141
Intuitive knowledge, 113
Iowa Intervention Project, 121
J
“Jet lag”, concept of, 26
Johnson Behavior System Model
(JBSM), 471, 475, 476
Johnson, D. E., theory of,
280–290
analysis, 285
assumptions, 282b
bibliography on, 340–341,
551–554
concepts, 283b
critique of, 286–288
description, 280–284
domain concepts, 283t
external components,
287–288
internal dimensions, 285–286
paradigmatic origins, 285–286
potential propositions, 284
subsystems of behavior,
281b
testing, 288–290
theorist background and, 285
Johnson model (JM), 477, 478
Journal of Advanced Nursing, 76
Journal of Nursing
Administration, 76
Journey, positioning for, 2–6
K
Kant, Immanuel, 40
Karolinska Institute, in
Stockholm, 87
Kepler, Johannes, 12
King, I.M., theory of, 55, 229–241
analysis, 234
assumptions, 229–230, 230b
bibliography on, 272–275,
554–559
in clinical practice, 237
conceptual framework for
nursing, 229–232, 231b
critique of, 236–240
description of, 229–234
domain concepts, 233–234t
external components, 239–240
internal dimensions, 235–236
paradigmatic origins of,
234–235
propositions of, 232, 236b
symbolic interactionism in,
235
testing of, 240–241
theorist background and, 234
King International Nursing
Group (KING), 241
King’s theory, of goal
attainment, 33
Knowers, types of, 16
Knowing
aesthetics pattern, 447
empirical pattern, 447
ethics, 447
personal knowledge, 447
Knowledge
barriers to, in theory
development, 48–49
base, for nursing theory, 32
development
component of, 179
goal of, 90
purposes of, 90–91
pursuit of, 113
Spinoza on, 113–114
as force and resource, 53–54
forms of, 113
pluralistic, in theory
development, 402
Knowledge of control, 459
Knowledge of disorder, 459
Knowledge of order, 458
Koaiba Bent Saad. See al-
Aslamiya, Rufaida Bent
Saad
Kuhn’s theory, 12, 428
to define progress, 429–431
L
Labeled phenomenon, 26
Labeling, 384
Labeling theory. See Factor-
isolating theory
Laws of understanding, 145
Leap theorizers, 17
Leininger, M., theory of
bibliography on, 559–560
Level of abstraction, theories by,
33–34
grand theories, 33
middle-range theories, 33–34
situation-specific theories, 34
Levine, M.E., theory of,
290–300
analysis, 296–297
assumptions, 293b
bibliography on, 341–343,
560–562
concepts, 294b
critique of, 297–299
description, 290–296
domain concepts, 295–296t
external components, 299
internal dimensions, 297
paradigmatic origins, 297
propositions, 294b
testing, 299–300
theorist background and, 296
Local models of excellence, 19
Loeb Center for Nursing and
Rehabilitation, 70
Logical empiricism
tenets of, 138–139
M
Macro-concepts, 442
Macy Foundation, 355
Mahidol University, in Bangkok,
87
Marginalization, 375
Marginalized/privileged
populations, 357
Maslow’s theory, 479
Maternal role attainment (MRA),
417
McDonald, F., theory of
bibliography on, 551
Medical model, 114
Meleis, A. I., theory of
bibliography on, 562–563
666 SUBJECT INDEX
LWBK821-Sub-index_663-674 07/01/11 6:20 PM Page 666
Mentor, 180b
Mentorship, 55
Metaparadigm, 456
Metaphors, 23
Metatheory
to concept development, 77
theory development in nursing
and, bibliography on,
508–517
Methods, philosophy and,
bibliography on, 503–506
Micro-concepts, 442
Microtheories, 419
Middle-range theories, 33–34,
77, 410–411
bibliography on, 631–632
definition of, 411
integrative process for
developing, 407–409, 408t
process for developing,
411–419, 412b
clinical observations, 412–413
clinical observations post
research findings, 414
critical reviews through
dialogues, 415–416
defining concepts, 413
integrative findings, 418–419
integrative literature review,
414–415
preliminary research, 413
research program, 413–414
researching again, 416–418
situation-specific theories,
367–368
tools for developing, 409–410
Multidimensional scaling
(MDS), 160
approach, 191
N
Nakajima, Hiroshi, 357
National goal, for nursing,
70–71
National Institute of
Complementary and
Alternative Health
Practices, 13
National Institute of Nursing
Research (NINR)
development, in
scholarliness, 14
National Institutes of Health
(NIH), 7
National League for Nursing
(NLN), 49, 63, 75
videotapes/audiotapes from,
632–633
National Research Service
awards, 61
Natural disasters, 105
Needs theorists, 162–163, 163t,
164t, 176t
Needs theory, 125, 132
Neuman, B., theory of, 300–311
in administration, 307
analysis, 305–306
assumptions, 301b
bibliography on, 343–345,
563–570
client system in, 307
concepts, 301b
critique of, 307–310
in curriculum development, 308
description, 300–305
domain concepts, 304t
environmental considerations
in, 306
external components, 310
internal dimensions, 306
paradigmatic origins, 306
propositions, 310b
reconstitution process, 305
research from, 307
testing, 310–311
theorist background and, 305
Neuman Systems Management
Tool, 310
Newman, M., theory of
bibliography on, 570–571
Nightingale, F., theory of, 40, 51,
59, 60, 104, 106
bibliography on, 571–573
to nursing research, 67–68
Non–criteria-based critiques, 24
Norms, of scholarliness, 11–13
Nurse–patient interactions, 102
Nurse practitioners–patient
interaction, 102
Nurses
empowerment of, 79–80
experience, 117–118
as nurses, 41–44, 50–52
roles and images of, 118,
176–177t
as scholars, 15
scholarship of integration, 17
sources for ideas, 114–115
as theorists, 47–48
as women, 44–47, 52–53
Nursing
care knowledge, 117
clarified and classified
concepts, 121–122
definition of, 10–11, 106–108,
163t, 165t, 170t
diagnosis
classifications, 120–121
definition, 120
discipline of, 431
focus of, 163t, 166t, 170t
functional orientation of, 42
goals of, 163t, 166t, 170t
images, metaphors, and roles,
175
images of, 162
caring/becoming theorists,
171–174
interaction theorists, 163–169
needs theorists, 162–163
outcomes theorists, 169–171
implications for, 430
interventions, classifications,
120–121
national goal for, 70–71
patterns of knowing in, 137–138
practice
combined sources of ideas,
122
component of, 179
extant, 115–116
ideal, 119
problems, 164t, 167t, 171t
process, 119
research, 122
scholarliness in, 9
indicators of, 14–15
norms of, 11–13
tools of, 13–14
sciences, fundamental, 209
systems theory, 208
theoretical development of, 371
theoreticians in, 141
theory, 122
areas of agreement, 175–177
chronology of, 161f
definition of, 128
primary focus, 174–175
schools of thought in, 162t
versus borrowed theory,
128–132
theory development
being theoretical, 122–124
resources, 122
sources for, 114–115
theoretically supportive
environment, 124
therapeutics, 120, 164t, 167t,
171t, 215
Nursing art, 92
Nursing client, 32, 98–100
Nursing coordinators (NC), 471
Nursing Development Conference
Group (NDCG), 212
SUBJECT INDEX 667
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Nursing diagnosis, 360
Nursing discipline. See
Discipline, of nursing
Nursing disciplined process, 242
Nursing domain, 96–106
central components of, 96
concepts central to, 97b
environment, 104–105
health, 106
nursing client, 98–100
nursing process, 103–104
nursing therapeutics, 105–106
relationships and interactions,
101–103
theoretical boundaries of, 96–97
transitions, 100–101
Nursing education, 42, 51
Nursing history, reality in, 40
Nursing informatics/medical
informatics, 358–359
Nursing Inquiry, 80
Nursing perspective
caring discipline, 91–93
definition of, 88
health-oriented discipline, 93–94
human science, 89–90
practice-oriented discipline,
90–91
Nursing process, 103–104, 247
Nursing profession, reward
structure of, 43
Nursing progress, stages in, 59
education and administration,
stage of, 60–61
integration, stage of, 65–66
philosophy, stage of, 64–65
practice, stage of, 60
research, stage of, 61–62
theory, stage of, 62–64
Nursing Research, 61, 67, 70, 71,
441
Nursing scholarliness versus
scholarliness in
disciplines, 8
Nursing Scholarship, 80
Nursing Science, 71
Nursing students, self-identity of,
46
Nursing theory. See also specific
theory, 10
birth of, 68–70
bibliography on, 506–508
definition of, 29–33
influence on nursing diagnosis,
359–361
revival, 76–77
Nursing, theory development in,
67t, 72t–74t
Nursing Theory Think Tank, 75
Nursing therapeutics, 105–106
Nutting, M.A., 69
O
Ontology, definition of, 26–27
Operational environment, 291
Orem, D., theory of, 55, 207–224
analysis, 212–217
assumptions, 211b
abstracts on, 482–489
bibliography on, 573–285
concepts, 212b
critique of, 217–220
description, 207–211
domain concepts, 214t
external components, 219–220
internal dimensions, 216–217
nursing process, 103
paradigmatic origins, 213–216
propositions, 215b
self-care requisites, 210b
testing, 220–224
theorist background and,
212–213
Organizational theory,
bibliography on, 619
Organizing propositions, 386–387
Orlando, I.J., theory of, 241–251
analysis, 244–247
assumptions, 243b
problems with, 243
bibliography on, 275–276,
585–588
concepts, 243–244, 244b
critique, 247–249
description, 241–244
domain concepts, 245t
external components of, 249
internal dimensions, 246–247
nursing process, 103
paradigmatic origins, 246
propositions, 247b
testing, 249–251
theorist background, 244–246
Out-of-discipline theorizers, 17
Outcomes theorists, 169, 170t,
171, 171t, 172t, 176t
P
Paradigm, 456
definition of, 27, 428
of Johnson theory, 285–286
of King’s theory, 234–235
of Levine theory, 297
of Neuman theory, 306
of Orem theory, 213–216
of Orlando theory, 246
of Paterson theory, 253–255
of Rogers theory, 315–316
of Roy theory, 331–332
of Travelbee theory, 262–263
of Wiedenbach theory, 269
of Zderad theory, 253–255
Paradigmatic origins of theory,
191–192, 216
Parse, R., theory of
bibliography on, 588–590
Parsimony, definition of, 27
Paterson, J.G., theory of, 251–258
analysis, 252–255
assumptions, 252b
bibliography on, 276–277,
590–594
concepts, 253b
critique of, 255–257
description, 251–252
domain concepts, 254t
external components, 256–257
internal dimensions, 255
paradigmatic origins, 253–255
propositions, 252b
testing, 257–258
theorist background and,
252–253
Patiency, 130
Patient Self-Determination Act
(PSDA), 238
Pattern Urge–Response Toileting
(PURT), 288–289
Peplau, H., theory of, 70
on basic science, 118
bibliography on, 594–595
Perceived view, 140–142, 140t
Perception of experience versus
sensation of experience, 40
Perceptual blocks, 49
Perceptual environment, 291
Person–environment interactions,
102
Personal knowing, 141
components in, 141
Personal knowledge, 16
Perspective See also Nursing
perspective.
characteristics, 89
on knowing, 142–144t
meaning of, 88
Phenomena
definition of, 27
delineation of, 384
describing, 382–384
sensing and taking in, 381–382
Phenomenological nursology, 255
Phenomenology, 253–254
Philosophy
668 SUBJECT INDEX
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definition of, 28
methods and, bibliography on,
503–506
stage of, 64–65
Physical model, 125
Physiological nursing theory
bibliography on, 624–625
Piaget’s theory, 118
Pioneering theories, 159, 160
analysis, 190–194, 190t
circle of contagiousness, 196
clarity, 195
comprehensive analysis, 191
concept analysis, 189–190, 190t
concepts of domain, 189
consistency, 195
critique of theory, 194–196,
195t, 197t, 199t
description, 185–186
diagram of theory, 196
evaluating
criteria for, 184t
framework for, 185
model, 204f
external components, 199, 199t
functional components, 186t, 188
internal dimensions, 192–194
relationship between structure
and function, 195–196
selection, criteria for, 180b
simplicity/complexity, 195–196
structural components,
186–188, 186t
support, 202–203
tautology/teleology, 196
testing, 200–202
usefulness
in administration, 198
in education, 198
in practice, 196–197
in research, 197–198
Planned staring, 453
Pluralism, 64
Postcolonialism views, 149–150
Postmodernism, 149–150
Poststructuralism, 149–150
Practical knowledge, 141
Practice
knowledge, 443
sources of, 116
theory, 419. See also Theory
development
abstracts on, 443–445
theory and, bibliography on,
522–528
stage of, 60
Practice-oriented discipline,
nursing as, 90–91
Practice-relevant theory, 462
Practitioner’s orientation, 44
Pragmatism theory, 152–153
Praxis, definition of, 28
Predictive theory, 129
Prescriptive theories, 34–35, 100,
129
structural components of, 35
Prevailing paradigm. See
Metaparadigm
“Principle of economy of
thought”, 27
Procedural knowers, 16
Professional identity, of nurse, 242
Professional nursing, definition
of, 107
Propositions, 457
existence, 386
of Johnson theory, 284
of King’s theory, 232, 236, 236t
of Levine theory, 294b
of Neuman theory, 310b
organizing, 386–387
of Orlando theory, 247b
on Paterson theory, 252b
process of developing, 386
of Roy theory, 333b
on Travelbee theory, 262b
on Wiedenbach theory, 269b
on Zderad theory, 252b
Psychoanalytic theory
bibliography on, 616–617
Psychosocial transition, 100
R
R01 program, 7
Rapport, 259, 264
Received knowers, 16
Received view, 138–140, 140t
Reconstitution, 305
Relational cultural theory, 79
Relational propositions, 187
Relationships, of nursing
domain, 101–103
Research and theory, 35
bibliography on, 520–522
knowing through, 362–365
Research Approach in Nursing
(RAIN), 310
Research enterprise, as barrier, 50
Research, stage of, 61–62
Research-based discipline, 50
Resonancy, 314
Resources, to theory development
conceptual resources, 54
knowledge, as force and
resource, 53–54
nurses
as nurses, 50–52
as women, 52–53
theory use and development,
forces for, 54–55
Reversible proposition, 188
Revolution
definition of, 428
Revolutionary theory of progress,
431
Rheumatoid arthritis (RA), 418
Rogerian First National
Conference, 76
Rogers, M.E., theory of, 55,
311–323
analysis, 314–316
assumptions, 312b
bibliography on, 345–348,
595–603
concepts, 312b
critique of, 316–320
description, 311–314
domain concepts, 313t
of energy fields, 33
external components, 319–320
internal dimensions, 316
paradigmatic origins, 315–316
testing, 320–323
theorist background and,
314–315
unitary human being,
characteristics of, 317t
Role clarification, 55
Role modeling, 55
Role rehearsal, 55
Role supplementation, 412
Roy, C., theory of, 55, 324–338
analysis, 327–332
assumptions, 324b
bibliography on, 348–351,
603–613
concepts, 328–329b
critique of, 332–336
description, 324–327
domain concepts, 330–331t
external components, 336
internal dimensions, 332
paradigmatic origins, 331–332
propositions, 333b
testing, 336–338
theorist background and,
327–331
Roy Adaptation Model (RAM),
324, 495, 496
S
Scholarliness, 7
characteristics of, 10t
meaning of, 13–14
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Scholarliness (Continued)
nurses as, 15
scholarship of integration, 17
in nursing, 9
indicators of, 14–15
norms of, 11–13
tools of, 13–14
revisiting scholarship, in 21st
century, 17–19
scholarship, categories of, 7
Scholarly discipline, 8–9
Scholars, definition of, 17
Scholarship
of application, 8
definition of, 18
categories of, 7
of discovery, 7
of integration, 7–8, 17
meaning of, 9
revisiting
in 21st century, 17–19
of teaching, 8, 18
Scholarship Reconsidered:
Priorities of the
Professoriate, 7
Science
definition of, 28
and theory, bibliography on,
519–520
Science of unitary human beings
(SUHB), 311
Scientia intuitiva, 113
Scientific discipline
development of, 430
Scientific theory, 457
Self-care, 486, 487, 488
Self-care agent, 209
Self-care deficit theory of
nursing (SCOTN), 207–
209, 213b
Self-care model, 488–489
Self-care movement, 13
Self-care requisites, 210b
types of, 209
Self-care theory, 208, 209
Self-concept mode, 326
Self-esteem, 326
Selye’s theory, 496
Semantic model, 126
Sensation of experience versus
perception of experience, 40
Sensing and taking in
phenomenon, 381–382
Sex-role identities, 52
of nurses, 44
Sex-role stereotyping, 46
Sexual subsystem, in Johnson
theory, 281b
Sharing, 387
Silent knowers, 16
Simultaneous concept analysis,
378–379
Single-domain theories, 419
Situation-producing theory, 128,
130, 451
Situation-relating theories, 451
Situation-specific theories, 34,
78, 419
bibliography on, 632
definition of, 419–420
integrative process for
developing, 407–409, 408t
model of, 423f
process for developing,
420–424, 424b
grounding in nursing domain
and perspectives, 420–421
review of literature, 422
selection of theory, 421
specifying populations
within a context, 421–422
sources and properties of,
419–420
tools for developing, 409–410
Situational transition, 100
Skepticism, 24
Skill in nursing activities, 92
Social policy statement, 10
Sociological framework, 114
Sociopolitical congruency, 180b
Southern Regional Educational
Board (SREB), 61
Special ontology, 27
Spinoza, on knowledge
development, 113–114
Stack, Harry, 70
Statement development, 386–387
Stochastic propositions, 188
Stress and adaptation
bibliography on, 622–624
Subjective knowers, 16
Suffering, 258
Sullivan’s theory title, 70
Symbolic interaction
bibliography on, 617–618
Symbolic interactionism and goal
attainment theory
Symbols, 23
Symphonic harmony, analogy of,
13
Synthesizers, 17
Synthesizers versus advocates,
76
Synthesizing process, 386
Systems theory, bibliography on,
621–622
T
Tabula rasa, 114
Tangible goal, for academics,
71–74
Tautology, definition of, 28
Taxonomies/interpretations, 359
nursing theory’s influence on
nursing diagnosis,
359–361
Technical nursing/expert nursing
practice, 357–358
Technology and information
systems, stage of, 66–67
Teleology, definition of, 28
“Tellington touch”, 334
Theoretical developments, of
nursing client, 99–100
Theoretical frameworks,
definition of, 28–29
Theoretical future, challenges
and opportunities for, 354
clinical theories, 362
conceptual theories, 362
disciplinary/interdisciplinary
knowledge, 355–356
empirical theories, 362
global/local theories, 356–357
integration or isolation of
theoretical discourses,
365–367
knowing through research and
knowing through theory,
362–365
marginalized/privileged
populations, 357
middle-range/situation-specific
theories, 367–368
nursing informatics/medical
informatics, 358–359
taxonomies/interpretations,
359
nursing theory’s influence on
nursing diagnosis, 359–361
technical nursing/expert
nursing practice, 357–358
Theoretical heritage, 2, 3
Theoretical knowledge, 51, 141
development of, 41
Theoretical nursing, 59
first attempts in, 59
interdisciplinarity, stage of, 66
technology and information
systems, stage of, 66–67
nursing progress, stages in, 59
education and
administration, stage of,
60–61
integration, stage of, 65–66
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philosophy, stage of, 64–65
practice, stage of, 60
research, stage of, 61–62
theory, stage of, 62–64
theory development,
milestones in, 67
concept development,
metatheory to, 77
evidence means research, 78
evidence and technology, as
resources, 79–80
Florence Nightingale, to
nursing research, 67–68
linking theory and practice, 79
middle-range theory, 77
national goal, for nursing,
70–71
nursing theories’ revival,
76–77
nursing theory, birth of, 68–70
situation-specific theory, 78
tangible goal, for academics,
71–74
theory syntax, 74–75
time to reflect, 75
Theoretical thinker, 354–355
Theoretical thinking, 3, 40, 354,
366
barriers, to theory development
conceptual barriers, 49–50
knowledge barriers, 48–49
nurses as nurses, 41–44
research enterprise, as
barrier, 50
theorists, nurses as, 47–48
women, nurses as, 44–47
resources, to theory
development
conceptual resources, 54
knowledge, as force and
resource, 53–54
nurses as nurses, 50–52
theory use and development,
forces for, 54–55
women, nurses as, 52–53
and theory, 23–25
Theorists, nurses as, 47–48
Theorization, 24
Theory, 29. See also Nursing
theory
administration and,
bibliography on, 538–542
assumptions, 25
components, 35
concept, 25–26
critical, and hermeneutics,
bibliography on, 625–626
definitions, 25
developmental, bibliography
on, 619–621
domain, 26
education and, bibliography
on, 532–538
epistemology, 26
evidence-based practice, 26
middle-range, bibliography on,
631–632
nursing and, 29–33
nursing taxonomies, diagnosis
and intervention,
bibliography on, 528–532
ontology, 26–27
organizational, bibliography
on, 619
paradigm, 27
parsimony, 27
phenomenon, 27
philosophy, 28
physiological nursing,
bibliography on, 624–625
practice and, 35–36
bibliography on, 522–528
praxis, 28
psychoanalytic, bibliography
on, 616–617
research and, 35
bibliography on, 520–522
role, bibliography on, 623–624
science, 28
science and, bibliography on,
519–520
systems, bibliography on,
621–622
tautology, 28
teleology, 28
theoretical frameworks, 28–29
and theoretical thinking, 23–25
types of
goal orientation, theories by,
34–35
level of abstraction, theories
by, 33–34
Theory analysis
critique and scientific,
bibliography on, 542–548
of Johnson theory, 285
of King theory, 234
of Levine theory, 296–297
of Neuman theory, 305–306
of Orlando theory, 244–247
of Paterson theory, 252–255
of Rogers theory, 314–316
of Roy theory, 327–332
of Travelbee theory, 262–263
of Wiedenbach theory, 267–270
of Zderad theory, 252–255
Theory and research, relationship
between, 11
Theory, and theoretical thinking, 7
Theory critique
analysis and scientific,
bibliography on, 542–548
of Johnson theory, 286–288
of King theory, 236–240
of Levine theory, 297–299
of Neuman theory, 307–310
of Orlando theory, 247–249
of Paterson theory, 255–257
of Rogers theory, 316–320
of Roy theory, 332–336
of Travelbee theory, 263–265
of Wiedenbach theory, 270
of Zderad theory, 255–257
Theory development, 7, 24, 42,
391–393
activities of, 392
characteristics of, 62t
conceptual barriers, 49–50
domain paradoxes, identifying,
124
conceptual models versus
theory, 125–128
nursing theory versus
borrowed theory, 128–132
forces and constraints in
nursing profession,
bibliography on, 518–519
women as scientists,
bibliography on, 517–518
human barriers
nurses as nurses, 41–44
nurses as theorists, 47–48
nurses as women, 44–47
knowledge barriers, 48–49
metatheory and, bibliography
on, 508–517
milestones in
1955–1960, 68–70
1961–1965, 70–71
1966–1970, 71–74, 72t, 73t,
74t
1971–1975, 74–75
1976–1980, 75
1981–1985, 76–77
1986–1990, 77
1991–1995, 77–78
1996–2000, 78
2001–2005, 79
2006–2010, 79–80
before 1955, 67, 68f
model of, 448
in nursing, 67t, 72t–74t
practice to theory strategy,
396–398
SUBJECT INDEX 671
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Theory development (Continued)
process of, 448
qualities necessary for, 43
research enterprise, as barrier, 50
research to theory strategy,
398–403
Dluhy’s proposal, 402–403
exemplar by a researcher,
400–401
resources for, 122–124
sources for, 114
basic science, 118–119
biomedical model, 116–117
extant nursing practice,
115– 116
ideal nursing practice, 119
nurses’ experience, 117–118
nursing process, 119
roles, 118
theory to practice to theory
strategy, 394–396, 394t,
396t
theory to research to theory
strategy, 403–404, 403t
Theory in a practice discipline,
451
Theory of evolution, 429t,
431–433
Theory of integration, 429t,
433–436
Theory of revolution, 428–429,
429t
Theory, stage of, 62–64
Theory syntax, 74–75
Theory synthesizers, 76
Theory testing
of Johnson theory, 288–290
of King theory, 240–241
of Levine theory, 299–300
of Neuman theory, 310–311
of Orlando theory, 244–247
of Paterson theory, 257–258
of Rogers theory, 320–323
of Roy theory, 336–338
of Travelbee theory, 265
of Wiedenbach theory,
270–271
of Zderad theory, 257–258
Theory use and development,
forces for, 54–55
Theory utilization, 24
Third-level theory, 129
To practice morally, 92
Tools, of scholarliness, 13–14
Transdisciplinarity, 356
Transitions, 100–101
Travelbee, J., theory of, 258–265
analysis, 262–263
abstracts, 501
assumptions, 260b
bibliography on, 277–278,
610–613
concepts, 260b
critique of, 263–265
description, 258–259
domain concepts, 261t
external components, 264–265
internal dimensions, 263
nursing process, 103
paradigmatic origins, 262–263
propositions, 262b
testing, 265
theorist background and, 262
Trophicognosis, 290, 291, 479
Truth
theories of, 151t
U
Understanding
laws of, 145
Unified theories versus diverse
theories, 450
Unique theory, 458
Universal self-care requisites,
209, 210b
University of Alexandria, in
Alexandria, 87
University of Pennsylvania, 12
University of Washington, 12
U.S. Public Health Services, 61
Utilization
selecting theories for, 180–183
V
Video and audio tapes on theory
conference, 634–635
FITNE, 633–634
Health Sciences Consortium,
634
National League for Nursing,
632–633
W
Watson, J., theory of
bibliography on, 613–615
Wellness–illness continuum, 307
Weltanschauung, 154
Western Council for Higher
Education in Nursing
(WCHEN), 61
Wiedenbach, E., theory of,
265–271
analysis, 267–270
assumptions, 266b
bibliography on, 278, 615–616
concepts, 267b
critique of, 270
description, 265–267
domain concepts, 268t
external components, 270
internal dimensions,
269–270
nursing process, 103
paradigmatic origins, 269
propositions, 269b
testing, 270–271
theorist background and, 267
Wilson’s method of concept
analysis, 376–378
Women
nurses as, 44–47
as scientists, theory
development, bibliography
on, 517–518
self-concept of, 46
society’s expectations of, 52
Women’s health movement, 53
Women’s Health Research
Center, 12
“Would-be disciplines”, 87
Y
Yale School of Nursing, 71
Yale school of thought, 51
Yeaworth, 48
Z
Zderad, L.T., theory of, 251–258
analysis, 252–255
assumptions, 252b
bibliography on, 276–277,
590–594
concepts, 253b
critique of, 255–257
description, 251–252
domain concepts, 254t
external components,
256–257
internal dimensions, 255
paradigmatic origins,
253–255
propositions, 252b
testing, 257–258
theorist background and,
252–253
672 SUBJECT INDEX
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Cover
Title Page
Copyright
Dedication
REVIEWERS
PREFACE
ACKNOWLEDGMENTS
CONTENTS
PART ONE: Our Theoretical Journey
CHAPTER 1: Positioning for the Journey
OUR THEORETICAL HERITAGE
ASSUMPTION, GOALS, AND ORGANIZATIONS
ORGANIZATION OF THE BOOK
ON A PERSONAL NOTE
REFLECTIVE QUESTIONS
CHAPTER 2: On Being and Becoming a Scholar
SCHOLARLINESS IN NURSING
NURSES AS SCHOLARS
REVISITING SCHOLARSHIP IN THE 21ST CENTURY
CONCLUSION
REFLECTIVE QUESTIONS
Acknowledgments
References
CHAPTER 3: Theory: Metaphors, Symbols, Definitions
THE DESTINATION: THEORY AND THEORETICAL THINKING
DEFINITIONS
TYPES OF THEORIES
THEORY COMPONENTS
USES OF THEORY
REFLECTIVE QUESTIONS
References
PART TWO: Our Theoretical Heritage
CHAPTER 4: From Can't to Kant: Barriers and Forces Toward Theoretical Thinking
BARRIERS TO THEORY DEVELOPMENT
RESOURCES TO THEORY DEVELOPMENT
CONCLUSION
REFLECTIVE QUESTIONS
References
CHAPTER 5: On the Way to Theoretical Nursing: Stages and Milestones
STAGES IN NURSING PROGRESS
MILESTONES IN THEORY DEVELOPMENT
CONCLUSION
REFLECTIVE QUESTIONS
Acknowledgments
References
PART THREE: Our Discipline and Its Structure
CHAPTER 6: The Discipline of Nursing: Perspective and Domain
NURSING PERSPECTIVE
DOMAIN OF NURSING KNOWLEDGE
DEFINITION OF NURSING
CONCLUSION
REFLECTIVE QUESTIONS
References
CHAPTER 7: Sources, Resources, and Paradoxes for Theory
SPINOZA ON KNOWLEDGE DEVELOPMENT
SOURCES FOR THEORY DEVELOPMENT
CLASSIFICATIONS OF NURSING DIAGNOSIS, NURSING INTERVENTIONS, AND DECISION MAKING
RESOURCES FOR THEORY DEVELOPMENT
IDENTIFYING DOMAIN PARADOXES
CONCLUSION
REFLECTIVE QUESTIONS
References
CHAPTER 8: Our Syntax: An Epistemological Analysis
KNOWING FROM THE RECEIVED VIEW TO POSTMODERNISM VIEW
TRUTH: FROM CORRESPONDENCE TO INTEGRATIVE VIEW OF TRUTH
CONCLUSION
REFLECTIVE QUESTIONS
References
PART FOUR: Reviewing and Evaluating: Pioneering Theories
CHAPTER 9: Nursing Theories Through Mirrors, Microscopes, or Telescopes
IMAGES OF NURSING, 1950–1970
THEORIES' PRIMARY FOCUS
IMAGES, METAPHORS, AND ROLES
AREAS OF AGREEMENT AMONG AND BETWEEN THEORISTS AND SCHOOLS OF THOUGHT
CONCLUSION
REFLECTIVE QUESTIONS
References
CHAPTER 10: A Model for Evaluation of Theories: Description, Analysis, Critique, Testing, and Support
SELECTING THEORIES FOR UTILIZATION
FRAMEWORK FOR EVALUATING THEORIES
CONCLUSION
REFLECTIVE QUESTIONS
References
CHAPTER 11: On Needs and Self-Care
DOROTHEA OREM
CONCLUSION
REFLECTIVE QUESTIONS
References
CHAPTER 12: On Interactions
IMOGENE KING—A THEORY OF GOAL ATTAINMENT
IDA ORLANDO
JOSEPHINE PATERSON AND LORETTA ZDERAD
JOYCE TRAVELBEE
ERNESTINE WIEDENBACH
CONCLUSION
REFLECTIVE QUESTIONS
References
CHAPTER 13: On Outcomes
DOROTHY JOHNSON
MYRA LEVINE
BETTY NEUMAN
MARTHA ROGERS
SISTER CALLISTA ROY
CONCLUSION
REFLECTIVE QUESTIONS
References
PART FIVE: Our Theoretical Future
CHAPTER 14: Challenges and Opportunities for a Theoretical Future
OPPORTUNITIES WITHIN PARADOXES
CONCLUSION
REFLECTIVE QUESTIONS
References
CHAPTER 15: Concept Development
CONCEPT EXPLORATION
CONCEPT CLARIFICATION
CONCEPT ANALYSIS
AN INTEGRATED APPROACH TO CONCEPT DEVELOPMENT
CONCLUSION
REFLECTIVE QUESTIONS
References
CHAPTER 16: Theory Development
THEORY DEVELOPMENT: EXISTING STRATEGIES
CONCLUSION
REFLECTIVE QUESTIONS
References
CHAPTER 17: Middle-Range and Situation-Specific Theories
THE INTEGRATIVE PROCESS FOR DEVELOPING MIDDLE-RANGE AND SITUATION-SPECIFIC THEORIES
TOOLS FOR DEVELOPING MIDDLE-RANGE OR SITUATION-SPECIFIC THEORIES
MIDDLE-RANGE THEORIES
SITUATION-SPECIFIC THEORIES
CONCLUSION
REFLECTIVE QUESTIONS
References
CHAPTER 18: Measuring Progress in a Discipline
A THEORY OF REVOLUTION
A THEORY OF EVOLUTION
A THEORY OF INTEGRATION
CONCLUSION
REFLECTIVE QUESTIONS
References
PART SIX: Our Historical Literature
CHAPTER 19: Historical Writings in Theory
SECTION I: Abstracts of Writings in Metatheory, 1960–1984
SECTION II: Abstracts of Writings in Nursing Theory, 1960–1984
DOROTHY JOHNSON
MYRA LEVINE
DOROTHEA OREM
MARTHA ROGERS
SISTER CALLISTA ROY
JOYCE TRAVELBEE
CHAPTER 20: Historical and Current Theory Bibliography
THEORY AND THEORIZING IN NURSING
NURSING THEORY AND THEORISTS
PARADIGMS THAT HAVE INFLUENCED NURSING
MIDDLE-RANGE THEORY
SITUATION-SPECIFIC THEORY
VIDEO AND AUDIO TAPES ON THEORY
AUTHOR INDEX
SUBJECT INDEX