Nursing

Copyright 2001 F.A.
Davis Company
Nursing Theories
and Nursing Practice
Marilyn E. Parker
Professor
College of Nursing
Florida Atlantic University
Boca Raton, Florida
F.A. DAVIS COMPANY
PHILADELPHIA
Copyright 2001 F.A. Davis Company
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Library of Congress Cataloging-in-Publication Data
Nursing theories and nursing practice / [edited by] Marilyn E. Parker.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-8036-0604-4
1. NursingPhilosophy. 2. Nursing. I. Parker, Marilyn E.
[DNLM: 1. Nursing TheoryBiography. 2. NursesBiography. WY 86 N9737 2000]
RT84.5 .N8793 2000
610.73'01dc21
00-030335
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This book is dedicated to my mother,

Lucile Marie Parker
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Preface/Acknowledgments
This book offers the perspective that nursing theory
is essentially connected with nursing practice, research, education, and development. Nursing theories, regardless of complexity or abstraction, reflect
nursing and are used by nurses to frame their thinking, action, and being in the world. As guides for
nursing endeavors, nursing theories are practical in
nature and facilitate communication with those being nursed as well as with colleagues, students, and
persons practicing in related health and illness services. At the same time, all aspects of nursing are essential for developing and evolving nursing theory.
It is hoped that these pages make clear the interrelations of nursing theory and various nursing endeavors, and that the discipline and practice of nursing
will thus be advanced.
This very special book is intended to honor the
work of nursing theorists and nurses who use these
theories in their day-to-day nursing care, by reflecting and presenting the unique contributions of eminent nursing thinkers and doers of our lifetimes. Our
foremost nursing theorists have written for this
book, or their work has been described by nurses
who have thorough knowledge of the work of the
theorist and deep respect for the theorist as person,
nurse, and scholar. Indeed, to the extent possible,
contributing authors have been selected by theorists
to write about their theoretical work. The pattern for
each chapter was developed by each author or team
of authors according to their individual thinking and
writing styles, as well as the scientific perspectives
of the chapter. This freedom of format has helped to
encourage the latest and best thinking of contributing authors; several authors have shared the insight
that in preparing a chapter for this book, their work
has become more full and complete.
This book is intended to assist nursing students in
undergraduate and graduate nursing programs to explore and appreciate nursing theories and their use
in nursing practice. In addition and in response to
calls from practicing nurses, this book is intended for
use by those who desire to enrich their practice by
the study of nursing theories and related illustrations
of nursing practice and scholarship. The first section
of the book provides an overview of nursing theory
and a focus for thinking about evaluating and choosing nursing theory for use in nursing practice. An
outline at the beginning of each chapter provides a

map for the chapter. Selected points are highlighted
in each chapter and space for notes is provided. The
book concludes with an appendix of nursing theory
resources. An instructors manual has been prepared
for this book; it reflects the experiences of many
who have both met the challenges and have had such
a good time teaching and learning nursing theory in
undergraduate and graduate nursing programs.
The design of this book highlights work of nurses
who were thinking and writing about nursing up to
fifty years ago or more. Building, then, as now, on
the writing of Florence Nightingale, these nurse
scholars have provided essential influences for the
evolution of nursing theory. These influences can be
seen in the theory presentations in the section of the
book that includes the nursing theories that are most
in use today. The last section of this book features
two theorists who initially developed nursing theories at the middle range. These scholars describe processes and perspectives on theory development, giving us views of the future of nursing theory as we
move into the twenty-first century. Each chapter of
the book includes both descriptions of a particular
theory and the use of the theory in nursing practice,
research, education, administration, or governance.
For the latest and best thinking of some of nursings finest scholars, all nurses who read and use this
book will be grateful. For the continuing commitment of these scholars to our discipline and practice
of nursing, we are all thankful. Continuing to learn
and share what you love keeps the work and the love
alive, nurtures the commitment, and offers both fun
and frustration along the way. This has been illustrated in the enthusiasm for this book shared by
many nursing theorists and contributing authors
who have worked to create this book and by those
who have added their efforts to make it live. For me,
it has been a joy to renew friendships with colleagues who have joined me in preparing this book,
and to find new friends and colleagues as contributing authors.
Nursing Theories and Nursing Practice 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 5th 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). It is the intention of the contributing authors
of the current edition of Nursing Theories and Nursing Practice to contribute some earnings from this
book to future conferences about nursing theory and
nursing practice.
Even deeper roots of this book are found early in
my nursing career, when I seriously considered leaving nursing for the study of pharmacy, because, in
my fatigue and frustration mixed with youthful hope
and desire for more education, I could not answer
the question What is nursing?and could not distinguish the work of nursing from other tasks I did
everyday. 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 consider the questions with me. I remember being asked Why would you ask that question? Youre a nurse; you must surely know what
nursing is. Such responses, along with a drive for serious consideration of my questions, led me to the library. I clearly remember reading several descriptions of nursing that, I thought, could have just as
well have been about social work or physical therapy. I then found nursing defined and explained in a
book about education of practical nurses written by
Dorothea Orem. During the weeks that followed, as I
did my work of nursing in the hospital, I explored
Orems ideas about why people need nursing, nursings purposes, and what nurses do. I found a fit of
her ideas, as I understood them, with my practice,
and 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 services,
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 practice. 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
vi
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.
Many faculty colleagues and students continue to
help me study nursing and have contributed to this
book in ways I would never have adequate words to
acknowledge. I have been fortunate to hold faculty
appointments in universities where nursing theory
has been honored and am especially fortunate today
to be in a College of Nursing where both faculty and
students ground our teaching, scholarship, and practice in nursing theory. I am grateful to my knowledgeable colleagues who reviewed and offered helpful suggestions for chapters of this book, and to
those who contributed as chapter authors. It is also
our good fortune that many nursing theorists and
other nursing scholars live in or willingly visit our
lovely state of Florida.
During the last year of our work on this book,
nursing lost three of the theorists acclaimed in this
book as essential influences on the evolution of nursing theory. Ernestine Wiedenbach died in the spring
of 1998. As this book was being prepared for production, word came of the death of Dorothy Johnson.
Hildegard Peplau died in March of 1999. Typical of
their commitments to nursing, both Dorothy Johnson and Hildegard Peplau had told me of their interests in this project, had advised me on the authors
they would like to have prepare the chapters on their
contributions, and had asked to be given updates on
our progress.
Perhaps we should expect that a work of love and
commitment, such as this book, and the contributors
who have devoted so much to it, would be affected by
major life events taking place during its development.
In addition to the recent loss of three of our nursing
theorists and mentors, several of us have experienced
more personal life transitions and major losses during
preparation of this work. Illnesses and deaths of
spouses and parents have touched us in profound
ways. There can be no doubt that our experiences of
transition are reflected within the pages of this book. I
am grateful for the tender sharing and deep understanding of author colleagues in so many lovely and
loving ways. I have written the dedication of this book
for my mother and hope this extends to other loved
ones we may choose to remember in this way.
This book began during a visit with Joanne DaCunha, an expert nurse and editor for F. A. Davis
Company, who has seen it to publication with what I
believe is her love of nursing. I am grateful for her
wisdom, kindness, and understanding of nursing.

Peg Waltners respect for the purposes of this book
and for the special contributions of the authors has
been matched only by her fine attention to detail.
Without the reliable and expert assistance of Marguerite Purnell, this manuscript might still be on my
dining room table. I thank my husband, Terry Wor-
den, for his abiding love and for always being willing
to help, and my niece, Cherie Parker, who, as a nursing graduate student, represents many nurses who
inspire the work of this book.
Marilyn E. Parker
West Palm Beach, Florida
vii
Nursing Theorists
Anne Boykin
Dean and Professor
College of Nursing
Boca Raton, Florida
Marilyn Anne Ray

Professor
College of Nursing
Boca Raton, Florida
Lydia Hall
Martha Rogers
Virginia Henderson
Sister Callista Roy

Professor of Nursing
Boston College
Boston, Massachusetts
Dorothy Johnson*
Imogene King
Professor Emeritus
College of Nursing
University of South Florida
Tampa, Florida
Savina Schoenhofer
Alcorn State University
Natchez, Mississippi
Madeleine Leininger
Professor Emeritus
College of Nursing
Wayne State University
Detroit, Michigan
Kristen Swanson
Associate Professor
School of Nursing
University of Washington
Seattle, Washington
Myra Levine
Jean Watson
Distinguished Professor
Founder, Center for Human Caring
School of Nursing
University of Colorado Health Science Center
Denver, Colorado
Betty Neuman
Beverly, Ohio
Margaret Newman*
St. Paul, Minnesota
Ernestine Wiedenbach
Florence Nightingale
Loretta Zderad*
Dorothea E. Orem
Orem & Shields, Inc.
Savannah, Georgia
Deceased
*Retired
Ida Jean Orlando (Pelletier)*

Belmont, Massachusetts
Josephine Paterson*
Rosemarie Rizzo Parse
Founder and Editor, Nursing Science Quarterly
Professor and Niehoff Chair
Loyola University
Chicago, Illinois
Hildegard Peplau
ix
Contributing Authors
Patricia D. Aylward, MSN
Sante Fe Community College
Gainesville, Florida
Lynne Dunphy, Ph.D.

Associate Professor
College of Nursing
Boca Raton, Florida
Sandra Schmidt Bunkers, Ph.D.

Chair of Nursing and Kohlmeyer
Distinguished Teaching Professor
Augustana College
Sioux Falls, South Dakota
Maureen Frey, Ph.D.

Nurse Researcher
Childrens Hospital of Michigan
Detroit, Michigan
Nettie Birnbach, Ed.D., FAAN

Professor Emeritus
College of Nursing
State University of New York at
Brooklyn
Brooklyn, New York
Theresa Gesse, Ph.D.

Associate Professor
Founder and Director, Nurse
Midwifery Program
School of Nursing
University of Miami
Miami, Florida
Howard Butcher, Ph.D.

Assistant Professor
College of Nursing
University of Iowa
Iowa City, Iowa
Shirley Countryman Gordon,

Ph.D.
Assistant Professor
College of Nursing
Boca Raton, Florida
William K. Cody, Ph.D.

Associate Professor and Chair
School of Nursing
University of North Carolina
at Charlotte
Charlotte, North Carolina
Bonnie Holoday, DNS, FAAN

Dean, Graduate School and
Associate Vice Provost for
Research
Clemson University
Clemson, South Carolina
Marcia Dombro, Ed.D.

Chairperson, Continuing
Professional/Community
Education Alliance
Miami-Dade Community College
Miami, Florida
Marjorie Isenberg, DNS, FAAN

Professor
College of Nursing
Wayne State University
Detroit, Michigan
xi
Renee Jester, MSN

Advanced Practice Nurse
Jensen Beach, Florida
Gail J. Mitchell, Ph.D.

Chief Nursing Officer
Sunnybrook Health Science Centre
Toronto, Ontario, Canada
Mary Killeen, Ph.D.

Associate Professor
Department of Nursing
University of Michigan-Flint
Flint, Michigan
Ruth M. Neil, Ph.D.

Assistant Professor
School of Nursing
University of Colorado Health
Science Center
Denver, Colorado
Susan Kleiman, MS
Clinical Specialist
Centerport, New York
Cherie M. Parker, MS
West Palm Beach, Florida
Danielle Linden, MSN

Deerfield Beach, Florida
Ann R. Peden, DSN

Associate Professor
College of Nursing
University of Kentucky
Lexington, Kentucky
Violet Malinski, Ph.D.

Associate Professor
Hunter-Bellevue School of Nursing
City University of New York
New York, New York
Margaret Dexheimer Pharris,

Ph.D.
Faculty, Adolescent Teaching
Project
Assistant Director Sexual Assault
Resource Service
School of Nursing
University of Minnesota
Minneapolis, Minnesota
Marilyn R. McFarland, Ph.D.

Adjunct Faculty
College of Nursing and Allied
Health
Saginaw Valley State University
University Center, Michigan
xii
Marguerite J. Purnell, MSN

Doctoral Student
University of Miami
Miami, Florida
Theris A. Touhy, ND
Assistant Professor
College of Nursing
Boca Raton, Florida
Maude Rittman, Ph.D.

Associate Chief of Nursing Service
for Research
Gainesville Veterans Administration
Medical Center
Gainesville, Florida
Marian C. Turkel, Ph.D.

Assistant Professor
College of Nursing
Boca Raton, Florida
Karen Schaeffer, DNSc

Nursing Education/Research
Bethlehem, Pennsylvania
Lyn Zhan, Ph.D.

Assistant Professor
College of Nursing
University of Massachusetts,
Boston
Boston, Massachusetts
Christina Leibold Sieloff, Ph.D.

Assistant Professor
School of Nursing
Oakland University
Rochester, Michigan
xiii
Consultants
Nancy Nightengale Gillispie, RN, Ph.D.
Chairperson and Associate Professor
Saint Francis College
Fort Wayne, Indiana
Marilyn Loen, Ph.D., RN
Metropolitan State University
St. Paul, Minnesota
Mary Taylor Martof, RN, Ed.D.
Associate Professor
Louisiana State University Medical Center School
of Nursing
New Orleans, Louisiana
Erin E. Mullins-Rivera, Ph.D., RN
Assistant Professor
Saint Francis College
Fort Wayne, Indiana
Anne T. Pithian, MSN, RN
Assistant Professor
St. Lukes College of Nursing
Sioux City, Iowa
Patsy Ruchala RN, Ph.D.
St. Louis University
School of Nursing
St. Louis, Missouri
xv
Overview of Contents
SECTION I
SECTION IV
Perspectives on Nursing Theory
Nursing Theory: Illustrating Processes

of Development
An introduction to nursing theory includes: definitions of nursing theory, nursing theory and nursing
knowledge, types of nursing theory, and nursings
need for theory. Choosing, analyzing, and evaluating
nursing theory focuses on questions from practicing
nurses about studying and using nursing theory, a
guide for choosing a theory to study, and several
frameworks for theory analysis and evaluation. A
guide for the study of nursing theory for use in nursing practice is presented, along with questions for selecting theory for use in nursing administration.
Two nursing theorists unique processes of developing nursing theory are presented in this section.
Each theorist has written about research and development of middle-range theory as well as about further exploration of theory in the contexts of programs of research and theory development. The
political and economic dimensions of one of the theories in contemporary nursing practice is illustrated.
APPENDIX
SECTION II
Evaluating Nursing Theory Resources
Evolution of Nursing Theory:

Essential Influences
SUBJECT INDEX
This section opens with a chapter on Florence

Nightingale and a description of her profound influence on the discipline and practice of nursing. Subsequent chapters present major nursing theories that
have both reflected and influenced nursing practice,
education, research, and ongoing theory development in nursing during the last half of the twentieth
century.
SECTION III
Nursing Theory in Nursing Practice,
Education, Research, Administration,
and Governance
The major nursing theories in use at the end of the
twentieth century are presented in this section. Most
chapters about particular nursing theories are written by the theorists themselves. Some chapters are
written by nurses with advanced knowledge about
particular nursing theories; these authors have been
acknowledged by specific theorists as experts in
presenting their work. Each chapter also includes a
section illustrating the use of the theory in nursing
practice, research, education, administration, or governance.
xvii
Contents
SECTION I
PERSPECTIVES ON NURSING THEORY

1. Introduction to Nursing Theory 00
2. Studying Nursing Theory: Choosing, Analyzing, Evaluating 00
3. Guides for Study of Theories for Practice and
Administration 00
SECTION II
EVOLUTION OF NURSING THEORY:

ESSENTIAL INFLUENCES
4. Florence Nightingale 00
Caring Actualized: A Legacy for Nursing
Lynne Hektor Dunphy
5. Hildegard E. Peplau 00
The Process of Practice-based Theory Development
Ann R. Peden
6. Ernestine Wiedenbach 00
Clinical Nursing: A Helping Art
Theresa Gesse and Marcia Dombro
7. Dorothy Johnson 00
Behavioral System Model for Nursing
Bonnie Holaday
8. Myra Levine 00
Conservation Model: A Model for the Future
Karen Moore Schaefer
9. Ida Jean Orlando (Pelletier) 00
The Dynamic Nurse-Patient Relationship
Maude R. Rittman
10. Lydia Hall 00
The Care, Core, and Cure Model
Theris A. Touhy and Nettie Birnbach
11. Virginia Avenel Henderson 00
Shirley Countryman Gordon
12. Josephine Paterson and Loretta Zderad 00
Humanistic Nursing Theory with Clinical Applications
Susan Kleiman
SECTION III
NURSING THEORY IN NURSING PRACTICE, EDUCATION,

RESEARCH, AND ADMINISTRATION
13. Part 1. Dorothea E. Orem The Self-Care Deficit Nursing Theory 00
Dorothea E. Orem
13. Part 2. Self-Care Deficit Nursing Theory: Directions for
Advancing Nursing Science and Professional Practice 00
Marjorie A. Isenberg
14. Part 1. Martha E. Rogers Science of Unitary Human Beings 00
Violet M. Malinski
14. Part 2. Nursing Science in the New Millennium: Practice and Research
within Rogers Science of Unitary Human Beings 00
Howard K. Butcher
15. Part 1. Rosemarie Rizzo Parse The Human Becoming School of Thought 00
15. Part 2. The Human Becoming Theory in Practice, Research, Administration,
Regulation, and Education 00
William K. Cody
Gail J. Mitchell
Sandra Schmidt Bunkers
16. Margaret A. Newman Health as Expanding Consciousness 00
Margaret Dexheimer Pharris
17. Part 1. Imogene King Theory of Goal Attainment 00
Imogene King
17. Part 2. Application of Kings Work to Nursing Practice 00
Christina Leibold Sieloff
Maureen Frey
Mary Killeen
18. Sister Callista Roy The Roy Adaptation Model 00
Sister Callista Roy and Lin Zhan
19. Betty Neuman The Neuman Systems Model and Global Applications 00
Patricia D. Aylward
20. Part 1. Jean Watson Theory of Human Caring 00
Jean Watson
20. Part 2. Caring for the Human Spirit in the Workplace 00
Ruth M. Neil
21. Part 1. Madeleine M. Leininger Theory of Culture Care Diversity
and Universality 00
Madeleine M. Leininger
21. Part 2. The Ethnonursing Research Method and the Culture Care Theory:
Implications for Clinical Nursing Practice 00
Marilyn R. McFarland
xx
Contents
22. Part 1. Anne Boykin and Savina O. Schoenhofer Nursing as Caring 00

Anne Boykin
Savina O. Schoenhofer
22. Part 2. The Lived Experience of Nursing as Caring 00
Danielle Linden
SECTION IV
NURSING THEORY: ILLUSTRATING PROCESSES

OF DEVELOPMENT
23. Kristen M. Swanson A Program of Research on Caring 00
Kristen M. Swanson
24. Part 1. Marilyn Anne Ray The Theory of Bureaucratic Caring 00
Marilyn Anne Ray
24. Part 2. Applicability of Bureaucratic Caring Theory to Contemporary Nursing
Practice: The Political and Economic Dimensions 00
Marian C. Turkel
APPENDIX
Evaluating Nursing Theory Resources 00

Marguerite J. Purnell
SUBJECT INDEX
Contents
xxi
Section I
Perspectives on Nursing Theory
Chapter 1
Introduction to Nursing Theory
Definitions of Nursing Theory

Nursing Theory in the Context of Nursing Knowledge
Types of Nursing Theory
Nursings Need for Nursing Theory
Nursing Theory and the Future
Summary
References
Marilyn E. Parker
Florence Nightingale taught us that nursing theories

describe and explain what is and what is not nursing
(Nightingale, 1859/1992). Today knowledge development in nursing is taking place on several fronts,
with a variety of scholarly approaches contributing
to advances in the discipline. Nursing practice increasingly takes place in interdisciplinary community settings, and the form of nursing in acute care
settings is rapidly changing. Various paradigms and
value systems that express perspectives held by several groups within the discipline ground the knowledge and practice of nursing. Because the language
of nursing is continually being formed and distinguished, it often seems confusing, as does any language that is new to the ears and eyes. Nurses who
have active commitments to the work of the discipline, whether in nursing practice, research, education, or administration, are essential for the continuing development of nursing theory. This chapter
offers an approach to understanding nursing theory
within three contexts: nursing knowledge, nursing
as a discipline, and nursing as a professional practice. The chapter closes with an invitation to share
with contributing authors of this book their visions
of nursing theory in the future.
your thoughts
DEFINITIONS OF NURSING THEORY

A theory, as a general term, is a notion or an idea
that explains experience, interprets observation, describes relationships, and projects outcomes. Theories
are mental patterns or
Theories are not discovered constructs created to
help understand and
in nature but are human
find meaning from our
inventions. 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. They are descriptions of our reflections, of what we observe, or of what we project
and infer. 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 reflections of understanding, guide our actions, help us set forth desired
outcomes, and give evidence 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 about nursing theory brought definitions of theory from other disciplines to direct future
work within nursing. A theory is a conceptual sys-
tem or framework invented for some purpose (Dickoff & James, 1968, p. 198). Ellis (1968, p. 117) defined theory as a coherent set of hypothetical, conceptual, and pragmatic principles forming a general
frame of reference for a field of inquiry. 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 offers a more open
definition of theory as a construct that accounts for
or organizes some phenomenon, and states simply
that a nursing theory describes or explains nursing.
Definitions of theory emphasize various aspects
of theory and demonstrate that even the conceptions
of nursing theory are various and changing. Definitions of theory developed in recent years are more
open and less structured than definitions created before the last decade. Not every nursing theory will fit
every definition of what is a nursing theory. For purposes of nursing practice, a definition of nursing theory that has a focus on the meaning or possible impact of the theory on practice is desirable. The
following definitions of theory are consistent with
general ideas of theory in nursing as well as in other
disciplines. They are inclusive enough to be used for
purposes of nursing practice, education, and admin-
Section I Perspectives on Nursing Theory
istration, as well as nursing research, but can also

provide a focus on one main nursing endeavor.
Theory is a set of concepts, definitions, and
propositions that projects a systematic view of
phenomena by designating specific interrelationships among concepts for purposes of describing, explaining, predicting, and/or controlling phenomena. (Chinn & Jacobs, 1987,
p. 70)
Theory is a creative and rigorous structuring
of ideas that projects a tentative purposeful
and systematic view of phenomena. (Chinn &
Kramer, 1995, p. 71)
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, predicting or prescribing nursing
care. (Meleis, 1997, p. 12)
Nursing theory is an inductively and/or deductively derived collage of coherent, creative,
and focused nursing phenomena that frame,
give meaning to, and help explain specific and
selective aspects of nursing research and practice. (Silva, 1997, p. 55)
NURSING THEORY
IN THE CONTEXT OF
NURSING KNOWLEDGE
The notion of paradigm can be useful as a basis for
understanding nursing knowledge. 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. 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. Kuhn set forth the view that science does not evolve as
As we continue to move a smooth, regular, continuing path of knowlaway from the historical
edge development over
conception of nursing as time, but that there are
periodic times of revopart of medical science,
lution when traditional
developments in the nurs- thought is challenged
ing discipline are directed by new ideas, and paradigm shifts occur. In
by several new addition, Kuhns work
worldviews. has meaning for nursing
and other practice disci-
Chapter 1 Introduction to Nursing Theory
plines because of his recognition that science is the

work of a community of scholars in the context of society. Because paradigms are broad, shared perspectives held by members of the discipline, they are often called worldviews. Paradigms and worldviews
of nursing are subtle and powerful, permeating all aspects of the discipline and practice of nursing.
Kuhns (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 medical science, developments in the nursing discipline are directed by several new worldviews. Among these are fresh and
innovative perspectives on person, nursing, and
knowledge development. Changes in the nursing
paradigm are being brought about by nursing scholars addressing disciplinary concerns based on values
and beliefs about nursing as a human science, caring
in nursing, and holistic nursing.
The literature offers additional ways to describe
and understand nursing theory. Fawcett (1993) asserts that nursing theory is one component of a hierarchical structure of nursing knowledge development
that includes metaparadigm, philosophy, conceptual
models, nursing theory, and empirical indicators.
These conceptual levels of knowledge development
in nursing are interdependent; each level of development is influenced by work at other levels. Walker
and Avant (1995) describe the importance of relating
theories that have been developed at these various
levels of abstraction.
Theoretical work in nursing must be dynamic;
that is, it must be continually in process and useful
for the purposes and work of the discipline. It must
be open to adapt and extend in order both to guide
nursing endeavors and to reflect development
within nursing. Although there is diversity of opinion
among nurses about terms used to describe theoretical development, the following discussion of types
of theoretical development in nursing is offered as a
context for further understanding nursing theory.
Metaparadigm for Nursing

The metaparadigm for nursing is a framework for the
discipline that sets forth the phenomena of interest
and the propositions, principles, and methods of the
discipline. The metaparadigm is very general and is
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 beliefs held about nursing. The metapara-
digm offers a context for developing conceptual

models and theories. Dialogue on the metaparadigm
of nursing today is dynamic because of the range of
considerations about what comprises the essence
and form of nursing.
All nurses have some awareness of nursings metaparadigm by virtue of being nurses. However, because the term may not be familiar, it offers no direct
guidance for research and practice (Walker & Avant,
1995; Kim, 1997). Historically, the metaparadigm of
nursing described concepts of person, environment,
health, and nursing. Modifications and alternative
concepts for this framework are being explored
throughout the discipline (Fawcett, 1993). An example of alternative concepts is the work of Kim (1987,
1997), which sets forth four domains focusing on
client, client-nurse encounters, practice, and environment. In recent years, increasing attention has
been directed to the nature of nursings relationship
with the environment (Schuster & Brown, 1994;
Kleffel, 1996). Newman, Sime, and Corcoran-Perry
(1991, p. 3) propose that a single focus statement,
nursing is the study of caring in the human health
experience, guide the overall direction of the discipline. Reed (1995) challenges nurses to continue the
dialogue about perspectives on knowledge development in the discipline.
Nursing Philosophy
Developments in the metaparadigm of nursing are
accompanied by changes in statements of values and
beliefs written as nursing philosophies. A philosophy
comprises statements of enduring values and beliefs
held by members of the discipline. These statements
address the major concepts of the discipline, setting
forth beliefs about what nursing is, how to think
about and do nursing, the relationships of nursing,

and the environment of nursing. Philosophical statements are practical guides for examining issues and
clarifying priorities of the discipline. Nurses use
philosophical statements to examine fit among personal, professional, organizational, and societal beliefs and values.
Conceptual Models of Nursing

Conceptual models are sets of general concepts and
propositions that provide perspectives on the major
concepts of the metaparadigm, such as person,
health and well-being, and the environment. Conceptual models also reflect sets of values and beliefs,
as in philosophical statements as well as preferences
for practice and research approaches. Fawcett (1993,
1999) points out that direction for research must be
described as part of the conceptual model in order to
guide development and testing of nursing theories.
Conceptual models are less abstract than the metaparadigm and more abstract than theories, offering
guidance to nursing endeavors but no distinct direction. Conceptual models may also be called conceptual frameworks or systems.
Nursing Theories
In general, nursing theory describes and explains the
phenomena of interest to nursing in a systematic way
in order to provide understanding for use in nursing
practice and research. Theories are less abstract than
conceptual models or systems, although they vary in
scope and levels of abstraction. Grand theories of
nursing are those general constructions about the nature and goals of nursing. Middle-range nursing theories point to practice and are useful in a defined set
of nursing situations. Theories developed at the mid-
your thoughts
dle range include specific concepts and are less abstract than grand theories. At the next level, nursing
practice theories address issues and questions in a
particular practice setting in which nursing provides
care for a specific population. In addition to considering the scope and levels of abstraction of nursing
theories, they are also sometimes described by the
content or focus of the theory, such as health promotion, and caring and holistic nursing theories.
TYPES OF NURSING THEORY

Nursing theories have been organized into categories and types. George (1995) sets forth categories
of theories according to the orientation of the theorist: nursing problems, interactions, general systems,
and energy fields. Another view is that nursing theory forms a continuum of grand theories at one end
and theories focused on practice at the other (Chinn
& Kramer, 1995; Walker & Avant, 1995; Fitzpatrick,
1997). Meleis (1997) describes types of nursing theory based on their levels of abstraction and goal orientation. Barnum (1998) divides theories into those
that describe and those that explain nursing phenomena. Types of nursing theories generally include
grand theory, middle-range theory, and practice theory. These will be described below.
Grand Nursing Theory

Grand theories have the broadest scope and present
general concepts and propositions. Theories at this
level may both reflect and provide insights useful for
practice but are not designed for empirical testing.
This limits the use of grand theories for directing, explaining, and predicting nursing in particular situations. Theories at this level are intended to be pertinent to all instances of nursing.
Development of grand theories resulted from the
deliberate effort of committed scholars who have engaged in thoughtful reflection on nursing practice
and knowledge and the many contexts of nursing
over time. Nursing theorists who have worked at this
level have had insights guided by nursing and related
metaparadigms and sometimes have experienced
leaps of knowing grounded in these insights. Although there is debate about which nursing theories
are grand in scope, the following are usually considered to be at this level: Leiningers Theory of Culture
Care Diversity and Universality, Newmans Theory of
Health as Expanding Consciousness, Rogers Science
of Unitary Human Beings, Orems Self-Care Deficit
Nursing Theory, and Parses Theory of Human Becoming. These theories are presented in the third
section of this book.
Middle-range Nursing Theory

Middle-range theory was proposed by Robert Merton (1968) in the field of sociology to provide theories that are both broad enough to be useful in complex situations 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 more narrow
in scope than grand theories and offer an effective
bridge between grand theories and nursing practice.
They present concepts and propositions at a lower
level of abstraction and hold great promise for increasing theory-based research and nursing practice
strategies.
The literature presents a growing number of reports of nurses experiences of developing and using
middle-range theory. The nursing practice issues to
which these nurses are responding are complex and
represent a wide range of practice arenas (Chinn,
1994). The methods used for developing middlerange theories are many and represent some of the
most exciting work being published in nursing today.
Many of these new theories are built on content of
related disciplines and brought into nursing practice
and research (Lenz, Suppe, Gift, Pugh, & Milligan,
1995; Polk, 1997; Eakes, Burke, & Hainsworth, 1998).
The literature also offers middle-range nursing theories that are directly related to grand theories of nursing (Olson & Hanchett, 1997; Ducharme, Ricard, Duquette, Levesque, & Lachance, 1998). Reports of
nursing theory developed at this level include implications for instrument development, theory testing
through research, and nursing practice strategies. Illustrations of the process and product of nursing theory developed at the middle range are presented in
Section IV of this book.
Nursing Practice Theory

Nursing practice theory has the most limited scope
and level of abstraction and is developed for use
within a specific range of nursing situations. Theories developed at this level have a more direct impact
on nursing practice than do theories that are more
abstract. Nursing practice theories provide frameworks for nursing interventions, and predict outcomes and the impact of nursing practice. At the
same time, nursing questions, actions, and procedures may be described or developed as nursing
practice theories. Ideally, nursing practice theories
are interrelated with concepts from middle-range
theories, or may be deduced from theories at the
middle range. Practice theories should also reflect
concepts and propositions of more abstract levels of
nursing theory. Theory developed at this level is

also termed prescriptive theory (Dickoff, James, &
Wiedenbach, 1968; Crowley, 1968), situation-specific
theory (Meleis, 1997), and micro theory (Chinn &
Kramer, 1995).
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. Benner (1984) demonstrated that dialogue with expert nurses in practice is fruitful for discovery and development of practice theory. Research findings on various nursing problems offer
data to develop nursing practice theories as nursing
engages in research-based development of theory
and practice. 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 ones own feelings, reevaluating the experience, and integrating new knowing with other
experience (Gray & Forsstrom, 1991).
NURSINGS NEED
FOR NURSING THEORY
Nursing theories address the phenomena of interest
to nursing, including the focus of nursing; the person,
group, or population
The day-to-day experience nursed; the nurse; the
relationship of nurse
of nurses is a major source
and nursed; and the
of nursing practice theory. hoped-for goal or purposes of nursing.
Based on strongly held values and beliefs about nursing, and within contexts of various worldviews, theories are patterns that guide the thinking about, being, and doing of nursing. They provide structure for
developing, evaluating, and using nursing scholarship and for extending and refining nursing knowledge through research. Nursing theories either implicitly or explicitly direct all avenues of nursing,
including nursing education and administration.
Nursing theories provide concepts and designs that
define the place of nursing in health and illness care.
Through theories, nurses are offered perspectives
for relating with professionals from other disciplines
who join with nurses to provide human services. Nursing has great expectations of its theories. Theories
must, at the same time, provide structure and substance to ground the practice and scholarship of nurs-
ing and also be flexible

and dynamic to keep
pace with the growth
and changes in the discipline and practice of
nursing.
Theories are patterns that

guide the thinking about,
being, and doing of
nursing.
Nursing Is a Discipline
Nursing has taken its place as a discipline of knowledge that includes networks of facts, concepts, and
approaches to inquiry. The discipline of nursing is
also a community of scholars, including nurses in all
venues where nursing occurs, which shares commitment to values, concepts, and processes to guide
the thought and work of the discipline. Consistent
with thinking of nursing scholars about the discipline of nursing (Donaldson & Crowley, 1978;
Meleis, 1997) is the classic work of King and
Brownell (1976). These authors have set forth attributes of all disciplines.
These have particular The discipline of nursing is
relevance for nursing
and illustrate the need a community of scholars,
for nursing theory. The including nurses in all
attributes of King and
venues where nursing
Brownell are used as a
framework to address occurs.
the need of the discipline for nursing theory. Each of the attributes is described below from the perspective of the discipline
of nursing.
Expression of Human Imagination

Nursing theory requires curiosity and wonder, as
well as critical thinking on the part of the theorists
and students of theory. Nursing theory is dependent
on the imagination and questioning of nurses in practice and on their creativity to bring ideas of nursing
theory into practice. In order to remain dynamic and
useful, our discipline requires openness to new ideas
and innovative approaches that grow out of members reflections and insights. There must be support
for creative exploration and expression in new theoretical ways.
Domain
A discipline of knowledge and professional practice
must be clearly defined by statements of the domainthe theoretical and practical boundaries of
that discipline and practice. The domain of nursing
includes the phenomena of interest, problems to be
addressed, main content and methods used, and
roles required of members of the discipline (Kim,
1997; Meleis, 1997). The processes and practices

claimed by members of the discipline community
grow out of these domain statements. Nursing theories containing descriptions of nursings domain may
incorporate a statement of focus of the discipline.
The focus may be set in statements about human, social, and ecological concerns addressed by nursing.
The focus of the discipline of nursing is a clear statement of social mandate and service used to direct the
study and practice of nursing (Newman, Sime, &
Corcoran-Perry, 1991).
Nightingale (1859/1992) may have led the call for
domain and focus by distinguishing nursing from medicine and other services. Later, Donaldson and Crowley (1978) stated that a discipline has a special way of
viewing phenomena and a distinct perspective that
defines the work of the discipline. The call for clarity
of focus continues in the current environment of nursing practice (Parse, 1997). Nursing theories set forth
focus statements or definitions of the discipline and
practice of nursing and direct thought and action to
fulfill the unique purposes of nursing. This enhances
autonomy, and accountability and responsibility are
defined and supported. The domain of nursing is also
called the metaparadigm of nursing, as described in
the previous section of this chapter.
Syntactical and Conceptual Structures

These structures essential to the discipline are inherent in each of the nursing theories. The conceptual
structure delineates the proper concerns of nursing,
guides what is to be studied, and clarifies accepted
ways of knowing and using content of the discipline.
This structure is grounded in the metaparadigm and
philosophies of nursing. The conceptual structure relates concepts within nursing theories, and it is from
this structure that we learn what is and is not nursing. The syntactical structures help nurses and other
professionals 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 impact of nursing practice.
In addition, these structures guide nursings use of
knowledge, research, and practice approaches developed by related disciplines. It is only by being thoroughly grounded in the concepts, substance, and
modes of inquiry of the discipline that the boundaries
of the discipline, however tentative, can be understood and possibilities for creativity across interdisciplinary 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 in nursing. The
complex concepts used in nursing scholarship and
practice require language that can be used and understood. The language of nursing theory facilitates
communication among members of the discipline.
Expert knowledge of the discipline is often required
for full understanding of the meaning of special
terms. At the same time, it is often realized that nursing chooses to use commonly understood language
in order to communicate more fully with those
served.
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 electronic media that have
your thoughts
developed over centuries to communicate the nature

and development of nursing. Conferences and other
forums on every aspect of nursing and for nurses of
all interests occur frequently throughout the world.
Nursing organizations and societies also provide critical communication links. Nursing theories form the
bases for many of the major contributions to the literature, conferences, societies, and other communication networks of the discipline of nursing.
Tradition
The tradition and history of the discipline of nursing
is evident in study of nursing theories that have been
developed over time. There is recognition that theories most useful today often have threads of connection with theoretical developments of past years. For
example, many theorists 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. Nursings practical experience and knowledge
have been shared, transformed into content of the
discipline, and are evident in the work of many nursing theorists (Gray & Pratt, 1991).
Values and Beliefs

Nursing has distinctive views of persons and strong
commitments to compassionate and knowledgeable
care of persons through nursing. Nurses often express their love and passion for nursing. Nurses in
small groups and in larger nursing organizations express values, hopes, and dreams for the future of
their discipline and offer recognition of and appreciation for achievements in the field. The statements
of values and beliefs are expressed in the philosophies of nursing that are essential underpinnings of
theoretical developments in the discipline.
Systems of Education
Nursing holds the stature and place of a discipline of
knowledge and professional practice within institutions of higher education because of the grounding
of articulated nursing theories that have set forth the
unique contribution of nursing to human affairs. A
distinguishing mark of any discipline is the education
of future and current members of the community.
Nursing theories, by setting directions for the substance and methods of inquiry for the discipline, provide the basis for nursing education and often the
framework to organize nursing curricula.
Nursing Is a Professional Practice

Closely aligned with attributes of nursing as a discipline described above is consideration of nursing
10
as a professional practice. Professional practice includes clinical scholarship and processes of nursing
persons, groups, and populations who need the special human service that is nursing. The major reason
for structuring and advancing nursing knowledge is
for the sake of nursing
practice. The primary The major reason for strucpurpose of nursing theories is to further the turing and advancing nursdevelopment and un- ing knowledge is for the
derstanding of nursing
practice. Theory-based sake of nursing practice.
research is needed in
order to explain and predict nursing outcomes essential to the delivery of nursing care that is both humane and cost-effective (Gioiella, 1996). Because
nursing theory exists to improve practice, the test of
nursing theory is a test of its usefulness in professional practice (Fitzpatrick, 1997). The work of nursing theory is moving from academia into the realm of
nursing practice. Chapters in the remaining sections
of this book highlight use of nursing theories in nursing practice.
Nursing practice is both the source of and goal for
nursing theory. From the viewpoint of practice, Gray
and Forsstrom (1991) suggest that through use of
theory, nurses find different ways of looking at and
assessing phenomena, have rationale for their practice and criteria for evaluating outcomes. Recent
studies reported in the literature affirm the importance of use of nursing theory to guide practice
(Baker, 1997; Olson & Hanchett, 1997; Barrett,
1998; ONeill & Kenny, 1998; Whitener, Cox, &
Maglich, 1998). Further, these studies illustrate that
nursing theory can stimulate creative thinking, facilitate communication, and clarify purposes and relationships of practice. The practicing nurse has an
ethical responsibility to use the theoretical knowledge base of the discipline, just as it is the nurse
scholars ethical responsibility to develop the knowledge base specific to nursing practice (Cody, 1997).
Integral to both the professional practice of nursing and nursing theory is the use of empirical indicators. These are developed to meet demands of clinical decision making in the context of rapidly
changing needs for nursing and the knowledge required for nursing practice. These indicators include
procedures, tools, and instruments to determine the
impact of nursing practice and are essential to research and management of outcomes of practice
(Jennings & Staggers, 1998). Resulting data form the
basis for improving quality of nursing care and influencing health-care policy. Empirical indicators,
grounded carefully in nursing concepts, provide
clear demonstration of the utility of nursing theory in

practice, research, administration, and other nursing
endeavors (Hart & Foster, 1998; Allison & McLaughlinRenpenning, 1999). Fawcett (1993) has placed empirical indicators in the hierarchy of nursing knowledge and relates them to nursing theory when they
are an outgrowth of particular aspects of nursing
theories.
Meeting the challenges of systems of care delivery
and interdisciplinary work demands practice from a
theoretical perspective. Nursings disciplinary focus
is essential within an interdisciplinary environment
(Allison & McLaughlin-Renpenning, 1999). Nursing
actions reflect nursing concepts and thought. Careful, reflective, and critical thinking is the hallmark of
expert nursing and nursing theories should undergird these processes. Appreciation and use of nursing theory offer opportunity for successful collaboration with related disciplines and practices, and
provide definition for nursings overall contribution
to health care. Nurses must know what they are doing, why they are doing what they are doing, what
may be the range of outcomes of nursing, and indicators for measuring nursings impact. These nursing
theoretical frameworks serve in powerful ways as
guides for articulating, reporting, and recording
nursing thought and action.
One of the assertions referred to most often in the
nursing theory literature is that theory is given birth
in nursing practice and, following examination and
refinement through research, must be returned to
practice (Dickoff, James, & Wiedenbach, 1968). Within
nursing as a practice discipline, 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 recommendations of nursing research are evaluated 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.
NURSING THEORY
AND THE FUTURE
Nursing theory in the future will be more fully integrated with all domains of the discipline and practice
of nursing. New, more open and inclusive ways to
theorize about nursing will be developed. These new
ways will acknowledge the history and traditions of
nursing but will move nursing forward into new
realms of thinking and being. Gray and Pratt (1991,
p. 454) project that nursing scholars will continue to

develop theories at all levels of abstraction, and that
theories will be increasingly interdependent with
other disciplines such as politics, economics, and
aesthetics. These authors expect a continuing emphasis on unifying theory and practice that will contribute to validation of the discipline of nursing.
Reed (1995) notes the
ground shifting with
It is important to question
reforming of philosophies of nursing sci- to what extent theories
ence and calls for a developed and used in one
more open philosophy, grounded in nurs- major culture are approings values, which priate for use in other
connects science, philosophy, and practice. cultures.
Theorists will work in
groups to develop knowledge in an area of concern
to nursing, and these phenomena of interest, rather
than the name of the author, will define the theory
(Meleis, 1992).
Nursings philosophies and theories must increasingly reflect nursings values for understanding,
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 societies, how
relevant are our nursing theories for the global community? Can nursing theories inform us 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, 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
will offer new ways to inform nurses for humane
leadership in national and global health policy.
Perspectives of various time worlds in relation to
present nursing concerns were described by Schoenhofer (1994). Faye G. Abdellah, one of nursings
finest international leaders, offers the advice that we
must maintain focusing on those we nurse (McAuliffe, 1998). Abdellah notes that nurses in other countries have often developed their systems of education, practice, and research based on learning from
our mistakes. She further proposes an international
electronic think tank for nurses around the globe to
dialogue about nursing (McAuliffe, 1998). Such opportunities could lead nurses to truly listen, learn,
11
and adapt theoretical perspectives to accommodate

cultural variations. We must somehow come to appreciate the essence and beauty of nursing, just as
Nightingale knew it to be. Perhaps it will be realized
that the essence of nursing is universal, and only the
ways of expressing nursing vary.
Many of the chapters of this book contain insights
and projections about nursing theory in the coming
century. It is somewhat frightening to write about
nursing theory in the twenty-first century and it
takes courage and perhaps more than a bit of humor
to do so. All of us have ways to look back to the year
1900; even if we were not present or cannot remember the context of our lives then, we have heard and
read about those times. All can realize the vast
changes that have taken place during the twentieth
century. Nurses and nursing have participated in
these changes. Nursing theorists and scholars who
are contributing authors for this book have not only
reflected and projected about the future, they have
also been willing to share with us their thoughts on
the future of nursing theory as we enter the new
millennium.
Summary
One challenge of nursing theory is the perspective
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 may be seen as
ambiguous or as full of possibilities. Continuing students of the discipline are required to study and
know the basis for their contributions to nursing and
to those we serve, while at the same time 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 discipline of
knowledge and professional practice provides a
frame of reference to clarify nursing theory. The wise
study and use of nursing theory can be a helpful
companion in the new millennium.
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Reed, P. (1995). A treatise on nursing knowledge development for the 21st century: Beyond postmodernism. Advances in Nursing Science, 17(3), 7084.
Schoenhofer, S. (1994). Transforming visions for nursing in the timeworld of Einsteins Dreams.Advances
in Nursing Science, 16(4), 18.
Schuster, E., & Brown, C. (1994). Exploring our environmental connections. New York: National League
for Nursing.
Silva, M. (1997). Philosophy, theory, and research in
nursing: A linguistic journey to nursing practice. In
King, I., & Fawcett, J. (Eds.), The language of nursing theory and metatheory. Indianapolis, IN: Center
Nursing Press.
Walker, L., & Avant, K. (1995). Strategies for theory
construction in nursing. Norwalk, CT: AppletonCentury-Crofts.
Whitener, L. M., Cox, K. R., & Maglich, S. A. (1998).
Use of theory to guide nurses in the design of health
messages for children. Advances in Nursing Science, 20(3), 2135.
13
Chapter 2
Studying Nursing Theory:
Choosing, Analyzing, Evaluating
Reasons for Studying Nursing Theory
Questions from Practicing Nurses about Using
Nursing Theory
Choosing a Nursing Theory to Study
An Exercise for the Study of Nursing Theory
Analysis and Evaluation of Nursing Theory
Summary
References
Marilyn E. Parker
The primary purpose for nursing theory is to advance

the discipline and professional practice of nursing.
One of the most urgent issues facing the discipline of
nursing is the need to bring together nursing theory
and practice. Their continuing separation is artificial.
Nursing can no longer afford to see these endeavors as
disconnected and 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 nursing.
This issue is highlighted by considering a brief encounter during a question 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? Im in
One of the most urgent the real world! I want
to connectbut how
issues of the discipline is can connections be
the need to bring together made between your
ideas and my reality?
nursing theory and
The nurse theorist repractice. sponded by describing the essential values and assumptions of her theory. The nurse said:
Yes, I know what you are talking about. I just didnt
know I knew it and I need help to use it in my practice (Parker, 1993, p. 4). To remain current in the
discipline, all nurses must be continuing students,
must join in community to advance nursing knowledge and practice, and must accept their obligations
to an ongoing investigation of nursing theories.
This chapter provides a focus on the study of nursing theories with the idea of review and selection of
nursing theory for use in any nursing endeavor: practice, education, administration, research, and development. Methods of analysis and evaluation of nursing theory set forth in the literature will be presented.
Although nursing theory is essential for all nursing,
the main focus of theory analysis and evaluation in
this chapter is the use of nursing theories in nursing
practice. The chapter begins with responses to the
questions: Why study nursing theory? What does the
practicing nurse want from nursing theory?
REASONS FOR STUDYING

NURSING THEORY
Nursing practice is essential for developing, testing,
and refining nursing theory. The everyday practice of
nursing enriches nursing theory. When nurses are
16
thinking about nursing, their ideas are about the content and structure of the discipline of nursing. Even
if nurses do not conceptualize them in this way, their
ideas are about nursing theory. The development of
many nursing theories has been enhanced by reflection and dialogue about actual nursing situations. We
might consider that aspects of nursing theories are
explored and refined in the day-to-day practice of
nursing. Creative nursing practice is the direct result
of ongoing theory-based thinking, decision making,
and action of nurses. Nursing practice must continue
to contribute to thinking and theorizing in nursing,
just as nursing theory must be used to advance understanding and the impact of practice.
Nursing practice and nursing theory are guided
by the same abiding values and beliefs. Nursing practice is guided by enduring values and beliefs as well
as by knowledge held by individual nurses. These values, beliefs, and knowledges echo those held by
other nurses in the discipline, including nurse scholars and those who study and write about nursings
metaparadigm, philosophies, and theories. In addition, nursing theorists and nurses in practice think
about and work with the same phenomena, including the person nursed, the actions and relationships
in the nursing situation, and the context of nursing.
Many nurses practice according to ideas and directions from other disciplines, such as medicine,
psychology, and public health. This is not uncommon to nursing historically and is deeply ingrained in
the medical system, as well as in many settings in
which nurses practice today. The depth and scope of
the practice of nurses who follow notions about
nursing held by other disciplines are limited 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 themselves and
those they nurse. These Creative nursing practice
nurses learn to reframe
their thinking about can be the direct result of
nursing knowledge and ongoing, theory-based
practice and are then
thinking, decision making,
able to bring knowledge from other disci- and action of nurses.
plines into their practicenot to direct their practice, but in order to
meet goals of nursing.
Nurses who understand nursings theoretical base
are free to see beyond immediate facts and delivery
systems, and are able to choose to bring the full
range of health sciences and technologies into their
practice. These nurses can envision and contribute

to the many possibilities of the discipline. Nurses
who study nursing theory realize that although no
group actually owns ideas, disciplines do claim ideas
for their use. In the same way, no group actually
owns techniques, though disciplines do claim them
for their practice. For example, before World War II,
nurses rarely took blood pressure readings. This was
not because they were unable, but because they did
not claim the use of this technique to facilitate their
nursing. Such realization can also lead to understanding that the things nurses do that are often called
nursing are not nursing at all. The techniques used
by nurses, such as taking blood pressure readings,
are actually activities that give the nurse access to
persons for nursing. Nursing theories inform the
nurse about what nursing is and guide the use of
other ideas and techniques for nursing purposes.
If nursing theory is to be useful, it must be
brought into practice. Nurses can be guided by nursing theory in a full range of nursing situations. Nursing theory can change nursing practice. Nurses
should no longer ignore the possibilities of theorybased practice, withholding this quality of nursing so
that persons they nurse never experience theorybased nursing. Chapters of this book affirm the use
of nursing theory in practice and the study and assessment of theory for ultimate use in practice.
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 are
key ways to study theory. These activities are demanding and deserve the full commitment of nurses
who undertake the work. Because it is understood
that study of nursing theory is not a simple, shortterm 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 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?
Is the theory specific to my area of nursing? Can

the language of the theory help me explain,
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 interdisciplinary setting?
Will those from other disciplines be able to
understand, facilitating cooperation?
Will my work meet the expectations of patients
and others? Will other nurses find my work
helpful and challenging?
My Personal Interests, Abilities,

and Experiences
Is the study of nursing theories in keeping 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?
What must I do? Am I able?
Resources and Support

Will this be useful to me outside the classroom?
What resources will I need to understand more
fully the terms of the theory?
Will I be able to find the support I need to study
and use the theory in my practice?
The Theorist, Evidence, and Opinion

Who is the author of this theory? What is the
background of nursing education and
experience brought to this work by the
theorist? Is the author an authoritative nursing
scholar?
What are the opinions of knowledgeable nurses
about the work of the theorist?
What is the evidence that use of the theory may
lead to improved nursing care? Has the theory
been useful to guide nursing organizations and
administrations? What about influencing
nursing and health-care policy?
Chapter 2 Studying Nursing Theory: Choosing, Analyzing, Evaluating
17
your thoughts
What is the evidence that this nursing theory

has led to nursing research, including questions
and methods of inquiry? Did the theory grow
out of nursing research reports? Out of nursing
practice issues and problems?
Does the theory reflect the latest thinking in
nursing? Has the theory kept pace with the
times in nursing? Is this the nursing theory for
the future?
CHOOSING A NURSING
THEORY TO STUDY
It is important to give adequate attention to selection
of theories for study. Results of this work may have
lasting influences on ones nursing practice. For all
the reasons already offered in this book, aspects of
ones personal and professional life may encounter
challenges and growth. It is not unusual for nurses
who begin to work with nursing theory to realize
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 wonder how to select and study nursing theories. Nurses and nursing
students in courses considering nursing theory 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 nursing.
The following exercise is grounded in the belief
that the study and use of nursing theory in nursing
18
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
bringing focus and freshness to that practice. This exercise calls on the nurse to think about the major
components of nursing, and calls forth the values
and beliefs nurses hold most dear. In these ways, the
exercise begins to parallel knowledge development
reflected in the nursing metaparadigm and nursing
philosophies as described in Chapter 1. From this
point on, the nurse is guided to connect nursing theory and nursing practice in the context of nursing situations. It is from these experiences that decisions
about nursing theory and practice are derived.
AN EXERCISE FOR THE STUDY

OF NURSING THEORY
Select a comfortable, private, and quiet place to reflect and write. Begin to be quiet and relaxed 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, without being
distracted, make notes, so you wont forget your
thoughts and feelings. If you are doing this exercise
with a group of colleagues, make an effort to wait
until later to share your reflections, and only then as
you wish to do so. When you have been still for a
time and have taken the opportunity to reflect on
your practice, you may proceed with the following
questions. Continue to reflect and to make notes as
you consider each question about your beliefs and
values.
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 those values I hold most dear?
What are the ties of these values with my
personal values?
How do my personal and nursing values
connect with what is important to society?
Nursing Situations
Reflect on a nursing situation, that is, an instance of
nursing in which you interacted with a person for
nursing purposes. This can be a situation from your
current practice or may come to your memory from
your nursing in years past. Consider the purpose or
hoped for outcome of the nursing.
Who was my patient as a person?

What were the needs for nursing the person?
Who was I as a person in the nursing situation?
Who was I as a nurse in the situation?
What was the interaction like between the
patient and myself?
What nursing responses did I offer to the needs
of the patient?
What other nursing responses might have been
possible?
What was the environment of the nursing
situation?
What about the environment was important to
the needs for nursing and to my nursing
responses?
Connecting Values and

the Nursing Situation
Nursing can change when we bring to awareness the
connections of values and beliefs and nursing situations. Consider that values and beliefs are the basis
for our nursing. Briefly describe the connections
of your values and beliefs with your chosen nursing
situation.
How are my values and beliefs reflected in the
nursing situation?
Are my values and beliefs in conflict in the
situation?
Do my values come to life in the nursing
situation?
Are my values frustrated?
Verifying Awareness and

Appreciation
In reflecting and writing about values and situations
of nursing that are important to us, we often come to
a fuller awareness and appreciation of nursing. Make
notes about your insights. You might consider these
initial notes the beginning of a journal in which you
record your study of nursing theories and their use
in nursing practice. This is a great way to follow
your progress and is a source of nursing questions
for future study. You may want to share this process
and experience with your colleagues. These are ways
to clarify and verify views about nursing and to
seek and offer support for nursing values and situations that are critical to our practice. If you are doing this exercise in a group, this is the time to share
your essential values and beliefs with your colleagues.
your thoughts
19
Using Insights to Choose Theory

The notes describing your experience will help in selecting a nursing theory to study and consider 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 do I believe are consistent with
my personal values and societys beliefs?
What do I want from the use of nursing theory?
Given my reflection on a nursing situation, do I
want theory to support this description of my
practice?
Do I hope to use nursing theory to improve my
experience of practice for myself and for my
patients?
Using Authoritative Sources

Use your questions and new insights to begin a literature search. Gather and use library resources, such
as CINAHL. Search the Internet and use on-line resources for information on nursing theories and their
use in practice, research, education, and administration. Join an on-line group dialogue about a particular nursing theory. You and your colleagues may seek
consultation for assistance with analysis and evaluation of specific nursing theories.
Using a Guide to Select a Nursing Theory

This is the time to explore using the following
guides for analysis and
The whole theory must be evaluation of nursing
theory. Done individustudied. Parts of the theory ally or as a group, this
without the whole will is an additional opportunity to learn and to
not be fully meaningful share. This is demandand could lead to ing work, but along
with the challenge,
misunderstanding. this can also be fun,
gratifying, and a good
way to strengthen bonds with colleagues.
ANALYSIS AND EVALUATION

OF NURSING THEORY
It is important to understand definitions of nursing
theory, as described in Chapter 1, before moving to
theory analysis and evaluation. These definitions direct examination of structure, content, and purposes
of theories. Although each of these definitions is adequate for study of any nursing theory, the definition
20
that seems to best fit with the particular purpose for

study of theory should be chosen. For example, one
of the definitions by Chinn and Jacobs (1987) and
Chin and Kramer (1995) may be chosen for using
theory in research. The definition by Silva (1997)
may be more appropriate for study of nursing theory
for use in practice. Another way to think about this is
to consider whether the definition of nursing theory
in use fits the theory being analyzed and evaluated.
Look carefully at the theory, read the theory as presented by the theorist, and read what others have
written about 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 analysis and evaluation, consider the level and scope of the theory, as
discussed in the previous chapter. Is the theory a
grand nursing theory? A philosophy? A middle-range
nursing theory? A practice theory? Not all aspects of
theory described in an evaluation guide will be evident in all levels of theory. For example, questions
about the metaparadigm are probably not appropriate to use in analyzing middle-range theories. Whall
(1996) recognizes 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.
Theory analysis and evaluation may be thought of
as one process or as a two-step sequence. It may be
helpful to think of analysis of theory as necessary for
adequate study of a nursing theory and evaluation of
theory as the assessment of the utility of a theory for
particular purposes. Guides for theory evaluation are
intended as tools to inform us about theories, and to
encourage further development, refinement, and use
of theory. There are no guides for theory analysis and
evaluation that are adequate and appropriate for
every nursing theory.
Johnson (1974) wrote about three basic criteria to
guide evaluation of nursing theory. These have continued in use over time and offer direction for guides
in use today. These criteria are 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
impact of nursing on persons receiving nursing;
and
describe social utility, or usefulness of the
theory in practice, research, and education.
Following are outlines of the most frequently
used guides for analysis and evaluation. These guides
are components of the entire work about nursing

theory of the individual nursing scholar and offer various interesting approaches to the study of nursing
theory. 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 analysis set forth by
Chinn and Kramer (1995) is to use guidelines for describing nursing theory that are based on their definition of theory that is presented in Chapter 1. The
guidelines set forth questions that clarify the facts
about aspects of theory: purpose, concepts, definitions, relationships, structure, assumptions, and
scope. These authors suggest that the next step in
the process of evaluation is critical reflection about
whether and how the nursing theory works. Questions are posed to guide this reflection:
Is the theory clearly stated?
Is it stated simply?
Can the theory be generalized?
Is the theory accessible?
How important is the theory?
Fawcett (1993) developed a framework of questions that separates the activities of analysis and evaluation. Questions for analysis in this framework flow
from the structural hierarchy of nursing knowledge
proposed by Fawcett and defined in Chapter 1. The
questions for evaluation guide examination of theory
content and use for practical purposes. Following is
a summary of the Fawcett (1993) framework.
For Theory Analysis,

Consideration Is Given To:
scope of the theory
metaparadigm concepts and propositions
included in the theory
values and beliefs reflected in the theory
relation of the theory to a conceptual model
and to related disciplines
concepts and propositions of the theory
For Theory Evaluation,

Consideration Is Given To:
significance of the theory and relations with
structure of knowledge
consistency and clarity of concepts, expressed
in congruent, concise language
adequacy for use in research, education, and
practice
feasibility to apply the theory in practical

contexts
Meleis (1997) states that the structural and functional components of a theory should be studied
prior to evaluation. The structural components are
assumptions, concepts, and propositions of the theory. Functional components include descriptions of
the following: focus, client, nursing, health, nurseclient interactions, environment, and nursing problems and interventions. After studying these dimensions of the theory, critical examination of these
elements may take place, as summarized below:
Relations between structure and function of the
theory, including clarity, consistency, and
simplicity
Diagram of theory to understand further 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, professional,
and social values, and significance
Summary
Nursing theory, knowledge development through research, and nursing practice are closely linked and
interrelated. In so many ways, the connections of
nursing practice with nursing theory bring the practicing nurse to the challenge of studying nursing theory. Considering a commitment to study nursing theory raises many questions from nurses about to
undertake this important work. Analysis and evaluation of nursing theory are the main ways of studying
nursing theory.
References
Chinn, P., & Jacobs, M. (1987). Theory and nursing:
A systematic approach. St. Louis: C. V. Mosby.
A systematic approach (4th ed.). St. Louis: Mosby
Year-Book.
Fawcett, J. (1993). Analysis and evaluation of nursing
theory. Philadelphia: F. A. Davis.
Johnson, D. (1974). Development of theory: A requisite
for nursing as a primary health profession. Nursing
Research, 23(5), 372377.
Meleis, A. (1997). Theoretical nursing: Development
and progress. Philadelphia: Lippincott.
21
Parker, M. (1993). Patterns of nursing theories in practice. New York: National League for Nursing.
Silva, M. (1997). Philosophy, theory, and research in
nursing: A linguistic journey to nursing practice. In
King, I., & Fawcett, J. (Eds.), The language of nursing theory and metatheory. Indianapolis, IN: Center Nursing Press.
22
Whall, A. (1996). The structure of nursing knowledge:

Analysis and evaluation of practice, middle-range,
and grand theory. In Fitzpatrick, J., & Whall, A.
(Eds.), Conceptual models of nursing:Analysis and
application (3rd ed.). Stamford, CT: Appleton &
Lange.
Chapter 3
Guides for Study of Theories
for Practice and Administration
Study of Theory for Nursing Practice
A Guide for Study of Nursing Theory for Use in Practice
Study of Theory for Nursing Administration
Summary
References
Marilyn E. Parker
Nurses, individually and in groups, are affected by

rapid and dramatic change throughout health and
medical systems. Nurses practice in increasingly diverse settings. Nurses often develop organized nursing practices through which accessible health care to
communities can be provided. Community members
may be active participants in selecting, designing,
and evaluating the nursing they receive. Interdisciplinary practice is frequently the norm.
Theories and practices from related disciplines
are brought to nursing to use for nursing purposes.
The scope of nursing practice is continually being
expanded to include additional knowledge and skills
from related disciplines, such as medicine and psychology. Although the majority of nurses practice in
hospitals, an increasing number of nurses practice
elsewhere in the community, taking the venue of
their practice closer to those served by nursing.
Groups of nurses working together as colleagues
to provide nursing often realize that they share the
same values and beliefs about nursing. The study of
nursing theories can
The scope of nursing prac- clarify the purposes of
nursing and facilitate
tice is continually being building a cohesive
expanded to include practice to meet these
purposes. Regardless
knowledge and skills from
of the setting of nursrelated disciplines. ing practice, nurses
may choose to study
nursing theories together in order to design and articulate theory-based practice. The exercise in Chapter 2 is offered to facilitate this work.
This chapter offers guides for continuing study of
nursing theory for use in nursing practice. Because
many nurses are creating new practice organizations
and settings, a guide for study of nursing theory for
use in nursing administration has been developed.
The guides are intended for use in conjunction with
the overall study of nursing theory, including the
methods of analysis and evaluation outlined in Chapter 2. The first guide is a set of questions for consideration in study and selection of a nursing theory for
use in practice. The second guide is an outline of factors to consider when studying nursing theory for
use in nursing organization and administration.
Responses to questions offered and points summarized in the guides may be found in nursing literature as well as by use of audiovisual and electronic
resources. Primary source material, including the
writing of nurses who are recognized authorities in
specific nursing theories and the use of nursing theory, should be used. Subsequent chapters of this
book offer such sources. Users of this guide are in-
24
vited to examine each question carefully and add

questions from other theory analysis and evaluation
guides to meet their particular purposes.
STUDY OF THEORY
FOR NURSING PRACTICE
Four main questions have been developed and refined to facilitate study of nursing theories for use in
nursing practice (Parker, 1993). These questions are
intended to focus on concepts within the theories as
well as points of interest and general information
about each theory. This guide was developed for use
by practicing nurses and students in undergraduate
and graduate programs of nursing education. Many
nurses and students have used these questions and
have contributed to their continuing development.
The guide may be used to study most of the nursing
theories developed at all levels. It has been used to
create surveys of nursing theories. An early motivation for developing this guide was the work by the
Nursing Development Conference Group (1973).
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 does the nurse think about when
considering nursing?
What are illustrations of use of the theory to
guide practice?
What is the purpose of nursing?
What do nurses do when they are practicing
nursing?
What are exemplars of nursing assessments,
designs, plans, and evaluations?
What indicators give evidence of quality
and quantity 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 and medical services?
How is nursing related to other disciplines
and services?
What is the place of nursing in

interdisciplinary settings?
What is the range of nursing situations in
which the theory is useful?
How can nursing situations be described?
What are attributes of the one nursed?
What are characteristics of the nurse?
How can interactions of the nurse and the
one nursed be described?
Are there environmental requirements for
the practice of nursing?
2. What is the context of development of the
theory?
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
nursing scholar?
What are central values and beliefs set forth
by the theorist?
What are major theoretical influences on this
theory?
What nursing models and theories
influenced this theory?
What are relationships of this theory with
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?
What images of nurses and nursing
influenced the theory?
What was the status of nursing as a
discipline and profession?
3. Who are authoritative sources for
information about development, evaluation,
and use of this theory?
Who are nursing authorities who 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 other nurses should be considered
authorities?
What major resources are authoritative sources
on the theory?
Books? Articles? Audiovisual media?

Electronic media?
What nursing societies share and support
work of the theory?
What service and academic programs are
authoritative sources?
4. How can the overall significance of the
theory to nursing be described?
What is the importance of the theory of nursing
over time?
What are exemplars of the use to structure
and guide individual practice?
Is the theory used to guide programs of
nursing education?
Is the theory used to guide nursing
administration and organizations?
Does published nursing scholarship reflect
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 theory
formulations?
Has the theory been used to develop new
nursing practices?
Has the theory influenced 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
the future of nursing?
How has nursing as a community of
scholars been influenced?
In what ways has nursing as a professional
practice been strengthened?
What future possibilities for nursing are
open because of this theory?
What will be the continuing social value of
the theory?
STUDY OF THEORY FOR

NURSING ADMINISTRATION
Literature on nursing delivery systems and administration have addressed the value of nursing theory
for use in administration of nursing and health-care
organizations (Huckaby, 1991; Walker, 1993; Young
& Hayne, 1988). Nurses in group practice may seek
to use a nursing theory that will not only guide their
practice, but also provide visions for the organiza-
Chapter 3 Guides for Study of Theories for Practice and Administration
25
tion and administration of their practice. A shared

understanding of the focus of nursing can facilitate
goal-setting and achievement as well as day-to-day
communication among nurses in practice and administration. Allison and McLaughlin-Renpenning (1999)
describe the need for a vision of nursing shared by all
throughout health care and nursing organizations.
These authors, using Orems general Self-Care Deficit
Nursing Theory (see Chapter 13), offer demonstration that a theory of nursing can guide practice as
well as the organization and administration.
The above guide for the study of nursing theories
for use in nursing practice can be extended to consider essential aspects of nursing in organizations.
The following questions are derived from components of a model for nursing administration (Allison
& McLaughlin-Renpenning, 1999). The questions are
intended to guide descriptions of the nursing organization. Responses to these questions can be used to
evaluate nursing theory for use in a nursing practice
organization.
What are purposes of the organization? Mission?
Goals?
What are the purposes of nursing? How do
these purposes contribute to the purposes of
the organization?
How can the range of nursing situations be
described? What is the population served?
What nursing and related technologies are
required for nursing?
What are the projections for nursing situations
and technological needs for the future?
How is communication facilitated? In nursing?
Among disciplines and services?
How are services for those nursed coordinated?

In what ways is nursing professional
development achieved? Career advancement?
How are research and development of nursing
practice and theory advanced?
Summary
This chapter has presented a guide designed for use
by nurses to study nursing theory for use in practice.
The guide is intended to be used along with more
general formats of analysis and evaluation of nursing
theory. This guide provides additional evaluative
components for use by nurses who are focusing on
nursing practice. An additional set of questions is offered for nurses who are considering nursing organization and administration. These questions are intended to further guide the study of nursing theory
for use in the organization and administration of
nursing.
References
Allison, S. E., & McLaughlin-Renpenning, K. E. (1999).
Nursing administration in the 21st century:A selfcare theory approach. Thousand Oaks, CA: Sage
Publications.
Huckaby, L. (1991). The role of conceptual frameworks
in nursing practice, administration, education, and
research. Nursing Administration Quarterly, 15
(3), 1728.
Nursing Development Conference Group. (1973). Concept formalization in nursing: Process and
product. Boston: Little, Brown & Co.
your thoughts
26
Orem, D. (1995). Nursing: Concepts of practice (5th

ed.). St. Louis: Mosby-Year Book.
Parker, M. (1993). Patterns of nursing theories in practice. New York: National League for Nursing.
Walker, D. (1993). A nursing administration perspective on use of Orems self-care nursing theory. In
Parker, M., Patterns of nursing theories in practice

(pp. 253263). New York: National League for
Nursing.
Young, L., & Hayne, A. (1988). Nursing administration: From concepts to practice. Philadelphia: W. B.
Saunders.
Chapter 3 Guides for Study of Theories for Practice and Administration
27
Section II
Evolution of Nursing Theory:
Essential Influences
Florence Nightingale at Embley in 1857: pencil drawing of her by

G. Scharf. This was one of the most active and fruitful periods of her life,
but as happened so often, she reacted with symptoms of nervous distress. From Elspeth Huxley: Florence Nightingale (1975), p. 139, G. P.
Putnams Sons, New York.
Chapter 4
Caring Actualized:
A Legacy for Nursing
Introducing the Theorist
Early Life and Education: The Seeds of Caring Planted
Spirituality: The Roots of Nightingales Caring
War: Caring Actualized
The Medical Milieu
The Feminist Context of Nightingales Caring
Ideas about Nursing: Expressions of Caring
Nightingales Assumptions
Summary
References
Bibliography
Lynne Hektor Dunphy
But out of suffering may come the cure. Better have

pain than paralysis! A hundred struggle and drown
in the breakers. One discovers the new world. But
rather, ten times rather, die in surf, heralding the
way to the new world, than stand idly on the shore!
for, consciously or not. . . .The first thought I can remember, and the last, was nursing work. . . .
Florence Nightingale, Cassandra (1852/1979)
Nightingale, the second and youngest daughter born

to Fanny Smith, age 32, and William Edward Nightingale, age 25, came into this world on May 12, 1820.
She was born in Florence, Italy, the city she was
named for, in Villa Colombia, and christened in its
drawing room. The Nightingales were on an extended European tour, begun in 1818 shortly after
their marriage. 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.
W. E. N., as Nightingales father was referred to affectionately, was by nature retiring and studious. He
had fallen for his opposite in the vivacious Fanny
Smith, who was ambitious and socially minded with
great aspirations for both daughters. Fanny was from
a distinguished, wealthy, liberal family, Unitarian in
religious outlook. Fannys father, William Smith, was
a well-known politician of the age, who sat for 46
years as a member of Parliament, in the House of
Commons. Sir Thomas Cook (1913), Nightingales
first and official biographer, describes William Smith
as follows: A stout defender of liberty of thought and
conscience, a persistent opponent of religious tests
and disabilities, and in religion, a Unitarian (Cook,
Vol. I, 1913, p. 5). He is also described as a leading
Abolitionist; he championed the seated factory workers; he did battle for the rights of Dissenters and
Jews (Woodham-Smith, 1983, p. 2). These themes
were to resonate throughout Nightingales life.
Smiths daughter, Fanny, however, was of a more outgoing nature. She chose to attend the Anglican
Church, rather than the Unitarian, primarily for social reasons, and when recalling her upbringing as
one of 10 siblings, she noted, We Smiths never
thought of anything all day but our own ease and
pleasure.
Nightingales father was also a professed Unitarian. Both parents were part of the class known as the
landed gentry, rich though not titled. Her family on
both sides was enormously wealthy, educated, well
traveled, and part of an elite inner circle of influential people of the day.
The Nightingales owned several homesa country home called Lea Hurst in Derbyshire; a town
house in London; and Embley Park, a large and lavish
home located in Hampshire, outside of London. It
was Fannys opinion that Lea Hurst was too small.
Why, it only has 15 bedrooms! she was heard to ob-
INTRODUCING THE THEORIST

Florence Nightingale transformed a calling from
God and an intense spirituality into a new social role
for women: that of nurse. Her caring was a public
one, expressed in and committed to people improving the quality of their lives. Work your true work,
she wrote, and you will find God within you. A reflection on this statement is to be found in a wellknown quote from Notes on Nursing (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 can be no doubt that her life in nursing exemplified and personified an ethos of caring. Jean Watson (1992, p. 83), in the 1992 commemorative edition of Notes on Nursing, observed, Although
Nightingales feminine-based caring-healing model
has transcended time and is prophetic for this centurys health reform, the model is yet to truly come
of age in nursing or the health care system.
This chapter reiterates Nightingales life from the
years 1820 to 1860, delineating the formative influences on her ideas about nursing. A biographical approach was used to examine her education, travel,
and spiritual background, her Crimean experiences,
the medical milieu, and her views on women, all providing historical context for her ideas about nursing
as we recall them today. Part of what follows is a
well-known tale, yet it remains a tale that is irresistible, casting an age-old spell on the reader, like
the flickering shadow of Nightingale and her famous
lamp in the dark and dreary halls of the Barrack Hospital, Scutari, on the outskirts of Constantinople,
circa 18541856. And it is a tale that still carries
much relevance for our nursing practice today.
EARLY LIFE AND EDUCATION:

THE SEEDS OF CARING PLANTED
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
32
Florence Nightingale, cited in Cook

(1913, p. 106)
Section II Evolution of Nursing Theory: Essential Influences
serve. W. E. N., an amateur architect, took an active

hand in the design of his houses (Cook, 1913; Huxley, 1975).
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. undertook the education of both his daughters. Florence
and her sister studied music; grammar; composition;
modern languages; Ancient Greek and Latin; constitutional history; and Roman, Italian, German, and
Turkish history; as well as mathematics (Barritt,
1973). Cook describes the following:
Among Florences papers were preserved
many sheets in her fathers handwriting, containing the heads of admirable outlines of the
political history of England and some foreign
states. Her own note-books show that in her
teens she had mastered the elements of Greek
and Latin. She analyzed the Tusculan Disputations. She translated portions of the Phaedo,
the Crito and the Apology. She had studied
Greek, Roman, and Turkish history. She had
analyzed Dugald Stewarts Philosophy of the
Human Mind. Her father was in the habit,
too, of suggesting themes on which his daughters were to write compositions. It was the
system of the College Essay. Florence has now
taken mathematics, wrote her sister in 1840,
and, like everything else she undertakes, she
is deep in them and working very hard. (Cook,
Vol. I, 1913, p. 13)
From an early age, Florence exhibited independence of thought and action. The sketch (Figure 41)
of W. E. N. and his daughters was done by one of
Fannys sisters, a beloved aunt, Julia Smith. It is
Parthenope, the older sister, who clutches her fathers 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 Nightingales education. Eighteen years after Florences birth, the
Nightingales and both daughters made an extended
tour of the Continent, covering France, Italy, and
Switzerland between the years of 1837 and 1838. In
1847, Nightingale went to Italy and France with
close friends, the Bracebridges, where they were to
witness the revolutions of 1848. In 1849, again with
the Bracebridges, Nightingale traveled to Egypt and
then on to Athens in 1850 (Sattin, 1987). From there,
Nightingale visited Germany, making her first acquaintance with Kaiserswerth, a Protestant religious
community that contained the Institution for the
Image/Text rights unavailable
Training of Deaconesses, with a hospital school, penitentiary, and orphanage. A Protestant pastor,
Theodore Fleidner, and his young wife had established this community in 1836, in part to provide
training for women deaconesses (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 nurses training (Cook, Vol. I, 1913; WoodhamSmith, 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 12 noon. Then
they had a 10-minute break for broth with vegetables. Three P.M. saw another 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 in a
spirit of reverence and dedication. Florence wrote,
Chapter 4 Florence Nightingale Caring Actualized:A Legacy for Nursing
33
The world here fills my life with interest and

strengthens me in body and mind (Huxley, 1975).
In 1852, Nightingale visited Ireland, touring hospitals and keeping notes on various institutions along
the way. Nightingale took two trips to Paris; in
1853, hospital training again was the goal, this time
with the sisters of St.
Her religious convictions Vincent de Paul, an
order of nursing sismade service to God, ters. In August 1853,
through service to she accepted her first
official nursing post
humankind, a driving force
as superintendent of
in her life. 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: THE ROOTS

OF NIGHTINGALES CARING
Today I am 30the age Christ began his Mission.
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 Gods 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 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 15 long and torturous years, from
1837 to 1853, for Nightingale to actualize her calling
to the role of nurse. This was a revolutionary choice
for a woman of her social standing and position, and
her desire to nurse met with vigorous family opposition for many years. Along the way, she turned down
34
several proposals of marriage, potentially, in her

mothers view, brilliant matches, such as that of
Richard Monckton Milnes. However, her need to
serve God and to demonstrate her caring through
meaningful activity proved stronger. She did not
think that she could be married and also do Gods
will.
This lengthy and protracted period, experienced
by a number of great young individuals who go onto
achieve a historic identity, was identified by Erik
Erikson as a moratorium. Erikson, noted most commonly in nursing for his developmental model of the
Eight Stages of Man (Erikson, 1950), also postulated an extended identity crisis and resolution for
certain individuals. These great young adults, unable to fit into existing societal roles, structures, and
ideologies, resolve their own crisis of identity by
evolving a new form of social organization, a new
way of looking at the world, or a new ideology (Erikson, 1958, 1974). In the case of the historic individual, his or her developmental task of identity is usually a role that is new, a lifes work that is original:
Still others [young adults], although suffering
and deviating dangerously through what appears to be a prolonged adolescence, eventually come to contribute an original bit to an
emerging style of life: the very danger which
they have sensed has forced them to mobilize
capacities to see and say, to dream and plan, to
design and construct, in new ways. (Erikson,
1958, pp. 1415)
Nightingale indeed fit this model, with welldocumented sufferings, confusion, and searchings
for truth during the years between 1837 and 1853
(Hektor, 1984). This period ended for Nightingale
when she assumed her first official post as nurse administrator in 1853, followed by her Crimean years,
1854 to 1856.
Joann G. Widerquist (1992, p. 49) identifies
Nightingales spirituality as a belief in perfectionism and perceives this as closely tied to underlying
Unitarian ideas. Although they were not unified by
doctrine or creed, the Unitarians, like the Quakers,
were a small group that wielded influence beyond
their numbers. Among other things, the Unitarians
believed in salvation by character as well as the progress of humankind onward and upward forever. Their
belief about salvation included both health and
wholeness (Widerquist, 1992, p. 50). Strains of these
ideas are also prevalent in Nightingales writings
about nursing.
Calabria and Macrae (1994) note that for Nightingale there was no conflict between science and spiri-
tuality; 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
universal laws as opposed to random happenings.
Nightingale referred to these laws, or the organizing
principles of the universe as Thoughts of God
(Macrae, 1995, p. 9). As part of Gods plan of evolution, it was the responsibility 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
carrying out such laws depends our responsibility (that much abused word). . . . Yet we
seem to be continually expecting that He will
work a miraclei.e. break his own laws expressly to relieve us of responsibility.
Nightingale elaborated her thoughts on this matter in
a letter to Benjamin Jowett, a religious advisor: It is a
religious act to clean out a gutter and to prevent
cholera, and that it is not a religious act to pray (in
the sense of asking) (Quinn & Prest, 1981, p. 18).
Influenced by the Unitarian ideas of her father
and her extended family, as well as by the more traditional Anglican church she attended, Nightingale remained for her entire life a searcher after 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) recasts Nightingale in the mode of religious
mystic. However, to Nightingale, mystical union
with God was not an end in itself, but the source of
strength and guidance for doing ones work in life.
For Nightingale, service to God was service to humanity (Calabria & Macrae, 1994, p. xviii).
During the 1850s Nightingale produced an 829page work in three volumes, which she had privately
printed in 1860. The first volume was entitled Suggestions for Thought to the Searchers after Truth
among the Artisans of England; the second and
third volumes were entitled simply Suggestions for
Thought to Searchers after Religious Truth. In a letter to John Stuart Mill (September 5, 1860), framing
her thoughts on this work, Nightingale wrote the following:
Many years ago, I had a large and very curious
acquaintance among the artisans of the North
of England and London. I learned that they
were without any religion whateverthough
diligently seeking after one, principally in
Comte and his school. Any return to what is

called Christianity appeared impossible. It is
for them that this book is written. (Calabria &
Macrae, 1994, p. ix)
A census completed in England in 1851 revealed that
most of the poor and working class had no faith, and
that religion was espoused primarily by the middle
class (Widerquist, 1992, p. 52). Nightingale viewed
the ideas presented in her religious treatise as an alternative to atheism. Nightingale was also an empiricist, but instead of abolishing God as did Comte, she
sought to unify religion and science in a way that
would bring order, meaning, and purpose to human
life. She viewed spirituality as a science and wrote
that our knowledge of God, as revealed in the laws
of the universe, should be continually evolving
(Macrae, 1995, p. 10). Given this unusual (for the
time) evolutionary view, Nightingale, ever the freethinker, was decidedly against a single set of teachings as a final authority. In Suggestions for Thought
(cited in Calabria & Macrae, 1994, p. 126) she wrote:
[b]ut mans capabilities of observation,
thought, and feeling exercised on the universe, past, present, and to come, are the
sources of religious knowledge.
In Nightingales view, nursing should be a search
for the truth, it should be a discovery of Gods laws
of healing and their proper application. 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.
WAR: CARING ACTUALIZED

I stand at the altar of those murdered men and
while I live I fight their cause
Nightingale, cited in Woodham-Smith (1983)
Nightingale had powerful friends and had gained

prominence through her study of hospitals and
health matters during her travels. When Great Britain
became involved in 1854 in the Crimean War,
Nightingale was ensconced in her first official nursing post at 1 Harley Street. Britain had joined France
and Turkey to ward off an aggressive Russian advance
in the Crimea (Figure 42). The interests of all was
the preservation of the balance of power. A successful advance of Russia through Turkey could threaten
the peace and stability of the European continent.
The first actual battle of the war, the Battle of
Alma, was fought in September 1854. It was written
35
of that battle that it was a glorious and bloody victory. The best technology of the times, the telegraph, was to have an effect on what was to follow.
In prior wars, news from the battlefields trickled
home slowly. However, the invention of the telegraph enabled war correspondents to telegraph
reports home with rapid speed. The horror of the
battlefields was relayed to a concerned citizenry. De-
36
scriptions 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?
(Woodham-Smith, 1983; Goldie, 1987).
The minister of war was Sidney Herbert, Lord
Herbert of Lea, who was the husband of Liz Herbert;
both were close friends of Nightingale. He had an
your thoughts
innovative solution: appoint Miss Nightingale and

charge her to head a contingent of nurses to the
Crimea, to provide help and organization to the deteriorating battlefield situation. It was a brave move on
the part of Sidney 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, Sidney Herbert, minister of war,
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 possesses. (Dolan, 1971, p. 2)
At the very same time, such that their letters actually
crossed, Nightingale wrote to Sidney Herbert, offering her services.
The unique blend of Nightingales background,
family friends, and connections in high places, combined with her own interests and proclivities, provided the impetus for the famous mission to the
Crimea, led by her. Accompanied by 38 hand-picked
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 Nightingales own
correspondence, as cited in a number of sources
(Cook, 1913; Huxley, 1975; Goldie, 1987; 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 commitment

to an environmental approach to health and illness:
The filth became indescribable. The men in
the corridors 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 mens foodMiss
Nightingale saw the skinned carcass of a sheep
lie in a ward all night . . . the stench from the
hospital could be smelled outside the walls.
(Woodham-Smith, 1983)
The immediate priority of Nightingale and her
small band of nurses on her arrival in the Crimea was
not in the sphere of medical or surgical nursing as
currently known; rather, their order of business was
domestic management. This is evidenced in the following exchange between Nightingale and one of
her party as they approached Constantinople: Oh,
Miss Nightingale, when we land dont let there be
any red-tape delays, let us get straight to nursing the
poor fellows! Nightingales reply: The strongest will
be wanted at the wash tub (Cook, 1913; Dolan,
1971).
37
Although the bulk of this work continued to be

done by orderlies after Nightingales arrival (with the
laundry farmed out to the soldiers wives), it was accomplished only with Nightingales persistence: 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 raising her voice, until the orderlies gave way
and the tub was emptied (Cook, 1913; Summers,
1988; Woodham-Smith, 1983).
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 able to be 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, feeding,
clean bed linen, clean bodies, and clean wards, was
essential to recovery (Summers, 1988). Following is
such a description:
Those who remember the cooking for the sick
which prevailed at Scutari before, and that introduced after the kitchen department underwent the female revolution, will be able to appreciate the difference which attention to this
point must make on the results of treatment
. . . it was in the management of those cases of
such frequent occurrence in the East, where a
lingering convalescencemost liable to relapsehas succeededthat the extras from
those special kitchens came to tell in the treatment. Nourishment, properly and judiciously
administered, was the sole medication on
which we could rely in such cases. It was often
of itself sufficient to cure, and it was in attending to this that the female nurses saved so
many lives. (Woodham-Smith, 1983)
Mortality rates at the Barrack Hospital in Scutari
fell. Some attribute the decline to the onset of
warmer weather in March 1855, thus ensuring freer
ventilation. Before this, in February, at Nightingales
insistence, the prime minister had sent to the Crimea
a sanitary commission to investigate the 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 hospital flowed, where a dead horse was found. During
the first two weeks of their work, the commission
cleared 556 handcarts and large baskets full of rub-
38
bish . . . 24 dead animals and 2 dead horses buried.

In addition, they flushed and cleansed sewers, limewashed walls, tore out shelves that harbored rats,
and got rid of vermin. The Commission, Nightingale
said, saved the British Army. Miss Nightingales anticontagionism was sealed as the mortality rates began
showing dramatic declines (Rosenberg, 1979).
Figure 43 illustrates Nightingales own handdrawn coxcombs, as they were referred to, as
Nightingale, being always aware of the necessity of
documenting outcomes of care, kept copious
records of all sorts (Cook, 1913; Rosenberg, 1979;
Woodham-Smith, 1983).
It was these events that set the stage for the solidification of the Nightingale legend and that recurring icon, The Lady with the Lamp. Lytton Strachey,
noted biographer of the Victorian age, provides us
with some of the most vivid descriptions of Miss
Nightingale, capturing the complexity of the real
woman:
Certainly she was heroic. Yet her heroism was
not that simple sort so dear to readers of novels and the compilers of hagiologies. . . . It was
made of sterner stuff. To the wounded soldier
on his couch of agony she might well appear
in the guise of a gracious angel of mercy; but
the military surgeons, and the orderlies, and
her own nurses, and the Purveyor, and Dr.
Hall, and even Lord Stratford himself could tell
a different story. It was not by gentle sweetness and womanly self-abnegation that she had
brought order out of the chaos in the Scutari
Hospital, that, from her own resources, she
had clothed the British Army, that she had
spread her dominion over the serried and re-
luctant powers of the official world; it was by

strict method, by stern discipline, by rigid attention to detail, by ceaseless labor, by the
fixed determination of indomitable will. (Strachey, 1918, p. 156)
He goes on to describe her physical demeanor:
Beneath her cool and calm demeanor lurked
fierce and passionate fires. As she passed
through the wards in her plain dress, so quiet,
so unassuming, she struck the casual observer
simply as the pattern of the perfect lady; but
the keener eye [saw] something more than
thatthe serenity of high deliberation in the
scope of the capricious brow, the sign of
power in the dominating curve of the thin
nose, and the traces of a harsh and dangerous
tempersomething peevish, something mocking, and yet something precisein the small
and delicate mouth. (Strachey, 1918, p. 156)
Strachey extends his description to Miss Nightingales voice:
As for her voice, it was true of it, even more
than her countenance, that it had that in it
one must fain call master. Those clear tones
were in no need of emphasis: I never heard
her raise her voice, said one of her companions. Only, when she had spoken, it seemed as
if nothing could follow but obedience. Once,
when she had given some direction, a doctor
ventured to remark that the thing could not be
done. But it must be done, said Miss Nightingale. A chance bystander, who heard the
words, never forgot through all his life the irresistible authority of them. And they were spoken quietlyvery quietly indeed. (Strachey,
1918, pp. 156157)
Florence Nightingale possessed moral authority, so
firm because it was grounded in caring, and in a
larger mission that came from her spirituality. For
Miss Nightingale, spirituality was a much broader,
more unitive concept than that of religion. Her spirituality involved the sense of a presence higher than
human presence, the divine intelligence that creates,
sustains, and organizes 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 the deepest, most potent resource for healing. Nightingale was to write in Suggestions for Thought (cited in Calabria & Macrae,
1994, p. 58) that human consciousness is tending to
become what Gods consciousness isto 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 (Rosenberg, 1979;
Welch, 1986; Widerquist, 1992; Slater, 1994; Calabria & Macrae, 1994; Macrae, 1995).
There were 4 miles of beds in the Barrack Hospital at Scutari, a suburb of Constantinople. 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)
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). 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, arriving at
Lea Hurst in Derbyshire on August 7, 1856, after 22
months in the Crimea, 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 (Figure 44). She took her family by surprise. The 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 hera one-
39
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).
Florence Nightingale, Notes on Nursing

(1860/1969, p. 8)
THE MEDICAL MILIEU

In watching disease, both in private homes and
public hospitals, the thing which strikes the experienced observer most forcefully is this, that the
symptoms or the sufferings generally considered to
be inevitable and incident to the disease are very
40
often not symptoms of the disease at all, but of

something quite differentof 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.
To gain a better understanding of Nightingales

ideas on nursing, one must enter the peculiar world
of nineteenth-century medicine and its views on
health and disease. Considerable new medical
knowledge had been gained by 1800. Gross anatomy
your thoughts
was well known; chemistry promised to throw light

on various body processes. Vaccination against smallpox existed. There were some established drugs in
the pharmacopoeia: cinchona bark, digitalis, and
mercury. Certain major diseases, such as leprosy and
the bubonic plague, had almost disappeared. The
crude death rate in western Europe was falling,
largely related to decreasing infant mortality as a result of improvement in hygiene and standard of living (Ackernecht, 1982; Shyrock, 1959).
Yet physicians at the turn of the century, in 1800,
still had only the vaguest notion of diagnosis. Speculative philosophies continued to dominate medical
thought, although inroads and assaults continued to
be made that eventually gave way to a new outlook
on the nature of disease: from belief in general states
common to all illnesses to an understanding of disease-specificity resultant symptomatology. It was this
shift in thoughta paradigm shift of the first order
that gave us the triumph of twentieth-century medicine, with all its attendant glories and concurrent
sterility.
The eighteenth century was host to two major traditions 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 persisted into the nineteenth century
and can be found in Nightingales philosophy.
Consistent with the speculative and philosophical
nature of her superior education (Barritt, 1973),
Nightingale, like many of the physicians of her time,
continued to emphatically disavow the 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 diseases 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-nineteenth century, there were two competing theories regarding
the nature and origin of disease. One view was
known as contagionism, postulating that some diseases were communicable, spread via commerce and
population migration. The strategic consequences 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 anticontagionism. It postulated that disease resulted from local environmental sources and arose out of miasmasclouds of
rotting filth and matter, activated by a variety of
things such as meteorologic 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 disease. Commerce
and infected individuals were left alone (Rosenberg, 1979).
William Farr, another Nightingale associate and
avid anticontagionist, was Britains statistical superintendent of the General Register Office. Farr categorized epidemic and infectious diseases as zygomatic,
meaning pertaining to or caused by the process of
41
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 atmosphere, the very air that was
breathed. What was at issue was the specificity of the
contaminating substance. Nightingale, and the anticontagionists, endorsed the position that a sufficiently intense level of atmospheric contamination
could induce both endemic and epidemic ills in the
crowded hospital wards [with particular configurations of environmental circumstances determining
which] (Rosenberg, 1979).
Anticontagionism reached its peak prior to the
political revolutions of 1848; the resulting 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 Nightingales clashes with the military 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. Likewise, the eclectic religious philosophy
she evolved contained attributes of the philosophy
of Unitarianism 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 (read environment) in the Nightingale model is consistent with
the views of the anticontagionists of her time. This
worldview was reinforced by Nightingales Crimean
experiences, as well as her liberal and progressive
political thought. Additionally, she viewed all ideas
as being distilled through a distinctly moral lens
(Rosenberg, 1979). As such, Nightingale was typical
of a number of intellectuals of her generation. These
thinkers struggled to come to grips with an increasingly complex and changing world order, and frequently combined a language of two disparate realms
of authority: the moral realm and the emerging scientific paradigm that has assumed dominance in the
twentieth century. Traditional religious and moral
assumptions were garbed in a mantle of scientific
objectivity, often spurious at best, however more
42
in keeping with the increasingly rationalized and

bureaucratic society accompanying the growth of
science.
THE FEMINIST CONTEXT OF

NIGHTINGALES CARING
I have an intellectual nature which requires satisfaction 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 active 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 Milness proposal of marriage: I know I could
not bear his life, she wrote, that to be nailed to a
continuation, an exaggeration of my present life
without hope of another would be intolerable to
methat voluntarily 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 suicide
(Nightingale, personal note cited in Woodham-Smith,
1983, p. 52). For Miss Nightingale there was no compromise. Marriage and pursuit of her mission were
not compatible. She chose the mission, a clear repudiation of the mores of her time, which were rooted
in the time-honored role of family 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 entitled,
Why Are Women Re- Notes on Nursing was
dundant? (Widerquist,
1992, p. 52). Many of written not to teach nurses
these women had no to nurse, but to help all
acceptable means of
women learn how to
support, and the development of a suitable oc- nurse.
cupation for women by
Nightingale, that of nursing, was a significant historical development and a major contribution by
Nightingale to the plight of women in the nineteenth
century. However, in other ways, her views on
women and the question of the rights of women
were quite mixed.
The book 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
your thoughts
women required this knowledge in order to take

proper care of their families during times of sickness
and to promote health, specifically what Nightingale
referred to as the health of houses, that is, the
health of the environment, which she espoused.
Nursing, to her, was clearly situated within the context of female duty.
Susan Reverby, historian, in Ordered to Care: The
Dilemma of American Nursing (1987, p. 43) traces
contemporary conflicts within the profession of
nursing back to Nightingale herself. She asserts that
Nightingales ideas about female duty and authority,
along with her views on disease causality, brought
about an independent fieldthat of nursingthat
was separate, and in the view of Nightingale, equal if
not superior, to that of medicine. But this field was
dominated by a female hierarchy and insisted on
both deference and loyalty to the authority of the
physician. Reverby 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.
Does the record support this evidence? Was
Nightingale a champion for womens rights or a regressive force? As noted earlier, the answer is far from
clear.
The economic policy of laissez-faire permeated
the day. The theory held that ultimately it was the
law of supply and demand that would promote competition, which in turn would produce the maximum number of goods and thus benefit society. In
this dog-eat-dog world, what would hold society together? In another paradox of the age, the solution
was a common set of moral standards, in the unfettered energetic actions of persons together with the
uniform subjugation of all to the national code of

Duty (Arnstein, 1988, p. 91).
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 expanding scientific progress, was agreed upon: the home. This
was considered by all 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 economic and/or legal rights, they nonetheless
yielded a major moral role (Houghton, 1957; Perkins, 1987; Arnstein, 1988).
There was hostility on the part of men as well as
some women to womens emancipation. Many intelligent womenfor example, Beatrice Webb, George
Eliot, and, at times, Nightingale herselfviewed the
emancipation of their sex with apprehension. In
Nightingales case, the best word might be ambivalence. There was a fear of weakening womens moral
influence, coarsening the feminine nature itself.
This stance is best equated with cultural feminism, defined as a belief in inherent gender differences. Women, in contrast to men, are viewed as
morally superior, the holders of family values and
continuity, refined, delicate, and in need of protection. This school of thought, important in the nineteenth century, used arguments for womens suffrage such as the following: [W]omen must make
themselves felt in the public sphere because their
moral perspective would improve corrupt masculine politics. In the case of Nightingale, these cultural feminist attitudes made her impatient with the
idea of women seeking rights and activities just
43
because men valued these entities (Campbell &

Bunting, 1990, p. 21).
Nightingale had chafed at the limitations and restrictions placed on women, especially wealthy
women with nothing to do: What these [women]
suffereven physicallyfrom 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 Cassandra, which was used as a rallying cry in many feminist circles, her view of the solution 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 occupationsthat of doctor, for exampleshe viewed with
hostility, and as inappropriate for women. Why
should these women not be nurses or nurse midwives, a far superior calling, in Nightingales view,
than that of a medicine man? (Monteiro, 1984).
Welch (1990) terms Nightingale a Christian feminist on the eve of her departure to the Crimea. She
returned even more skeptical of women. Writing to
her close friend Mary Clarke Mohl, she described
women that she worked with in the Crimea as being
incompetent and incapable of independent thought
(Woodham-Smith, 1983; Welch, 1990). 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 the rights of women.
In other words, Nightingale, despite the clear
freedom in which she lived her own life, nonetheless
genderized the nursing role, leaving it rooted in nineteenth-century morality. Nightingale is seen constantly trying to improve the existing order, and to
work within that order; she was above all a reformer,
seeking to improve the existing order, not to radically change the terrain.
Lady Margaret Rhondda, leading British feminist
and wife of Lord Rhondda, the minister of food during World War I, had the following to say about reformers: [N]ow almost every womens organization
recognizes that reformers are far more common than
Feminists, that the passion to decide to look after
your fellow men, to do good to them in your way, is
far more common than the desire to put into everyones hand the power to look after themselves(cited
in Firestone, 1971). And it is clear that Nightingale
44
was foremost a reformer. The word reform comes

from the Latin re, meaning again, and formare,
meaning to form: thus, to form again, to make
better,to improve or remove faults. Readings from
the history of the humanitarian and philanthropic
movements of nineteenth-century Britain make clear
that it was reform that was on the minds of most. A
radical position calls for a whole new order; a reformist position seeks to make the existing order better, but does not question the status quo.
One of Nightingales goals, as a reformer, was to
create employment for women. In Nightingales mind,
the specific scientific activity of nursinghygiene
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 performance of every minutes practical duty. (Nightingale, 1860/1969)
And this practical duty was the work of women.
This conception of the proper division of labor resting upon work demands internal to each respective
science, nursing and medicine, obscured the professional inequality. This inequity was heightened by
the later successes of medical science. The scientific
grounding espoused by Nightingale for nursing was
ephemeral at best, as later nineteenth-century discoveries proved much of her analysis wrong, although nonetheless powerful. Much of her strength
was in her rhetoric; if not always logically consistent,
it certainly was morally resonant (Rosenberg, 1979).
Despite exceptional anomalies, such as women
physicians, what Nightingale effectively 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.
Because this natural division of labor was rooted in
the family, womens work outside the home ought to
resemble domestic tasks and complement the male
principle with the female. Thus, nursing was left
on a shifting sand 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 twentieth century.
Nightingale failed to provide institutionalized
nursing with an autonomous future, on an equal parity with medicine. She did, however, succeed in providing womens work in the public sphere, establishing for numerous women an identity and source of
employment. Although that public identity grew out
of womens domestic and nurturing roles in the fam-
ily, 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).
If cherished Victorian institutionsthe family, the
patriarchal state, and God the Fatherare examined
closely and through the life of a woman such as
Nightingale, one can see the power that surges beneath the apparent victimization of women in this
society. The subjugation of women can then be seen
as a reflexive and defensive response.
A woman, Queen Victoria, presided over the age:
Ironically, Queen Victoria, that panoply of family happiness and stubborn adversary of female independence, could not help but shed her aura upon single
women. The queens early and lengthy widowhood,
her relentlessly 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. 120121). Both
Nightingale and the queen saw themselves as working
through men, yet their lives add new, unexpected,
and powerful dimensions to the myth of Victorian
womanhood, particularly that of a woman alone and
in command (Auerbach, 1982, pp. 120121).
Nightingales clearly chosen spinsterhood repudiated the Victorian family. Her unmarried life provides a
vision of a powerful life lived on her own terms. This
is not the spinsterhood of conventionone to be
pitied, one of broken heartsbut a radically new image. She is freed from the trivia of family complaints
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 Stracheys 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 dont imagine with my talents, and my European reputation and my
beautiful letters and all that, Im going to stay
dangling around my mothers drawing room all
my life! . . . [Y]ou must look upon me as your
vagabond son . . . I shant 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)
This is the female hero, creating herself, emerging
most vividly in idioms wrested from men who could
not have imagined her (Auerbach, 1982, p. 121).
Did Nightingale fail in her basic undertaking? Was

her scope of vision, though broad enough to carry
the nursing profession into the twentieth century,
not adequate for the new twenty-first century? Was
Nightingale able to sever her ties with male politicians and medical men? Has not nursing been sold
out time and again to these same two groups? Clearly,
she did not wholeheartedly throw her lot in with the
early suffragettes. Are these some of the same reasons
the nursing profession finds itself in such an intractable position today, as Reverby has suggested? Is
the limited vision of some of our early founders still
obscuring the contemporary view of the future?
The true legacy Florence Nightingale left is that of
her own heroic lifethe life of a rebel. Florence
Nightingale lived an independent life, one that she
had fought for fiercely, on her own terms. According
to Auerbach (1982, p. 121), the Victorian spinster
lived a psychic life of silence, exile, and cunning.
For heroes of both sexes it is in such conditions that
myths are born, giving rise to new selves and new
lives. It is now up to us, individually and collectively,
to imagine and to create this new life. The gauntlet is
there, for us to pick up, if we dare.
IDEAS ABOUT NURSING:

EXPRESSIONS OF CARING
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, suggested

that nursing became a science when Nightingale
identified her laws of nursing, also referred to as the
laws of health, or nature (Barritt, 1973). The remainder of all nursing theory may be viewed as mere
branches, and acorns, all fruit of the roots of
Nightingales ideas. Early writings of Nightingale,
compiled in Notes on Nursing: What It Is and What
It Is Not (1860/1969), provided the earliest systematic perspective for defining nursing. Analysis and application of universal laws would promote well-being and relieve the suffering of humanity, according
to Nightingale. This was the goal of nursing.
As noted by the caring theorist Madeline
Leininger, Nightingale never defined human care or
caring in Nightingales Notes on Nursing (1859/
1992, p. 31), and she goes on to wonder if Nightin-
45
gale 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 Nightingales
conceptualizations 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 actions and the
drama of her life.
Nightingale did not theorize in the way we are accustomed to today. Patricia Winstead-Fry (1993), in a
review of the 1992 commemorative edition of
Nightingales 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. 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 continue to be relevant, and, some would argue, prescient.
Karen Dennis and Patricia Prescott (1985) note
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 Nightingales century-old vision
of nursing. As part of a larger study, they collected a
large base of descriptions from both nurses and physicians describing good nursing practice. Over 300 individual interviews were subjected to content analysis; categories were named inductively and validated
by four members of the project staff, separately.
Noting no marked differences in the descriptions
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 promotion of health, observation of the sick, and attention to physical environment. Also referred to by
Nightingale as the health of houses, this physical environment included ventilation of both the patients
rooms and the larger environment of the house;
light, cleanliness, and the taking of food; attention to
the interpersonal milieu, which included variety;
and not indulging in superficialities with the sick or
giving them false encouragement.
The authors note that the words change but the
concepts do not (Dennis & Prescott, 1985, p. 80).
46
In keeping with the tradition established by Nightingale, they note that nurses continue to foster an interpersonal milieu that focuses on the person, while
manipulating 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, nurse scholar, does not compare
Nightingale to contemporary nurse theorists; nonetheless, she refers to her frequently. Meleis states
that it was Nightingales conceptualization of environment as the focus of nursing activity and her
deemphasis of pathology, emphasizing instead the
laws of health (as yet unknown), that were the earliest differentiation of nursing and medicine. Meleis
(1997, pp. 114116) describes Nightingales concept 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 Nightingales observations
and experiences. The art of observation was identified 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 theoretical base of nursing might
have evolved if we had continued to consider extant
nursing practice as a source of ideas.
Pamela Reed and Tamara Zurakowski (1983/1989,
p. 33) call the Nightingale model visionary. They
state: At the core of all theory development activities in nursing today is the tradition of Florence
Nightingale. They also suggest four major factors
that influenced her model of nursing: religion, science, war, and feminism, all of which are discussed
in this chapter.
Margaret Newman, twentieth-century nurse theorist, cites Nightingale in recognizing the need for
knowledge specific to nursing. She quotes Nightingale as follows: I believe . . . that the very elements
of nursing are all but unknown . . . are as little understood for the well as for the sick (Nightingale, cited
in Newman, 1972, pp. 449453). Newman (Nightingale, 1859/1992, p. 44) was to note the following
about Nightingale: Nightingales views on health,
person-environment interaction in relation to health,
and the nurses place in facilitating health set the
direction for nursing knowledge development.
Newman states that it was Nightingale, as early as
1859, who established the essential parameters of
nursing knowledge: nurse, person, environment,
and health.
The assumptions in the following section were
identified by Victoria Fondriest and Joan Osborne
(1994).
your thoughts
NIGHTINGALES 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 utilized through observation
and empirics to define the nursing discipline.
7. Nursing is both an empirical science and an art.
8. Nursings concern is with the person in the environment.
9. The person is interacting with the environment.
10. Sick and well 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 goal of nursing is the best condition for nature to act upon (Nightassisting the patient in ingale, 1860/1969). This
retention of vital pow- must not be interpreted
as a passive state, but
ers by meeting his or her
rather one that reflects
needs and putting him or the patients capacity
for self-healing facilitaher in the best condition
ted by nurses ability to
for nature to act upon. create an environment
conducive to health. The
focus of this nursing activity was the proper use of
fresh air, light, warmth, cleanliness, quiet, proper se-
lection and administration of diet, and monitoring

the patients expenditure of energy and observing.
This activity was directed toward the environment
and the patient.
Health was viewed as an additive process, the result of environmental, physical, and psychological
factors, not just the absence of disease. Disease was
the reparative process of the body to correct a problem, and could provide 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. This was dependent upon
proper environmental controlfor example, sanitation. The environment was what the nurse manipulated. It included those physical elements external to
the patient. Nightingale isolated five environmental
components essential to an individuals health: clean
air, pure water, efficient drainage, cleanliness, and
light.
The patient is at the center of the Nightingale
model, which incorporates a holistic view of the person as someone with psychological, intellectual, and
spiritual components. This is evidenced in her acknowledgment of the importance of variety. For example, she wrote of the degree . . . to which the
nerves of the sick suffer from seeing the same walls,
the same ceiling, the same surroundings (Nightingale, 1860/1969). Likewise, her chapter on chattering hopes and advice illustrates an astute grasp of
human nature and of interpersonal relationships. She
remarked upon the spiritual component of disease
and illness, she felt they could present 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 somebody
47
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 edFive environmental factors ucation to care for
those suffering from
were essential to health: disease. Above all,
clean air, pure water, nursing was service
to God in relief of
efficient drainage, cleanman; it was a callliness, and light. ing and Gods work
(Barritt, 1973). Nursing activities 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 Nightingales
views on nursing as an art and a science. Again,
this was a reflection of the marriage, essential to
Nightingales underlying worldview, of science and
spirituality. On the surface, these might appear to be
odd bedfellows; however, this marriage flows directly from Nightingales underlying religious and
philosophic views, which were operationalized in
her nursing practice. Nightingale was an empiricist,
valuing the science of observation with the intent
of use of that knowledge to better the life of humankind. The application of that knowledge required an artists skill, far greater than that of the
painter or sculptor:
Nursing is an art; and if it is to be made an art,
it requires as exclusive a devotion, as hard a
preparation, as any painters or sculptors
work; for what is the having to do with dead
canvas or cold marble, compared with having
to do with the living bodythe Temple of
Gods 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)
of Nightingales commitment to empiricism Nursing is an art . . . It is

and experiential knowl- one of the Fine Arts; I had
edge, her early education and religious expe- almost said, the finest of
rience also shaped this the Fine Arts.
emerging
knowledge
(Hektor, 1992).
According to Nightingales 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 between person, nurse, and environment. However, neither the person nor the environment is discussed as influencing, in turn, the nurse.
Nightingales education, spiritual development, her
time in the Crimea, as well as the role of women in
the nineteenth century all affected the development
of Nightingales ideas about nursing (Figure 45).
Although it is difficult to describe the interrelationship of the concepts in the Nightingale model,
Figure 46 is a schema that attempts to delineate
this. Note the prominence of observation on the
outer circle, important to all nursing functions, as
well as the interrelationship of the specifics of the in-
Nightingales ideas about nursing health, the environment, and the person were grounded in experience; she regarded ones sense observations as
the only reliable means of obtaining and verifying
knowledge. Theory must be reformulated if inconsistent with empirical evidence. This experiential
knowledge was then to be transformed into empirically based generalizations, an inductive process, to
arrive at, for example, the laws of health. Regardless
48
terventions such as bed and bedding and cleanliness of rooms and walls that go into making up the
health of houses (Fondriest & Osborne, 1994).
Summary
NIGHTINGALES LEGACY
OF CARING
Philip and Beatrice Kalisch (1987, p. 26) describe
the popular and glorified images that arose out of the
portrayals of Florence Nightingale during and after
the Crimean Warthat of nurse as self-sacrificing, refined, virginal, an angel of mercya 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, like Florence

Nightingale (Kalisch & Kalisch, 1987, p. 20). Well
over 100 years later the amount of scholarship on
Nightingale provides a more realistic albeit still compelling portrait of a complex and brilliant woman
again, to quote Auerbach (1982) and Strachey
(1918), a demon, a rebel. . . .
There are various goals to historical inquiryto
analyze, to provide insight into current problems
through reflection on the patterns revealed in the
past. It may also have descriptive and aesthetic aims:
to document and describe anew, and to inspire and
refresh. That is the intent of this chapter.
Florence Nightingales 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
nursings caring base that began in essence with the
nursing life of Florence Nightingale. Nightingales
49
caring, as demonstrated in this chapter, extended beyond the individual patient, beyond the individual
person. She herself said that the specific business of
nursing was the least important of the functions into
which she had been forced in the Crimea. Her caring
encompassed a broadened spherethat of the British
Army, and indeed the entire British Commonwealth.
The unique aspects of her 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
enabling her to fulfill her needs for leadership and
authority. I am assuming that you are studying nursing because you care about people, because you
deeply care about health care. We are challenged, as
historian Susan Reverby noted, with the dilemma of
how to practice our integral values of caring in a
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 humanistic one. Florence
Nightingales legacy of connecting caring with activism can then truly be said to continue.
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53
Chapter 5
Hildegard E. Peplau
The Process of Practice-based
Theory Development
The Experiences of a Third-generation Peplau Student
Peplaus Process of Practice-based Theory Development
Peplaus Practice-based Process and a Program of Research
Peplau for the Future
Summary
References
Bibliography
Ann R. Peden

Hildegard Peplau was an outstanding leader and pioneer in psychiatric nursing whose career spanned
seven decades. A review of the events in her life also
serves as an introduction to the history of modern
psychiatric nursing. With the publication of Interpersonal Relations in Nursing in 1952, Peplau provided a framework for the practice of psychiatric
nursing that would result in a paradigm shift in this
field of nursing. Prior to this, patients were viewed
as objects to be observed. Peplau taught that patients
were not objects but subjects, and that we, as psychiatric nurses, must participate with the patients,
engaging in the nurse-patient relationship. This was a
revolutionary idea. Although Interpersonal Relations in Nursing was not well received when it was
first published in 1952, it has since been reprinted
(1988) and translated into at least six languages.
Hildegard Peplau was born on September 1,
1909, in Reading, Pennsylvania. She described herself as coming from a working-class family. For young
women at that time, there were limited career options: nursing, teaching, or becoming a nun. Peplau
lacked money for an education that would prepare
her to be a teacher. She chose nursing, because as a
diploma-school student, she would be paid while
working to become a registered nurse. She entered
nursing for practical reasons, seeing it as a way to
leave home and have an occupation. As she adapted
to nursing school, she made the conscious decision
that if she were going to be a nurse, then she would
be a good one (Peplau, 1998).
As a child, Peplau was a keen observer. She witnessed the influenza epidemic of 1918, and the
delirious behaviors of individuals with high fevers.
She also saw, daily, individuals who lived in her community who were considered odd or eccentric. As a
child she was not allowed to make fun of these individuals and had to be respectful toward them. Their
behaviors fascinated her.
In 1931, Peplau graduated from the Pottstown
(Pennsylvania) Hospital School of Nursing. During
Peplaus basic nursing education, psychiatric nursing
was not emphasized. She spent four afternoons a
month at Norristown State Hospital. Students were
not allowed to speak with physicians; physicians
were viewed as important people, and nursing students were the workers. No nursing instructor accompanied the students to Norristown State Hospital; however, Peplau was fortunate to meet Dr.
Arthur Noyes, who was a psychiatrist at that hospital. He encouraged students to ask questions. Peplau
described Dr. Noyes as a friend to psychiatric nurs-
56
ing, urging nurses to learn a trained technique that

would guide them in caring for psychiatric patients.
Peplau identified him as an early influence on her
nursing career.
Peplau served as the college head nurse and later
as executive officer of the Health Service at Bennington College, Vermont. While working there as a nurse,
she began taking courses that would lead to a bachelor of arts degree in interpersonal psychology. Dr. Eric
Fromm was one of her teachers at Bennington. An experience while working in the Health Service served
to pique Peplaus interest in psychiatric nursing. A
young student with symptoms of schizophrenia came
to the clinic seeking help. Peplau did not know what
to do for her. The student left Bennington to receive
treatment and returned to complete her education
later. The successful recovery of this young woman
was a positive experience for Peplau.
Bennington offered its students eight-week field
experiences during the winter. Peplau spent one of
these experiences at Bellevue, at that time the best
psychiatric program available. While at Bellevue,
Peplau attended lectures given for the medical staff
and worked on the psychiatric wards. Peplau spent
another field experience at Chestnut Lodge in
Rockville, Maryland. This experience was probably
the most influential in the development of Peplaus
ideas about interpersonal theory and nursing. While
at Chestnut Lodge, she received weekly supervision
from Freida Fromm Reichmann. She also was introduced to the work of Harry Stack Sullivan which was
an important introduction to theory development in
psychiatric nursing. Additionally, she spent field experiences with Dr. David Levy, a leading child psychiatrist of that time, and did private duty nursing
with psychiatric patients who were confined to their
homes. These experiences fueled Peplaus interest in
psychiatric nursing (Peplau, 1998).
Upon graduation from Bennington, Peplau joined
the Army Nurse Corps. She was assigned to the
School of Military Neuropsychiatry in England. This
experience introduced her to the psychiatric problems of soldiers at war and allowed her to work with
many great psychiatrists, including the Menningers.
After the war, Peplau attended Columbia University
on the GI Bill and earned her masters in psychiatricmental health nursing.
In 1946, the Mental Health Act was passed. It
identified four disciplines that would receive federal
support for education. During the first few years after this act was passed, schools with programs in
psychiatric nursing could not spend all the money allotted. There were, at that time, few programs that
offered masters degrees, fewer teachers who could
teach in these programs, and a limited number of students with bachelors of science in nursing degrees
who were eligible. Psychiatric nursing was ripe for
a leader to emerge.
After her graduation in 1948, Peplau was invited
to remain at Columbia and teach in their masters
program. She immediately searched the library for
books to use with students, but she found very few.
At that time, the psychiatric nurse was viewed as a
companion to patients, someone who would play
games and take walks but talk about nothing substantial. In fact, nurses were instructed not to talk to patients about their problems, thoughts, or feelings.
Peplau began teaching at Columbia, knowing that
she wanted to change the education and practice of
psychiatric nursing. There was no direction for what
to include in graduate nursing programs. She took
educational experiences from psychiatry and psychology and adapted them to nursing education.
Peplau described this as a time of innovation or
nothing. Peplaus innovation in nursing education
was criticized by her colleagues.
Her goal was to prepare nurse psychotherapists,
referring to this training as talking to patients
(Peplau, 1960, 1962). She arranged clinical experiences for her students at Brooklyn State Hospital, the
only hospital in the New York City area that would
take them. At the hospital, students were assigned to
back wards, working with the most chronic and severely ill patients. Each student met twice weekly
with the same patient, for a session lasting one hour.
According to Peplau, the nurses resisted this practice
tremendously and thought this was an awful thing to
do (Peplau, 1998). Using carbon paper, verbatim
notes were taken during the session. Students then
met individually with Peplau to go over 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.
Peplau struggled daily to keep her students working at this clinical site. She and her students were
challenged not to make waves or risk losing this experience at Brooklyn State. Although they were assigned to the most severely ill patients, Peplau and
her students met few licensed personnelonly untrained attendants. As patients showed improvement
as a result of the interactions with Peplau and her
students, the untrained staff behaved in ways that
seemed to indicate that they wanted patients to stay
sick. This was Peplaus first introduction to illnessmaintaining behaviors that were common in state
hospitals. As she reported, The pathology of the patients we worked with was so blatant, we couldnt
miss it (Peplau, cited in Hatherleigh, 1998).
In 1955, Peplau left Columbia to teach at Rutgers,

where she began the Clinical Nurse Specialist program in psychiatric-mental health nursing. The students were prepared as nurse psychotherapists, developing expertise in individual, group, and family
therapies. Peplau required of her students unflinching self-scrutiny, examining their own verbal and
nonverbal communication and its effects on the
nurse-patient relationship. Students were encouraged to ask, What message am I sending?
In 1956, Peplau began spending her summers
touring the country, offering week-long clinical
workshops in state hospitals. This activity was instrumental in teaching interpersonal theory and the importance of the nurse-patient relationship to psychiatric nurses. The workshops also provided a forum
from which Peplau could promote advanced education for psychiatric nurses. Her belief that psychiatric nurses must have advanced degrees encouraged
large numbers of psychiatric nurses to seek masters
degrees and eventual certification as psychiatricmental health clinical specialists.
During her career as a nursing educator, a total
of 100 students had the opportunity to study with
Peplau. These students have become leaders in psychiatric nursing. Many have gone on to earn doctoral
degrees, becoming psychoanalysts, writing prolifically in the field of psychiatric nursing, and entering
and influencing the academic world. Their influence
has resulted in the integration of the nurse-patient relationship and the concept of anxiety into the culture of nursing. In 1974, Peplau retired from Rutgers.
This allowed her more time to devote to the larger
profession of nursing. Throughout her career, Peplau
actively contributed to the American NursesAssociation (ANA) by serving on various committees and
task forces. Peplau lived in New York City and later
New Jersey; this close proximity to ANA and National
League for Nursing (NLN) headquarters enabled her
to participate in policy making and influence nursing
practices (Sills, 1998). She served as chairperson of
the ANA Division of Psychiatric Mental Health Nursing and was a member of the ANA Congress on Nursing Practice. As a member of this congress, Peplau argued for the certification of specialists in nursing.
She is the only person who has been both the executive director and president of ANA. Peplau served on
the ANA committee that wrote the Social Policy
Statement. For the first time in nursings history,
nursing had a phenomenological focushuman
responses.
Peplau held 11 honorary degrees. In 1994, she
was inducted into the American Academy of Nursings Living Legends Hall of Fame. She was named
Chapter 5 Hildegard E. Peplau The Process of Practice-based Theory Development
57
one of the 50 great Americans by Marquis Whos

Who in 1995. In 1997, Peplau received the Christiane Reiman Prize, nursings most prestigious
award. In 1998, she was inducted into the ANA Hall
of Fame.
Internationally, Peplau was an advisor to the
World Health Organization (WHO); she was a member of their First Nursing Advisory Committee and
contributed to WHOs first paper on psychiatric nursing. She served as a consultant to the Pan-American
Health Association, and served two terms on the International Council of Nurses Board of Directors.
Even after her retirement, she continued to mentor
nurses in many countries.
Peplau entered the field of psychiatric nursing at a
time when there were no role models. She described
herself as never having a mentor, although she mentored countless students and nurses herself. As she
was developing as a psychiatric nurse and leader,
Peplau learned more from the many psychiatrists she
worked with than from nurses. Grayce Sills, colleague and long-time friend of Peplau, wrote, [T]he
persistent theme is that of a woman of uncommon
intellect, socialized outside the 1940s model of nursing in the United States, who developed a paradigm
of professionalism. She then brought, in a half century of commitment, a model of professionalism that
has permeated every aspect of her long and distinguished career. It is a legacy that will survive and
continue to serve the profession well into the 21st
century (Sills, 1998, p. 171).
Hildegard Peplau died in March 1999 at her home
in Sherman Oaks, California.
THE EXPERIENCE OF A THIRDGENERATION PEPLAU STUDENT

In 1987, I began doctoral study at the University of
Alabama at Birmingham. At that time, Dr. Elizabeth
Morrison was assigned as my faculty advisor and
chaired my dissertation committee. Dr. Morrison is
one of the 100 students who studied directly with
Peplau and is a Peplau scholar. Peplau described her
as a professors delight: intelligent, responsible, responsive, career-oriented and always cheerful . . .
she has taken her own career and further professional development seriously and has contributed
greatly to the advancement of the profession
(Peplau, personal communication, September 16,
1998). After Dr. Morrisons graduation from Rutgers,
she maintained a relationship with Peplau and has
tested Peplaus theory in practice (Morrison, 1992;
Morrison, Shealy, Kowalski, LaMont, & Range, 1996).
58
While beginning work on my dissertation, I began

to read the writings of Peplau more carefully. Like
most psychiatric nurses, I applied her interpersonal
theory in my clinical practice. I had actually been
taught interventions developed by Peplau as an undergraduate nursing student in psychiatric nursing.
However, like many nurses educated before the
1980s, I was not told that a theorist named Peplau
was guiding my practice. This I discovered after graduating from my baccalaureate program, when I began to read Peplaus work, especially her writings on
anxiety and hallucinations (Peplau, 1952, 1962). In
the course of reading her work with the eye of a
doctoral student, I discovered her paper on theory
development that had been presented at the first
Nursing Theory Conference in 1969. In that paper,
Peplau (1989a) described the process of practicebased theory development. Reading this work
was very exciting. In the paper, Peplau described
a methodology for developing theory in practice.
This will be described more completely later in this
chapter.
As my dissertation proposal developed, Dr. Morrison encouraged me to send it to Peplau for her to
read. This idea made me extremely anxious, but Dr.
Morrison persisted. She had talked to Peplau and
Peplau said that she would be glad to read my proposal. This began a correspondence with Peplau that
continued for years, until her death in 1999. She enriched my professional life and I am honored that she
was interested in what I thought and what I was doing. When considering the link between Peplau, Elizabeth Morrison, and me, I consider myself a thirdgeneration student of Peplau. From the beginning of
her research career, Peplau provided guidance, direction, and feedbackanswering many questions,
sharing resources, and providing contacts with other
psychiatric nurse researchers. She shared her knowledge and expertise with countless numbers of psychiatric nurses. In fact, this has been a hallmark of
her professional lifesharing, developing, and responding to nurses as they sought knowledge. Psychiatric nursing has benefited from the leadership of
this scholar who was always ahead of her timea
pioneer who led the way in nursing.
PEPLAUS PROCESS OF PRACTICEBASED THEORY DEVELOPMENT

In 1969, at the first Nursing Theory Conference,
Hildegard Peplau proposed a research methodology
to guide development of knowledge from observations in nursing situations (Peplau, 1989a, p. 22).
Peplau asserted that nursing was an applied science

and that nurses used established knowledge for beneficial purposes. According to Peplau (1988, p. 12),
nurses not only use the knowledge that producing
scientists publish, but they, in practice, create the
context whereby this knowledge is transformed into
nursing knowledge, linking nursing processes with
nursing practice (Reed, 1996). Peplau urged nurses
to use nursing situations as a source of observations
from which unique nursPeplau urged nurses to use ing concepts could be
derived. Practice pronursing situations as a vided the context for
source of observations initiating and testing
nursing theory. To difrom which unique nursing
rect nurses in the deconcepts could be derived. velopment of practicebased theory, Peplau
(1989a) proposed a three-step process that would assist in this pursuit.
Theory development begins with observations
made in practice. In the first step, the nurse observes a phenomenon, which is then named, categorized, or classified. The nurse relies on an already existing body of knowledge from which to derive the
name of the concept or phenomenon. By relying on
existing literature to assist in naming the concept,
further information about the concept is gained. Included in this step are the continuing clinical observations of the nurse who seeks regularities in the
phenomenon. Peplau (1952) identified several methods of observation, including participant observation, spectator observation, and interviewer and random observation. Participant observation, in which
the nurse observes while participating, yields the
most valuable clinical knowledge. This includes the
recording of observations of both self and other in

order to analyze the interpersonal process. Peplau
identified the participant observer as one of the characteristic roles of the professional nurse (Peplau,
1989b). Validation of the nurses observations, either
with other professionals or with patients, is encouraged, in order to decrease observer bias (Peplau,
1989c). A nurse enters clinical situations with theoretical understanding, personal bias, and previously
acquired nursing knowledge (Reed, 1996, p. 31).
In the second step of the process, the nurse sorts
and classifies information about the phenomenon.
Decoding, subdividing data, categorizing data, identifying layers of meaning at different levels of abstraction, and applying a conceptual framework to explain the phenomenon may occur as a means of
interpreting observations (Peplau, 1989b). At that
time, a structure for obtaining more information
about the phenomenon emerges. Further observation or interviewing leads to a clearer, more explicit
description of the phenomenon or concept. The
nurse works to identify all of the behaviors associated with the concept. Included in this step is the
collection of information about patterns or processes
that accompany the phenomenon.
Using Peplaus process, clinical data are collected
via observation and interview. Verbatim recordings
of interactions with patients are examined for regularities. The nurse, as the interviewer, assists the patient in providing a thorough description of the concept or process. Peplau (1989d) offered interview
techniques that encouraged description, for example: Describe one time that you were . . .; Describe
one example . . .; Say more about that . . .; and Fill
in the details about that experience (Peplau, 1989d,
pp. 221222). Only by thorough description of the
your thoughts
59
concept or process can the nurse assure that all

of the behaviors associated with the process are
identified.
The last step of the process leads to the development of interventions. Peplau viewed nursing interventions as those that assisted patients in gaining interpersonal and intellectual competencies evolved
through the nurse-patient relationship (OToole &
Welt, 1989, p. 351). Useful interventions are derived
and tested (Peplau, 1989c).
Peplau used this process to study clinical phenomena. Both she and her students collected verbatim recordings of interactions with patients. These
recordings were examined for regularities. Similarlooking data were then transcribed onto 3-by-5-inch
index cards, which were then sorted, classified, and
counted. As early as 1948, Peplaus students at Teachers College (Columbia University) were asked to
make carbon copies of their interactions with patients. Peplau studied these and noticed that the students could not talk in a friendly way until the patients had said I need you or I like you. Her analysis
of similar nurse-patient interactions led to her theory
of anxiety and subsequently to nursing interventions
to decrease anxiety (OToole & Welt, 1989).
ber 14, 1990). Verbatim transcripts of the audiotaped

interviews were analyzed. The process of recovering
in women who were
depressed was initiated
Peplaus process provided
by a crisis or turning
point experience. It direction and structure for
continued with profes- four studies of women resional support and the
support of friends and covering from depression,
family. Recovering, ac- concluding with testing a
cording to the participants, required determi- nursing intervention.
nation, work over time,
and a series of successes that enhanced self-esteem
and maintained balance. The process was dynamic,
occurring in a nonserial order, with back-and-forth
movement among the categories and phases. It was
internal and ongoing. This study raised many questions and provided further direction for study. While
participating in the interviews, the women shared
strategies or techniques that facilitated recovering
(Peden, 1994). These included cognitive skills, positive self-talk, and use of affirmations. They also identified negative thinking as the most difficult symptom to overcome.
Follow-up Study
PEPLAUS PRACTICE-BASED
PROCESS AND A PROGRAM
OF RESEARCH
Peplaus process of practice-based theory development has directed a program of research in the area
of depression in women (Peden, 1998). Beginning
with the identification of a clinical phenomenon,
women recovering from depression, and culminating in the testing of an intervention to reduce negative thinking in depressed women, Peplaus process
of practice-based theory development has provided
direction and structure for four studies.
The treatment of depression had been studied extensively. However, lacking in the literature were
womens accounts of recovering from depression. A
thorough description of the process of recovering in
women with depression was not reflected in the literature. The identification of a clinical phenomenon
and a review of available information related to that
phenomenon were the first step in Peplaus process.
In the second step, a descriptive, exploratory
study (Peden, 1993) was conducted. Seven women
who were recovering from depression were interviewed and a process of recovering was described.
Peplau assisted in the design of the semistructured
interview guide (personal communication, Decem-
60
Continuing in step 2 of the process, a follow-up

study (Peden, 1996) was conducted a year later, to
describe further the process of recovering in women
who had been depressed. No new phases of the recovering process were identified. Interventions that
assisted patients in recovering instilled hope, were
psychoeducational in nature, included cognitive interventions that change thinking styles, and provided for individualized treatment.
Pedens study (1996) concluded with the realization that more information was needed on the symptom of negative thinking. To understand a phenomenon, one must analyze its etiology, its cause, its
meaning, and any clues to successful intervention
(Peplau, 1989c). At the suggestion of Peplau (personal communication, January 16, 1993), work began, returning to the first step of the process, to
gather more information about the symptom of negative thinking.
Negative Thinking
A qualitative study (Peden, 2000) was designed to describe the nature or inherent quality of negative
thoughts, their content or subject matter, and the
origins of the negative thoughts experienced by
women with major depression. The participants also
shared strategies they used to manage the negative
thoughts. The sample consisted of six women with a

diagnosis of major depression who were experiencing or had experienced negative thoughts and were
willing to talk about the experiences. The women
participated in a series of six group interviews, the
purpose of which was to elicit negative views/
thoughts held by the group participants. The group
interviews were conducted weekly, for 6 consecutive weeks. Each interview lasted 1 hour. A semistructured interview guide, developed in consultation with Peplau (personal communication, January
16, 1993), was used to facilitate the interviews. The
group interviews focused on the womens life experiences, views of self and significant others, lifestyles,
and past experiences. Descriptions of negative
thoughts held by the women were sought.
Verbatim transcripts were examined for regularities (Peplau, 1989b). A coding guide was developed.
Codes were derived from available literature and
based on recommendations from Peplau (personal
communication, January 16, 1993); other codes that
emerged from the initial review of the data. Codes included negative thinking related to self, negative
thinking related to significant others, interactions
with significant others, and developing view of self.
After coding the data, recurring themes were sought
(Peplau, 1989a).
For the six women who participated in the study,
the negative thoughts had their origins in childhood.
Common childhood experiences included suppression of emotion, restrictive parenting, learning to be
passive, lack of praise or compliments, high parental
expectations, stifled communication, and lack of
emotional support. The negative thoughts focused
primarily on self, being different, disappointing self
and others, not being perfect, and always failing. The
women described their self-talk as constant, negative,
and demeaning. They identified various means of
managing the negative thoughts. Once again, the use
of affirmations, positive self-talk, and learning to
change thinking were identified as reducing negative
thinking. Steps 1 and 2 of the process of practicebased theory development had provided direction for
moving into the third step, design of an intervention.
Testing an Intervention
A 6-week group intervention was designed specifically to incorporate cognitive-behavioral techniques
to assist in reducing negative thinking in depressed
women. As described earlier, thought stopping and
positive self-talk (or affirmations) were identified as
key strategies in reducing negative thoughts. The intervention was designed using specific content from
Gordon and Tobins (1991) Insight program, The De-
pression Workbook (Copeland, 1992), and the investigators own clinical experiences with depressed
women. Affirmations, direct actions, thought stopping, and information on distorted thinking styles
were introduced to the group members. Depressed
women benefit from group treatment (Gordon & Tobin, 1991; Van Survellan & Dull, 1981). Group sessions allow contact with peers with similar problems, reduce isolation, promote change, and are
cost-effective. Guided by Peplaus (1952) Theory of
Interpersonal Nursing, the introduction of cognitivebehavioral techniques did not occur until the second
group session. The focus of the first week was on enhancing the development of the nurse-patient relationship to decrease anxiety, increase trust and security within the group, and lay the foundation for the
intervention.
To pilot-test the intervention, 13 women with a
diagnosis of major depression were randomly assigned either to a control or to an experimental
group. All subjects were under psychiatric care in an
outpatient clinic and receiving antidepressant medication. The experimental group (n = 5) participated
in the 6-week cognitive-behavioral group intervention for 1 hour per week. The control group (n = 8)
continued with routine psychiatric care.
Pre- and post-test measures were collected on depression using the Beck Depression Inventory (Beck,
Ward, Mendelson, Mock, & Erbaugh, 1961) and negative thinking using the Crandall Cognitions Inventory (Crandall & Chambless, 1986) and the Automatic Thoughts Questionnaire (Hollon & Kendall,
1980). Feedback from the five participants in the experimental group indicated that the intervention was
beneficial. There were significant decreases from
pretest to post-test in the experimental group in negative thoughts ( p < .05) and depressive symptoms
( p < .05) and an increase in self-esteem ( p < .05).
The reduction in depressive symptoms in both
groups was expected. However, for the experimental group, the Beck Depression Inventory (BDI)
mean scores decreased from 22 (moderate to severe
depression) to 7 (normal), a reduction of 15 points
from pre- to post-test. For the control group, the
Beck scores decreased from 18 (moderate depression) to 11 (mild depression), a reduction of 7 points.
Although the sample size was small, the intervention
had a significant positive effect on depression.
Testing the Intervention with

At-Risk Women
Upon recommendation of Peplau (personal communication, January 16, 1993), the intervention was
61
your thoughts
tested on at-risk college women to determine if it

had preventive effects (Peden, Hall, Rayens, &
Beebe, 2000). A randomized controlled prevention
trial was conducted to test the efficacy of a cognitivebehavioral group intervention in reducing negative
thinking and depressive symptoms and enhancing
self-esteem in a sample of 92 college women ages 18
to 24. Depression risk status was determined by
scores on the Center for Epidemiologic StudiesDepression Scale (CES-D) (Radloff, 1977) and the BDI
(Beck and coworkers, 1961).
As they were enrolled, the participants were randomly assigned to either the control or experimental
groups. Those participants assigned to the experimental group participated in the 6-week cognitivebehavioral group intervention. Data on self-esteem,
depressive symptoms, and negative thinking were
collected from both groups 1 month after the intervention and at 6-month follow-up sessions to assess
the interventions long-term effects. Currently, 18month follow-up data are being collected.
Based on the preliminary findings of this study,
the intervention did have a positive effect on depressive symptoms, negative thinking, and self-esteem in
a group of at-risk college women. Reducing negative
thinking in at-risk individuals may decrease the risk
for depression. At this point, plans are underway to
test the intervention with other at-risk groups to continue to gather support for its preventive effects.
PEPLAU FOR THE FUTURE

Study of Peplaus work is very timely. She proposed,
in 1969, using practice as the basis for theory development. At that time this was a radical idea. Now the
trend is to return to practice for knowledge develop-
62
ment. Peplau used clinical situations to derive theories inductively that were then tested in clinical practice. She also applied existing social science theories
to nursing phenomena, combining induction (observation and classification) with deduction (the application of known concepts and processes to data).
This provided a creative, nonlinear approach to the
formation of ideas.
She also proposed the linkage of qualitative and
quantitative methods. Using her methodology, the
nurse would begin with an in-depth look at a phenomenon, which would evolve into a quantitative
study testing an intervention directed at the phenomenon. These ideas, proposed during the positivist period of nursing, were
highly revolutionary. It Peplaus theory keeps
is unlikely that Peplaus
contemporaries would pace with postmodern
have embraced her pro- influences, reinforcing
cess of practice-based
theory development. In nurses awareness of the
fact, the debates related knowledge-rich context
to knowledge developof practice, at the level of
ment in nursing and the
accompanying quantita- the patient.
tive/qualitative rift did
not occur until the 1980s. However, as nursing has
come to recognize practice knowledge as one of the
ways of knowing, researchers may return to Peplaus
ideas offered at the first Nursing Theory Conference
(Peplau, 1969) for direction.
Peplaus theory is very timely today, keeping pace
with the postmodern influences that have reinforced
nurses awareness of the knowledge-rich context of
practice, at the level of the patient. A study of
Peplaus work introduces you to a woman whose
ideas were ahead of her time. These ideas have

arrived!
Summary
Peplaus process of practice-based theory development came at a time in nursing when grand theories
were being developed and theoretical nursing was
highly valued. These theories are now being criticized as too broad and too remote from nursing to be
applied. The trend now is to return to practice for
knowledge development. Peplau, always ahead of
her time, provided an approach to knowledge development through the scholarship of practice; nursing
knowledge is developed in practice as well as for
practice (Reed, 1996, p. 29). Peplau used observations in clinical situations as the basis for hypotheses
and interventions that were then tested in clinical
practice. She also applied existing theories from the
social sciences to nursing phenomena:
The process of combining induction (observation and classification) with deduction (the application of known concepts and processes to
data) provides a creative nonlinear approach
to the formation of ideas, one that uses the
data of practice, as well as extant theories as
the basis of those formulations. (OToole &
Welt, 1989, p. 355)
Peplaus methodology also linked qualitative and
quantitative methods. After a qualitative, in-depth
look at a phenomenon, a quantitative study would be
developed to test an intervention directed at the phenomenon. Peplaus ideas and approach to nursing
were highly revolutionary at the time; few of her
contemporaries openly embraced her process of
practice-based theory development. It was not until
the 1980s that nursing scholars debated approaches
to knowledge development in nursing and a rift developed between advocates of quantitative versus
qualitative approaches. However, as nursing has
come to recognize practice knowledge as one of the
ways of knowing, researchers may return to the
ideas Peplau offered at the first Nursing Theory Conference (Peplau, 1989a) for direction:
Peplaus theory has kept pace with post modern influences that have reinforced nurses
awareness of the knowledge-laden context of
practice, at the level of the patient. (Reed,
1996, p. 30)
The use of Peplaus process of practice-based
theory development as a research methodology has
provided the structure for developing my program of

research in the area of depression in women. The
identification of a clinical problem and an in-depth
look at its etiology, patterns, and processes directed
the design and testing of an intervention. As interventions were tested and supported in clinical research, the findings were reported to support the
growing body of psychiatric nursing knowledge.
Peplaus Theory of Interpersonal Nursing and her
mentorship have been invaluable to me in developing each phase of my research program.
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66
group. Comprehensive Nurse Quarterly, 5(3),

6681.
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Peplau, H. E. (1987). American NursesAssociation social policy statement: Part I. Archives of Psychiatric
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CHAPTERS AND PAMPHLETS
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Peplau, H. E. (1968). Operational definitions and nursing practice. In Zderad, L. T., & Belcher, H. C.
(Eds.), Developing behavioral concepts in nursing.

Atlanta: Southern Regional Education Board.
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Peplau, H. E. (1992). Notes on Nightingale. In F.
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THESES
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Project, Teachers College, Columbia University,
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67
Chapter 6
Clinical Nursing: A Helping Art
The Evolution of Wiedenbachs Prescriptive Theory
The Prescriptive Theory
Wiedenbachs Theory and Clinical Practice
Wiedenbachs Theory and Clinical Teaching
Summary
References
Bibliography
Theresa Gesse and Marcia Dombro

The focus of this chapter is a review of the theoretical
work of Ernestine Wiedenbach. A complete acknowledgment of her work, however, must include something about this extraordinary person who lived the
philosophy that was the basis of her nursing theory.
Wiedenbach was born in 1900 in Germany to an
American mother and a German father who migrated
to the United States when Ernestine was a child. The
affluent family supported the idea of a college eduction for their daughter and she graduated with a
bachelor of arts degree from Wellesley College in
1922. Her later interest in a nursing career was reluctantly accepted by her family. Pursuing nursing in
this era was atypical for someone who came from a
family of gentility.
Her independent characteristics overruled her
parents reluctance and she enrolled in a hospital
school of nursing. Early in her studies there, her advocacy for quality nursing education and her leadership role with her classmates resulted in dismissal
from the school. Through the intervention of friends
and faculty, including that of Adelaide Nutting, who
realized her potential, she was admitted to Johns
Hopkins School of Nursing and graduated in 1925
(Nickel, Gesse, & MacLaren, 1992.)
Wiedenbach had many interests and held a variety
of professional positions. Because of her interest in
education, she began taking graduate courses parttime at Columbia University. She was also involved
with the New York State NursesAssociation and with
various nursing committees. After completing a master of arts in 1934, she became a professional writer
for the American Journal of Nursing (AJN).
This position brought new opportunities to experience many different facets of nursing and to meet
national leaders in both nursing and health care. Her
tenure in the AJN office included the years during
World War II, when she played a critical role in the
recruitment of nursing students and military nurses.
After the war, she returned to clinical practice
and to her love of maternal-child nursing. At age 45,
she began her studies in nurse-midwifery. At the Maternity Center in New York City, her personal mentors included such pioneers as Hazel Corbin and Hattie Hemschemeyer.
In 1952, Wiedenbach joined the faculty of Yale
University School of Nursing where her roles as
practitioner, teacher, author, and theorist would be
consolidated. She retired from Yale in 1966 as an associate professor emeritus and subsequently held
part-time positions at California State University and
the University of Florida. She eventually moved to a
70
Miami, Florida, retirement village with her college

roommate and lifelong friend, Caroline Falls.
In 1972, Marcia Dombro, who was active in Miamis childbirth education movement, heard that
Wiedenbach was living nearby. She telephoned and
requested Wiedenbachs participation in a childbirth
education conference being held at Florida International University (FIU). Wiedenbach graciously accepted and invited Dombro to her house for tea to
discuss it further.
Following this contact and the childbirth education conference, Wiedenbach and Falls became involved in developing and teaching a university
course on communication in nursing. Her pattern of
intellectual productivity continued with the publication of another book: Communication: Key to Effective Nursing (Wiedenbach & Falls, 1978).
Wiedenbachs love for interaction with students
persisted even after her mobility decreased. She and
Caroline Falls continued to give informal seminars in
their home for Professor Theresa Gesse and the University of Miami nurse-midwifery students. They enjoyed discussing the past, present, and future of
nursing and nurse-midwifery and she always reminded students and faculty of the need for clarity of
purpose, based on reality.
This rekindling of ties to the nursing education
community did not deter Wiedenbach from being an
advocate for the residents of the retirement village.
She was an activist in promoting change in policies
and practices related to nutrition and creative activities for the many talented residents now in their late
stages of life. She was adamant about improvement
of the quality of life and level of independence for
those who lived in the village, where she continued
to apply her prescriptive theory of nursing in everyday living. 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. Wiedenbach continued to be
productive and maintain a central purpose as long as
she was able.
In 1992, events began to occur that profoundly affected Wiedenbachs remaining years. During this period, her friend Caroline Falls died of heart failure,
and Hurricane Andrew destroyed the retirement village, causing a temporary relocation into unfamiliar
surroundings. Susan Nickel, who had become a personal friend, searched for Wiedenbach after the
storm and found her in an area nursing home.
Wiedenbach was much in need of the caring that she
herself had promoted so strongly in nursing. Wiedenbach stayed at Ms. Nickels home for several months
until the retirement village was restored.
your thoughts
Until the end of her life, Wiedenbach continued

to maintain the independent spirit that originally fueled her productivity and creativity. In April 1998,
Wiedenbach died at age 98.
THE EVOLUTION OF
WIEDENBACHS
PRESCRIPTIVE THEORY
Fellow Yale University faculty members William Dickoff and Patricia James were acknowledged by Wiedenbach for noting her early theory conceptualization
and for their continuing guidance in its development. They were professors and theorists in Yales
Department of Philosophy who conducted seminars
for the School of Nursing faculty on philosophical
constructs, theory development, and research. It
was through this association that Wiedenbach initially sought their feedback on her work, which they
determined was a prescriptive theory. In Wiedenbachs words, I had written the first book, Dickoff,
James and Wiedenbach (1968), Family Centered Maternity Nursing, and Bill and Pat read it. We were discussing it and they said, You know, its interesting.
Youve really followed pretty much the pattern of a
prescriptive theory. They said, Yes, you have the
agent, you have the recipient.
Ida Orlando was a fellow faculty member at Yale.
According to Wiedenbach, she was interested in the
dynamics of interaction and was anxious to have a
clinical area where she could put her theories to
practice. Wiedenbach encouraged Orlando: By all
means, go ahead, do it right here on the maternity
service. . . . [We] used to talk a great deal about purpose. This was one of the things that startled me
when I was teaching students. I would ask them, . . .

Whats your purpose in nursing? They would look
blank and they would just say, Its just to take care of
people . . . of those
who need care. Thats Theory is an abstract phenot a real purpose in
nursing. It is your nomenon that lies dormant
commitment which in the mind until it is
specifies what you
want to accomplish given expression either
through your actions. through action and/or
So I had in my book,
the purpose, and through words.
talked
about the
agent, which is the nurse [and] the recipient, who
would be the mother or the family (Nickel, 1981b,
videotaped interview).
Another colleague at Yale was Virginia Henderson,
who, along with Wiedenbach and Orlando, made
unique contributions to nursing theory. Orlando was
the youngest of the three, by more than 25 years.
They frequently discussed their shared belief in the
integration of mind, body, and spirit (Nickel, 1981a,
videotaped interview).
THE PRESCRIPTIVE THEORY

The following are excerpts from Wiedenbachs personal papers, in which she explained the essence of
her prescriptive theory. In an unpublished paper presented at Duke University on May 8, 1970 (Wiedenbach, 1970, p. 1), she prefaced her presentation
with impressions about the topic title she had been
given. She stated, I take issue with the concept implied in your topic for inquiry, namely Application of
Chapter 6 Ernestine Wiedenbach Wiedenbachs Clinical Nursing: A Helping Art
71
Theory to Nursing Practice. It suggests to me that

theory is something apart from practiceand that it
must be developed and then appliedlike one might
a poulticeto nursing practice.
She then defined theory as an abstract phenomenon that lies dormant in the mind until it is given
expression either through action and/or through
words (Wiedenbach, 1970, p. 1). She continued,
[P]ractice is a concrete phenomenon, characterized
primarily by action. And when that action is goaldirected, as nursing practice may be said to be, then
practice immediately becomes theory-based. Theory
thus would seem to be inextricably interlocked with
practice. . . . To say that theory may be applied to
practice suggests, furthermore, that practice precedes theory (we practice first and then formulate a
theory for our practice). Actually I think it is the
other way around. Theory of some sort precedes
practice (Wiedenbach, 1970, p. 1).
Wiedenbachs explanation of her prescriptive
theory follows: Account must be taken of the motivating factors that influence the nurse not only in doing what she does but also in doing it the way she
does it with the realities that exist in the situation in
which she is functioning. Such account is incorporated in a prescriptive theory (Wiedenbach, 1970,
p. 2).
Three ingredients essential to a prescriptive theory
are:
1. The nurses central purpose in nursing. It constitutes the nurses professional commitment.
2. The prescription. It indicates the broad general
action that the nurse deems appropriate to fulfillment of her central purpose.
3. The realities. They are the aspects of the immediate situations that influence the results the nurse
achieves through what she does (Wiedenbach,
1970, p. 3).
During the presentation, Wiedenbach referred to
her article in the American Journal of Nursing
(1963) and her book, Meeting the Realities in Clinical Teaching (1969), in which she presented her
concept of prescriptive theory. However, during this
presentation, she expressed the need at this time to
elaborate further on these concepts to her audience.
The following is her explanation of the components
of the theory and their interrelationships: It defines
the quality [the nurse] desires to bring about or sustain in her patients condition, attitude, or situation,
and specifies what she recognizes to be her social responsibility in caring for him. It is the outcome that
ideally she consistently strives to obtain through her
nursing action (Wiedenbach, 1970, p. 3).
72
She emphasizes that the nurses central purpose is

grounded in her philosophy, those beliefs and values that shape her attitude toward life, toward fellow
human beings and toward herself. The three concepts that epitomize the essence of a philosophy are:
1. Reverence for the gift of life.
2. Respect for the dignity, autonomy, worth, and individuality of each human being.
3. Resolution to act dynamically in relation to ones
beliefs. (Wiedenbach, 1970, p. 4)
She took the position that one must explore each
of these, since the beliefs on which a philosophy is
founded, determine the validity of the concept. If
the concepts have meaning for the nurse and she can
subscribe to them, that will serve her as valuable
guides for making choices and decisions. For example, the second conceptrespect for the dignity, autonomy, worth and individuality of each human beingwhen I explored it for the beliefs on which I
think it is founded, revealed, among others, the following four beliefs:
1. Each human being is endowed with unique potential to developwithin himselfresources
that enable him to maintain and sustain himself.
2. The human being basically strives toward selfdirection and relative independence, and desires
not only to make best use of his capabilities and
potentialities, but to fulfill his responsibilities as
well.
3. The human being needs positive social interaction in order to make best use of his capabilities
and realize his self-worth.
4. Whatever the individual does, represents his best
judgment at the moment of doing it. (Wiedenbach, 1970, p. 4)
Wiedenbach felt that her beliefs guided her thinking when trying to formulate a statement of purpose
that I can regard as my central purpose in nursing.
She went on to say, Because you may want to know
what it is, Ill state it. It is to motivate the individual
and/or facilitate his efforts to overcome the obstacles
that may now as well as later, interfere with his ability to respond capably to the demands made of him
by the realities in his situation (Wiedenbach, 1970,
p. 4).
She emphasized that this was her own central
purpose in nursing, and that otherseach of you,
for instance, may hold different beliefs and thus you
may see your overall commitment in nursing somewhat differently from the way I see mine. She was
equally emphatic that it is a personal central purpose in nursing rather than the central purpose of
nursing (Wiedenbach,
1970 [emphasis added]).
central purpose in nursing She further stated: To
formulate ones central
is a soul-searching purpose in nursing is a
experience. soul-searching experience. Has each of you, I
wonder, undergone it, and are you willing and ready
to present your central purpose in nursing for examination and discussion when appropriate? (Wiedenbach, 1970, p. 5).
In her elaboration of the second component, prescription, Wiedenbach explained that it specifies
both the nature of the action that will most likely
lead to fulfillment of the nurses central purpose in
nursing, and the thinking process that determines it.
She categories nursing as a practice that is disciplineand goal-directed: [P]resumably, the nurse has
thought through the kind of results she wants to obtain from what she does, gears her action to obtaining them and accepts accountability not only for
what she does but for the outcome of her acts as
well. Nursing action, thus, is a deliberate action
(Wiedenbach, 1970, p. 5).
It is in the explanation of deliberate action that
Wiedenbach illustrates the linkage of these components with the concepts of her philosophy. She delineates three kinds of deliberate action:
To formulate ones
1. Mutually understood and agreed upon

2. Patient-directed
3. Nurse-directed
Each of these three may have a very different effect on the patienta fact that the nurse needs to
recognize before she acts. . . . The kind of action she
will resort to, depends, I think, on her clarity about
her central purpose in nursing, and consequently on
the way she may view the patient at any particular
moment that she is caring for him (Wiedenbach,
1970, p. 6).
Wiedenbach then presented an example of a
nurses bed-bath assignment to illustrate her point.
Note the incorporation of her philosophical concepts:
Her action may be considered to be mutuallyunderstood and agreed-upon, if it reflects that
she respects the patients dignity, worth, autonomy and individuality, and she makes sure
that [the patient] is psychologically receptive
to her giving him the bath before she starts the
procedure. This kind of action suggests that
the nurses central purpose in nursing is to facilitate the patients effort to respond capably
to the bed-bath what she desires to give him.
The effect of this kind of action on the patient

will, in all probability, be positive. He presumably understands that she is about to do or is
doing and is in accord with her efforts and action. (Wiedenbach, 1970, p. 6)
Using the same example, she explains patientdirected as assisting according to the patients needs
and directions:
This kind of action implies that the nurses
central purpose in nursing is to be accessible
to the patient to give whatever help he indicates he wants in relation to his bed-bath. Thus
she supports what she assumes to be his desire
for independence. (Wiedenbach, 1970, p. 6)
She explains nurse-directed action in the bed-bath
example as follows:
[T]he nurse respects the patients dignity and
worth, but not particularly his individuality
and autonomy. She gives him the bath without
consulting him about it, and thus implies that
she, the nurse, knows best what the patient
needs. For this kind of action, the nurses central purpose would seem to be to do for the patient (or with him) what she thinks he needs
to have done for or with him.
Prescription thus represents a directive to the
nurse for effecting the kind of results she desires. It is inextricably tied to her central purpose in nursing. Consequently, once she has
formulated her central purpose and has accepted it as her commitment she not only has
established the prescription for her nursing,
but is ready to implement it within the realities
of the clinical situation. (Wiedenbach, 1970,
p. 7)
Wiedenbach professed that there are realities in
nursing practice that are physical, physiological,
emotional and spiritual that are at play in a situation
in which nursing action occurs at any given moment (Wiedenbach, 1970, p. 7). She describes these
as follows:
The Agent, who is the nurse or her delegate, and
who supplies the propelling force for any nursing
action that may be taken.
The Recipient, the patient, who receives the agents
action or in whose behalf the action is taken
The Framework, which comprises all the extraneous factors and facilities in the situation that affect the nurses ability to obtain the kind of results she wants to obtain, through her nursing.
73
The Goal, which represents the end to be attained

through the activity which the nurse plans or undertakes in behalf of the patient. And
The Means, which comprise the activities and devices through which the nurse is enabled to attain her goal. (Wiedenbach, 1970 p. 7)
Wiedenbach expressed in her presentation the need
to elaborate on features of the realities because of
their strong influence on effective nursing practice.
She described the nurse as the agent who supplies the propelling force for the overt actions that
determine the effectiveness of her practice(Wiedenbach, 1970, p. 8). She emphasized the responsibility
of the nurse,
. . . not only for clarifying her central purpose
in nursing and her prescription for fulfilling it,
but also for recognizing the responsibilities
that are hers by virtue of her resolve to fulfill
her central purpose and implement her prescription. (Wiedenbach, 1970, p. 8)
Four responsibilities of the agent (nurse) that she
considered to be outstanding are:
1. To reconcile her assumptions about the realities
in the clinical situation with her central purpose
in nursing. (This presumes not only that she has
clarified her central purpose in nursing for herself, but that she respects the need to validate her
assumptions before acting on them!)
2. To specify the objectives of her practice in terms
of behavioral outcomes that are realistically attainable.
3. To practice nursing in accordance with her objectives.
4. To engage in related activities which contribute
to her self-realization as to the improvement of
nursing practice (p. 8).
The patient is viewed as the recipient of the
nurses ministrations in a vulnerable position. She explains that this is so because the patient subjects
himself to anothers care. There is a risk of losing
ones individuality, dignity, worth, and autonomy.
However, according to Wiedenbach, the patient has
. . . one unassailable resource that he can use
as a secret weapon! It is his sensitivityhis
feelings. [By the use of it] he can defeat or frustrate those responsible for his care, by thwarting their efforts to obtain the results they
desire from their efforts and ministrations.
(Wiedenbach, 1970, p. 9)
Wiedenbach used an enema procedure as an example of this. The success of the procedure was di-
74
rectly related to the patients (recipients) cooperation in receiving and holding the enema fluid. Because of a lack of sensitivity about the patients feelings of autonomy, the nurses efforts were thwarted.
The patients feelings, thus, were a powerful mechanism in his defense (Wiedenbach, 1970, p. 9).
The next reality defined is the framework:
In nursing practice, the framework constitutes
a complex of factors which, though [intangible] as a whole, have, nevertheless, potential
for limiting or expanding the scope of the
nurses ability to function as she would like to
function at any given time. It derives from a
combination of extraneous elements and circumstances which imagined or real are present or are introduced into every nursing situation. By their existence, they share the course
of events. In addition, they influence not only
the care with which the nurse is able to
achieve desired results from her nursing, but
also the ease with which the patient is able to
benefit from the nurses ministrations. (p. 10)
The arrival of fresh linen or the unexpected absence of a nursing staff member are two of many examples Wiedenbach cited as factors that could shape
the course of events (Wiedenbach, 1970, p. 10).
She views the framework as
. . . a conglomerate that may include objects,
existing or missing, policies, setting, atmosphere, time of day, humans and happenings
that may be current, past and recalled, or anticipated. Depending on its makeup, it may
promote, complicate, facilitate, alter, impair
or impede the nurses ability to function effectively in her practice.
She pointed out that not only must the nurse recognize that a framework always exists to be reckoned with, but also, the patient must be aware of it
and we must strive to enable our patient to cope
with it capably as well (Wiedenbach, 1970, p. 11).
The fourth aspect of the realities is the goal. She
describes goal as the end to be attained through
whatever the nurse undertakes in her practice. She
states: In the context of a prescriptive theory, goal is
included in any statement of purpose. She uses the
example of an individuals capability as a specified
goal in any given situation that the nurse might strive
toward. However, in the context of realities, the goal
specifies the particular result which the nurse desires to achieve through the particular activity she
plans or initiates (p. 11). One example she gives is
that of relieving a patient of discomfort when carry-
ing out a procedure. She believes that stipulation of

an activitys goal gives focus to the nurses action, implies her reason for taking it and paves the way for its
effective realization (p. 11).
She emphasizes that one cannot reach a goal simply by articulating it. She cites three necessary and
distinct steps. These are:
1. Goal in intent specifies the attitude that the nurse
believes the patient must manifest in order to be
able to benefit from her ministrations. It is an attitude, consequently that she needs to foster or engender consciously, as part of her effort to attain
her activitys goal. Goal in intent derives mainly
from the nurses central purpose in nursing. If
her purpose, for instance, is to have the patient
benefit from her ministrations, her goal in intent
will most likely be inducement of a receptive attitude toward them, on the patients part. If, on
the other hand, her purpose is to have the patient become independent of her ministrations,
her goal in intent might be inducement of an assertive attitude on her patients part. (Wiedenbach 1970, p. 12)
2. Goal in application specifies the kind of framework that the nurse believes is essential to
achievement of the goal she has set for the activity she plans to undertake. I think it could be
called a supportive framework [environment]
which means that the nurse has available to her,
appropriate equipment with which to carry out
the activity; that the physical environment is adjusted to the patients tolerance and the nurses
ease in functioning; and that the human elements
consisting not only of professionals but also of
nonprofessionals who may also include the patients family, are accepting of the nurses plan to
engage in a particular activity in the patients behalf. (p. 12)
She explains that goal in application is often taken
for granted but needs to be recognized and respected not only as an integral part of the nurses
practice, but as one that is crucial to her obtaining
the kind of results she desires from what she does
(p. 12).
3. Goal in execution specifies the relationship that
the nurse desires to maintain between the realities and her activity while she is actually carrying
out the activity. I would designate it as a symbiotic relationship. (p. 13)
Wiedenbach elaborates on goal in execution in reference to the nurses characteristics: Attainment of the
goal calls for vigilance, sensitivity, and wisdom on
the part of the nurse, all the while that she is engaging in the activity; vigilance for signs of resistance in
the patient toward the activity; and sensitivity to untoward changes in the framework or in herself that
could prevent attainment of the activitys goal and
wisdom in dealing objectively and kindly with what
she is aware of in the situation so that the patients
ability to benefit from the activity may be supported,
restored, or enhanced (Wiedenbach, 1970, p. 13).
Wiedenbach reiterated the importance of these
three goals in action to effective nursing. Although
their significance may not always be recognized,
when the nurse makes their attainment a conscious
part of her nursing, she is taking a major step toward
obtaining desired results in her practice (p. 13).
The last of the realities is described as the means.
These are:
The expedients that the nurse uses to achieve
the objectives of her practice. They include
the whole gamut of skills, knowledge, techniques, procedures and devices that the nurse
may use to identify her patients experienced
need for help[,] [a]dminister the help he
needs, or validate that the help she gave was
indeed helpful. (Wiedenbach, 1970, p. 13)
Although Wiedenbach (1970) views the means as
. . . indispensable resources the nurse relies
on, their value for the patient depends largely
on the way the nurse uses them. It is the
nurses way of giving a treatment, for example, that enables the patient to benefit from it,
not just the fact that he is given a treatment.
And it is her way of expressing her concern,
not just the fact that she is present or speaks
that enables him to reveal his fears. The nurses
way of using the means available to her to
achieve the results she desires, in her practice,
is an individual matter, determined to a large
degree, by her central purpose in nursing and
the prescription she regards as appropriate to
its fulfillment. (p. 13)
Wiedenbach summarized her presentation to the
audience at Duke University (1970) by stating that:
This then is my concept of a prescriptive theory of nursing. Its components are, first of all,
a central purpose that suggests the nurses reason for beingthe mission she believes is hers
to accomplish. Second, a prescription that
suggests the action she deems appropriate to
the accomplishment of her mission. And third,
the realities, which, by their pervasiveness,
challenge the nurses ingenuity and creativity
75
your thoughts
as she endeavors to fulfill her central purpose

in nursing through her practice.
Like all theory, a prescriptive theory, too, is
a system of conceptualizations invented for
some purpose. The relationship to practice is
close and inseparable. Its value manifests itself
when each nurse probes the depths of her
value system and beliefs, makes them explicit,
uses them as the basis of her theory of nursing
practice, and reflects them in everything she
does. (p. 14)
tion of help needed and validation that the

help provided fulfilled its purpose, fills the circle adjacent to the core. The next circle holds
the essential concomitants of direct service:
coordination, i.e., charting, recording, reporting, and conferring; consultation, i.e., conferencing, and seeking help or advice; and collaboration, i.e., giving assistance or cooperation
with members of other professional or nonprofessional groups concerned with the individuals welfare. The content of the fourth circle represents activities which are essential to
WIEDENBACHS THEORY
AND CLINICAL PRACTICE
Wiedenbach consistently emphasized purpose and
patient in her many writings and presentations
about her perspective of nursing practice. She
stated: The practice of clinical nursing is goal directed, deliberately carried out and patient centered (Wiedenbach, 1964, p. 23). Figure 61 represents a spherical model she created in 1962 that
depicts the experiencing individual as the central
focus. The published version of the model appeared
two years later in her text Clinical Nursing: A Helping Art (Wiedenbach, 1964). In a presentation entitled A Concept of Dynamic Nursing at a conference
in Pittsburgh, Pennsylvania (Wiedenbach, 1962,
p. 7), she 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 individuals experienced need for help, ministra-
76
the ultimate well-being of the experiencing individual, but only indirectly related to him;
nursing education, nursing administration and
nursing organizations. The outermost circle
comprises research in nursing, publication
and advanced study, the key ways to progress
in every area of practice.
In this same presentation, Wiedenbach shared
schematic drawings of the elements of the second
sphere (circle), identification, ministration, and validation. These are presented here in Figures 62, 63,
and 64. These also were later edited and published
in Clinical Nursing: A Helping Art (Wiedenbach,
1964).
She explained the elements of the second sphere
to her presentation audience (Wiedenbach, 1962,
p. 9) in the following way:
Implicit in identification is the individualization of the individual and what he is experiencing. This calls for awareness of how the individual differs in appearance, manner, and
behavior, from any other individual, and from
the nurses expectation of him. It calls for
recognition too, that the individuals perception of his condition or situation grows out of
his background of experiences and understandings, which may be called his frame-ofreference; while the nurses perception of it is
in relation to her background of experiences
and understandings, that is, her frame-of-reference. Activity in this unit of Practice (identification) is directed toward ascertaining 1)
whether the individual is experiencing discomfort or incapability; 2) the cause of the discomfort or incapability he may be experiencing; 3) the need required to restore comfort or
capability; and 4) whether the need represents
a need-for-help, one, in other words which the
individual is unable to meet himself, unaided.
The unit Ministration involves providing
the help which is needed. Underlying it, is the
assumption that the individual must be accepting of any applied resource, be it a bit of advice, a recommendation, or a comfort or therapeutic measure, if he is to derive maximum
benefit from it. Application of resource, thus,
is dependent first of all, on selection of one
which is appropriate to the need which has
been identified, and second, on its acceptability to the individual. In this unit of Practice,
i.e., Ministration-of-Help-Needed, the full range
of resources to which the nurse has access
may come into play, and the greater her stock
of resources, the greater her potential for effective service. Included in such range would
be her own beliefs, values, knowledge, skills
and know-how; those of others whom she
knows or of whom she has heard, i.e., members of other professions or the laity; and
those represented by facilities of the community and beyond.
Validation has as its goal, evidence that, as a
result of the help that was provided, the individual is experiencing improvement in his feeling of comfort and capability in relation to his
immediate situation. Such improvement may
be measured by the individuals verbal and
non-verbal behavior, on the assumption that
he will respond behaviorally, to how he is currently experiencing his situation. Implicit in
this unit are 1) clarification of the meaning to
the individual, of his behavior; and 2) classification of his meaning according to the nurses
concept of comfort and capability in the context of the individuals situation. Essentially,
this means that to validate the effectiveness of
Practice, how the individual is experiencing
his immediate situation must be consistent
with the nurses expectation of the outcome of
her ministration.
Wiedenbachs clinical application of her prescriptive theory was always evident in her logical clinical
examples. They often related to general basic nursing
procedures, but more so with maternity nursing
practice. In discussing the practice and process of
nursing, she stated:
The focus of Practice is the experiencing individual, i.e., the individual for whom the nurse
is caring, and the way he and only he perceived his condition or situation. For example,
a mother had a red vaginal discharge on her
first postpartum day. The doctor had recognized it as lochi, a normal concomitant of the
phenomenon of involution, and had left an order for her to be up and move about. Instead
of trying to get up, the mother remained, immobile in her bed. The nurse who wanted to
help her out of bed expressed surprise at the
mothers unwilling to do so, when she seemed
to be progressing so well. The mother explained that she had a red discharge, and this
to her was evidence of onset of hemorrhage.
This terrified her and made her afraid to move.
Her sister, she added, had hemorrhaged and almost lost her life the day after she had her
baby two years ago. The nurse expressed her
77
78
79
understanding of the mothers fear, but then

encouraged her to compare her current experience with that of her sister. When the mother
tried to do this, she recognized gross differences, and accepted the nurses explanation of
the origin of the discharge. The mother then
voiced her relief, and validated it by getting
out of bed without further encouragement.
(Wiedenbach, 1962, pp. 67)
In another example, she recalled an experience as a
student:
. . . assigned to a multiparous woman in early
labor. With each mild contraction, the woman
would clutch the students hand and scream,
Nurse, dont leave me! After observing this
behavior for some
The practice of clinical time, Wiedenbach
asked the woman
nursing is goal directed, why she was acting
deliberately carried out so frightened. The
woman replied that
and patient centered. she overheard the
physician tell a
nurse that she would dilate that night and the
woman interpreted this as die late that night.
Wiedenbach told the historian that this incident revealed to her how little a woman may
80
know about the process of childbirth and how

carefully one must explain things to them. She
believes that this experience impressed upon
her the importance of always understanding
the meaning of a patients behavior. (Nickle,
Gessey, & MacLaren, 1992, p. 162)
Critics of Wiedenbachs work have indicated that
utilization of her practice theory is limited to the responsive patient. A graduate student chose Wiedenbachs concepts to demonstrate the use of identification, ministration, and validation in providing care
for a newborn infant in intensive care (Miller, 1985).
She believes that Wiedenbachs prescriptive theory is
adaptable to a nonresponsive patient as well, and
presented the following example.
Miller described identification as a need for
observation, understanding, cause, help needed,
which she translated into signs and symptoms of respiratory distress. She called this a physiological perception and a need-for-help. Ministration was interpreted as the nurses response to the infants hypoxic
state by taking appropriate measures. Validation was
achieved by the infants positive response to the ministration (Miller, 1985, pp. 1011). This situation has
merit for a linking of most of the concepts of Wiedenbachs prescriptive theory in the care of this ill newborn.
McKenna (1997) has observed that Wiedenbachs

theory emerged from a strong clinical practice association. He cites Orlando and Travelbee as well as
Wiedenbach, all of whom, while giving or observing
nursing care, used grounded theory methods of data
collection, that is, case studies, interviews, and observations. Wiedenbach, Orlando, and Travelbee analyzed likenesses and differences of the data and then
developed concepts and linkages. McKenna called
this a practice-theory strategy (McKenna, 1997).
Wiedenbach addressed this in her thinking
about theory as being an abstract phenomenon. It develops within the mind but derives
from reality and influences action. It is the outgrowth of an intellectual process set in motion
by observations. From them, ideas are generated. Then, by means of the intellect, the
ideaswell call them conceptsmay be consciously brought into meaningful relationship
with one another for such purposes as to identify or isolate factors, to characterize or classify them, to predict effect from cause, or to
prescribe a course of action by which to obtain desired results. When such a relationship
is articulated, a theory has been formulated.
(McKenna, 1997, p. 1057)
However, Wiedenbach considered nursing a
practical phenomenon that involved action. She
believed that this was necessary to understand the
theory that underlies the nurses way of nursing.
This involved knowing what the nurse wanted to accomplish, how she went about accomplishing it, and
in what context she did what she did (Wiedenbach,
1970, p. 1058). This, then, is the foundation of the
central purpose, prescription, and realities of the
prescriptive theory in clinical practice.
WIEDENBACHS THEORY
AND CLINICAL TEACHING
There is a uniqueness in Wiedenbachs prescriptive
theory in that it is so adaptable to nursing education
as well as to clinical practice. She logically related
the concepts of the three main components of her
theory to education in a practice discipline. In her
text, Meeting the Realities in Clinical Teaching
(Wiedenbach, 1969), she defined the components
as:
Purposeto motivate the student and/or facilitate her efforts to overcome the obstacles that
nowor may laterinterfere with her ability
to gain the knowledge, insights, and skill she
needs [as the agent] who is responsible, as the

propelling force, for student learning. (p. 9).
PrescriptionFactors that, when combined,
give direction to the instructors action as well
as the thinking process that hopefully will lead
to the results desired. (p. 11)
RealitiesThe factors are listed here, that influence teaching and learning. These are:
1. The agentthe instructor who is responsible, as the propelling force, for student
learning.
2. The recipientthe student, who is presumed to want specific knowledge, skills,
abilities and understanding that will enable
her to assume professional responsibilities.
3. The frameworkthe complex factors
(such as time of day, people present, atmospheric conditions, activities going on,
et cetera) that limit or expand the scope of
the instructors and students abilities to
function.
4. The goalthe end to be attained
a. goal-in-intentthe attitude of the student
b. goal-in-applicationthe kind of framework essential for successful learning.
c. goal-in-executionthe students realization of her potential for learning.
5. The meansthe sum and substance of the
teaching program. (Wiedenbach, 1969, pp.
21156)
Wiedenbach believed very strongly in the need to
develop ones own philosophy, as well as central purpose, and expected each student to do so. She felt
that the clinical instructors basic philosophy of nursing would influence her attitude toward the student
and could serve as a frame of reference for decision
making (Nickel, 1981a). She taught as well as practiced from the framework of her prescriptive theory
and therefore presented a consistency for students in
both classroom and clinical activities.
Encouraging students to think was very important
to Wiedenbach and made its appearance in many
ways. She distributed a list of eight Student Responsibilities (expected behaviors) to her students. The
list included being friendly, helpful, neat, prompt,
and seeking help when needed, but the last on the
list was THINK!
She instituted a Summary of Thinking as a means
of evaluation of students. In composition, students
were encouraged to identify what they had learned
by their experiences, not only in terms of skills, but
81
also factors which affected his/her ability to gain

them. The Summary of Thinking reconstructed the
students activities in terms of purpose and outcomes (Nickel, 1981a, p. 75).
A letter from Wiedenbach dated May 27, 1958, to
a student gave the following suggestions regarding
her thesis:
1. Organize the study in terms of the stated purpose.
2. Give a clear statement of the hypothesis.
3. Present the collected data in tables.
4. Make your analysis from the tables.
5. Draw your conclusions and state them succinctly.
(Nickel, 1981, p. 76)
The emphasis on individual responsibility and reflection was clear in a presentation Wiedenbach gave, in
which she stated, How much better it would be,
wouldnt you agree . . . if each nurse would think
through, deliberately, the theory that she would like
her practice to reflect. Only by making it explicit for
herself, I believe, can she harmonize her practice
with her theory, and give it the constancy, consistency, and the spiritual meaning that nursing, in its
finest connotation, implies (Wiedenbach, 1970, pp.
1415).
Summary
The central purpose of this chapter has been to share
rather than critique or analyze Wiedenbachs work. It
is a privilege to have access to her personally verbalized thoughts and explanations of her prescriptive
theory. Through audio- and videotapes acquired by
Nickel, and other personal materials she reviewed

and reported on in her thesis, in addition to the authors personal contacts and recollections, it has
been possible to bring about an account of Wiedenbachs work that summarizes but cannot equal the
theorists own writing.
Her philosophy continues to be reflected in todays focus on humanism and on transculturalism
in nursing literature, practice, and education, as well
as in health care in general. Her focus on the respect
for dignity, worth, autonomy, and individuality became a part of the philosophy of the American College of Nurse-Midwives in 1961 and has remained a
hallmark of nurse-midwifery practice.
In 1983, social scientist Donald Schon wrote a
text on the need for reflection when carrying out
ones professional service. He presented his analysis
of what he called reflective-in-action. He noted that
most professions practice technical rationality, that
is, problem solving by applying specialized scientific
knowledge in a routinized manner. He believed that
rather than a standard application of knowledge, one
must reflect on action taken or to be taken and also
recognize the individual differences of those receiving services. Thus, such reflection leads to inquiry
and ultimately to new theories and new knowledge.
Davies (1995, p. 167) noted the disjuncture between theory and practice that plagues nursing education. She instituted reflective activities for her
students in their clinical practice in an effort to address this problem. Of many findings reported, two
of particular consequence were that the students began to accept more responsibility for their learning
and identifying their own learning needs, and they
began to view the client as the central focus. In their
your thoughts
82
reflection, they began to expand in terms of their

thinking and nursing action (Davies, 1995).
The introduction of prescriptive theory in nursing by Dickoff, James, and Wiedenbach (1968) more
than 30 years ago was evolutionary for nursing theory. However, it was never taken seriously because
nurse theorists focused on middle-range theories that
were believed necessary for nursing to be accepted
as a scientific discipline. (Lenz, Supp, Gift, and associates, 1995; Ruland & Moore, 1998). Today, there is
renewed interest in the work of Wiedenbach and the
concepts she promoted. Perhaps it is a matter of going back to our roots to grasp the essence of nursing
too often swallowed by technology and impersonal
care and driven by economics; or perhaps it is the
recognition, finally, that Wiedenbachs early efforts
to link theory, practice, and research had merit. She
herself recognized that she never systematically validated her theory or published such results (Nickel,
Gesse, & MacLaren, 1992, p. 166). The challenge to
do so is ours. In Wiedenbachs own words:
May each of you spark nurses in and of the future, to make theory a conscious part of their
practice. The opportunity you have to do this
is exciting! And it is rewarding, for, by helping
nurses to uncover the theory that underlies
their practice, you are paving the way for
them to render a finer quality of service to the
patient, and to gain a deepened sense of fulfillment for themselves. (Wiedenbach, 1970,
p. 15)
References
Davies, E. (1995). Reflective practice: Focus for caring.
Journal of Nursing Education, 34(167).
Dickoff, J., James, P., & Wiedenbach, E. (1968). Theory
in a practice discipline. Nursing Research, 14(5).
Lenz, E., Supp., F., Gift, A., Pugh, L., & Milligan, R.
(1995). Collaborative development of middle range
nursing theories: Toward a theory of unpleasant
symptoms. Advances in Nursing Science, 17(1).
McKenna, H. (1997). Nursing theories and models.
London: Routledge.
Miller, C. (1985). Nursing theory. Unpublished paper,
Barry University, Miami, FL.
Nickel, S. (1981a). A historical nursing review:The life
and career contributions of Ernestine Wiedenbach.
Unpublished thesis, University of Miami.
Nickel, S. (1981b). Audio-visual taped interview with
Ernestine Wiedenbach. Tape 1, October 20, 1980;
Tape 2, February 2, 1981; Tape 3, May 22, 1981.
Copy in University of Miami School of Nursing Archives, Coral Gables, FL.
Nickel, S., Gesse, T., & MacLaren, A. (1992). Her professional legacy. Journal of Nurse Midwifery, 3(161).
Ruland, C., & Moore, S. (1998). Theory construction

based on standards of care: Proposed theory of the
peaceful end of life. Nursing Outlook, 46(169).
Wiedenbach, E. (1962). A concept of dynamic nursing:
Philosophy, purpose, practice and process. Paper
presented at the Conference on Maternal and Child
Nursing, Pittsburgh, PA. Archives, Yale University
School of Nursing, New Haven, CT.
Wiedenbach, E. (1963). The helping art of nursing.
American Journal of Nursing, 63(11).
Wiedenbach, E. (1964). Clinical nursing:A helping art.
New York: Springer.
Wiedenbach, E. (1969). Meeting the realities in clinical teaching. New York: Springer.
Wiedenbach, E. (1970). A systematic inquiry:Application of theory to nursing practice. Paper presented
at Duke University, Durham, NC (authors personal
files).
Wiedenbach, E., & Falls, C. (1978). Communication:
Key to effective nursing. New York: Tiresias Press.
Bibliography
BOOKS
Schon, D. (1983). The reflective practitioner. New
York: Basic Books.
Wiedenbach, E. (1958/1967). Family centered maternity nursing (2nd ed. rev.). New York: Putnam.
Wiedenbach, E. (1972/1977). Maternity nursing today.
In The nursing process in maternity nursing (2nd
ed. rev). New York: McGraw Hill Publishing.
JOURNAL A RTICLES
Wiedenbach, E. (1940, January). Toward educating 130
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Wiedenbach, E. (1942, November). Overcoming mental barriersA true story. American Journal of
Nursing, 42, 12471252.
Wiedenbach, E. (1949, August). Childbirth as mothers
say they like it. Public Health Nursing, 51,
417426.
Wiedenbach, E. (1960, May). Nurse-midwifery . . . Purpose, practice and opportunity. Nursing Outlook, 8,
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Wiedenbach, E. (1962, Summer). Contributions of
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Wiedenbach, E. (1968, June). Nurses role in family
planning. Nursing Clinics of North America, 3(6),
355365.
Wiedenbach, E. (1968, May). Genetics and the nurse.
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UNPUBLISHED MANUSCRIPTS
Wiedenbach, E. (1961). Growth and development of
the nurse-midwifery program at Yale. Unpublished
manuscript, Yale University School of Nursing.
Wiedenbach, E. (1962). Professional nursing practice
focus and components. Unpublished manuscript,
Yale University School of Nursing, New Haven, CT.
Wiedenbach, E. (1963). Suggested statement of philosophy. Unpublished manuscript, Yale University
School of Nursing, New Haven, CT.
Wiedenbach, E. (1965). Qualities and competencies
students are expected to acquire. Unpublished manuscript, Yale University School of Nursing, New
Haven, CT.
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Wiedenbach, E. (1965). Emergency maternal and

newborn care. Paper presented to the Connecticut
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UNPUBLISHED RECORDING
Wiedenbach, E. (1981). Audiovisual taped interview
with Ernestine Wiedenbach. February 14, 1981. University of Miami School of Nursing Archives, Coral
Gables, FL.
Chapter 7
Dorothy Johnson
Behavioral System Model
for Nursing
The Johnson Behavioral System Model
Major Concepts of the Model
Role of the Model in Nursing Practice, Administration,
Research, and Education
Summary
References
Bonnie Holaday

The grand theorists discussed in this book are all
different from one another, yet most of them agree to
attach enormous importance to the idea of frameworks that give meaning and significance to phenomena of interest to nursing. Dorothy Johnsons
earliest publications pertained to what knowledge
base nurses needed for nursing care (Johnson, 1959,
1961). Throughout her career, Johnson stressed that
nursing had a unique independent contribution 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 at Vanderbilt University in 1968. Her model was the first to
provide both a guide to understanding and a guide to
action. These two ideasunderstanding seen first as
a holistic, behavioral system process mediated by a
complex framework and second as an active process
of encounter and responseare central to the work
of other theorists who followed her lead and developed conceptual models for nursing practice.
Dorothy Johnson was born on August 21, 1919, in
Savannah, Georgia. She received her associate of arts
degree from Armstrong Junior College in Savannah,
Georgia, in 1938 and her bachelor of science in nursing degree from Vanderbilt University in 1942. She
practiced briefly as a staff nurse at the Chatham-Savannah Health Council before attending Harvard University, where she received her master of public
health (MPH) in 1948. She began her academic career at Vanderbilt University School of Nursing. A call
from Lulu Hassenpplug, dean of the School of Nursing, enticed her to go to the University of California
at Los Angeles (UCLA) in 1949. She served there as
an assistant, associate, and professor of pediatric
nursing until her retirement in 1978. She moved to
Key Largo and later to New Smyrna Beach and continued her interest in systems as a shell collector.
During her academic career Dorothy Johnson addressed issues related to nursing practice, nursing
education, and nursing 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, National
League for Nursing, and American Nurses Association to examine the role of the clinical nurse specialist, the scope of nursing practice, and the need for
nursing research. She also completed a Public Health
Servicefunded research project (Crying as a Physiologic State in the Newborn Infant) in 1963 (Johnson & Smith, 1963). The foundations of her model
86
and her beliefs about nursing are clearly evident in

these early publications. Dorothy Johnsons body of
published work includes more than 30 articles, 4
books, and numerous proceedings, reports, and abstracts.
Ms. Johnson received many awards, including the
Founders Medal from Vanderbilt University (1942),
the Faculty Award from UCLA graduate students
(1975), the Lulu Hassenplug Distinguished Achievement Award from the California Nurses Association
(1977), the Vanderbilt University School of Nursing
Award for Excellence in Nursing (1981), and induction as an honorary fellow in the American Academy
of Nursing (1997). She enjoyed activities with the
Class of 42 and took great pride in the career
achievements of her former students. Dorothy Johnson, RN, MPH, FAAN passed away in February 1999.
THE JOHNSON BEHAVIORAL

SYSTEM MODEL
Paradigmatic Origins
Johnson has noted that her theory 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 nursings concern is a focus on
the person rather than the disease. Systems theorists
(Buckley, 1968; Chin, 1961; Parsons & Shils, 1951;
Rapoport, 1968; and Von Bertalanffy, 1968) were all
sources for her model. Johnsons background as a pediatric nurse is also evident in the development of
her model. In her papers, Johnson cited developmental literature to support the validity of a behavioral system model (Ainsworth, 1964; Crandal, 1963;
Gerwirtz, 1972; Kagan, 1964; and Sears, Maccoby, &
Levin, 1954). Johnson also noted that a number of
her subsystems had biological underpinnings.
Johnsons theory and her related writings reflect
her knowledge about both development and general systems theories. I
think her model demonJohnsons model incorpostrates a marvelous fitting together of theory rates five principles of sysand concepts from both
tem thinking: wholeness
areas. The combination
of nursing, develop- and order, stabilization,
ment, and general sys- reorganization, hierarchic
tems introduces into
the rhetoric about nurs- interaction, and dialectical
ing theory development contradiction.
some of the specifics
that make it possible to test hypotheses and conduct

critical experiments. I will conclude this section
with a discussion of some aspects of my own thinking about Johnsons use of development and systems
in the Johnson Behavioral System Model (JBSM).
Johnsons model incorporates five core principles
of system thinking: wholeness and order, stabilization, reorganization, hierarchic interaction, and dialectical contradiction. Each of these general systems
principles has analogs in developmental theories that
Johnson used to verify the validity of her model
(Johnson, 1980, 1990). Wholeness and order provide
the basis for continuity and identity, stabilization for
development, reorganization for growth and/or
change, hierarchic interaction for discontinuity, and
dialectical contradiction for motivation. Johnson
conceptualized a person as an open system with organized, interrelated, and interdependent subsystems.
By virtue of subsystem interaction and independence, the whole of the human organism (system)
is greater than the sum of its parts (subsystems).
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 being comprised of subsystems and the environment as being
comprised of physical, interpersonal (e.g., father,
friend, mother, sibling), and sociocultural (e.g., rules
and mores of home, school, country, and other cultural contexts) components that supply the sustenal
imperatives (Grubbs, 1980; Holaday, 1997; Johnson,
1990; Meleis, 1991).
The developmental analogy of wholeness and order is continuity and identity. Given the behavioral
systems potential for plasticity, a basic feature of the
system is that both continuity 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.
Johnsons work infers that continuity is in the relationship of the parts rather than in their individuality.
Johnson (1990) noted that at the psychological level,
attachment (affiliative) and dependency are examples of important specific behaviors that change over
time while the representation (meaning) may remain
the same. Johnson (1990, p. 28) stated: [D]evelopmentally, dependence behavior 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. In terms of behavioral system balance, this pattern of dependence to
independence may be repeated as the behavioral system engages in new situations during the course of a
lifetime.
Stabilization or behavioral system balance is another core principle of the JBSM. Dynamic systems
respond to contextual changes by either 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
external conditions. Human thermoregulation is an
example of a homeostatic process that is primarily
biological but is also behavioral (turning on the
heater). Narcissism or the use of attribution of ability
or effort are behavioral homeostatic processes we
use to interpret activities so they are consistent with
our mental organization.
From a behavioral system perspective, homeorhesis is a more important stabilizing process than is
homeostatis. In homeorhesis 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 removed but soon shows age-appropriate motor skills. An adult newly diagnosed with asthma who
does not receive proper education until a year after
diagnosis can successfully incorporate the material
into her daily activities. These are examples of homeorhetic processes or self-righting tendencies that can
occur over time.
What we as nurses observe as development or
adaptation of the behavioral system is a product of
stabilization. When a person is ill or threatened with
illness, he or she is subject to biopsychosocial perturbations. The nurse, according to Johnson (1980,
1990), acts as the external regulator, and monitors
patient response and looks for successful adaptation
to occur. If behavioral system balance returns, there
is no need for intervention, and if not, the nurse intervenes to help the patient restore behavioral system balance. It is hoped that the patient matures and
with additional hospitalizations the previous patterns of response have been assimilated and there are
few disturbances.
Adaptive reorganization occurs when the behavioral 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
Chapter 7 Dorothy Johnson Behavioral System Model for Nursing
87
your thoughts
points best in new situations. To the extent that the

behavioral system cannot assimilate the new conditions with existing regulatory mechanisms, accommodation must occur either as a new relationship
between subsystems or by the establishment of a
higher order or different 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).
The difference between stabilization and reorganization is that the latter involves change or evolution. A behavioral system is embedded in an environment, but it is capable of operating independently of
environmental constraints 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 where 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.
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, stabilization and reorganization will also demonstrate a hierarchic structure
(Buckley, 1968). Hierarchies, or a pattern of relying
on particular subsystems, lead to a degree of stability.
A disruption or failure will not destroy the whole system but leads instead to a decomposition to the next
level of stability.
88
The judgement that a discontinuity has occurred

is typically based on a lack of correlation between assessments at two points of time. Ones lifestyle (or
ones usual set, choice, and action) prior to surgery
is not a good fit postoperatively. These discontinuities can provide opportunities for reorganization
and development.
The last core principle is the motivational force
for behavioral change. Johnson (1980) described
these as drives and noted that these responses are developed and modified over time through maturation,
experience, and learning. I have also discussed stabilization and reorganization as reactions to environmental changes. A persons activities in the environment lead to knowledge and development. However,
by acting 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 include the biological, psychological, cultural, familial, social, and physical setting. The person needs
to resolve (maintain behavioral system balance of) a
cascade 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. Behavioral system balance is restored and a
new level of development is attained.
In summary, I believe Johnsons pragmatic origins
included general systems theory as well as dominant
themes from developmental theory. This has given
the model some unique features that are absent in
other models. One may analyze the patients response in terms of behavioral system balance, and,
from a developmental perspective, ask, Where did
this come from and

where is it going? The
lection of behavioral sub- developmental component necessitates that
systems that interrelate to we identify and underform the behavioral system. stand the processes of
stabilization and sources
There are eight subsys- of disturbances that lead
tems, along with their to reorganization. These
need to be evaluated by
goals and functions.
age, gender, and culture.
The combination of systems theory and development identifies nursings
unique social mission and our special realm of original responsibility in patient care (Johnson, 1990,
p. 32).
The client is seen as a col-
MAJOR CONCEPTS OF THE MODEL

Person
Johnson conceptualized a nursing client as a behavioral system. The behavioral system is orderly, repetitive, systematic, and organized with interrelated and
interdependent biological and behavioral subsystems. The client is seen as a collection of behavioral
subsystems that interrelate to form the behavioral
system. The system may be defined as those complex, overt actions or responses to a variety of stimuli present 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 and limits the
interaction between the person and environment,
and establishes the relationship of the person to the
objects, events, and situations in the environment.
Johnson (1980, p. 209) considered such behavior to
be orderly, purposeful and predictable; that is, it is
functionally efficient and effective most of the time,
and is sufficiently stable and recurrent to be
amenable to description and exploration.
The parts of the behavioral system are called subsystems. They carry out specialized tasks or functions needed to maintain the integrity of the whole
behavioral system and manage its relationship 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. However, in
my 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 71. Johnson noted that these subsystems are found cross-culturally and across a broad
range of the phylogenetic scale. She also noted the

significance 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 structure, 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 are those
activities carried out to meet these goals. These behaviors may vary with each individual, depending on
the persons age, sex, motives, cultural values, social
norms, and self-concepts. In order for the subsystem
goals to be accomplished, behavioral system structural components must meet functional requirements of the behavioral system.
Each subsystem is composed of at least four structural components that interact in a specific pattern.
These parts are 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 whose existence can be supported
by 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 attainment, and in drive strength. With drives as the impetus for the behavior, goals can be identified and are
considered universal.
Behavioral set is a predisposition to act in a certain way in a given situation. The behavioral set represents a relatively stable and habitual behavioral pattern of responses to particular drives or stimuli. It is
learned behavior and is influenced by knowledge, attitudes, and beliefs. Set contains two components:
perseveration and preparation. Perseveratory set
refers to consistent tendency to react to certain stimuli with the same pattern of behavior. The preparatory set is contingent upon the function of the perseveratory set. The preparatory set functions to
establish priorities for attending or not attending to
various stimuli.
The conceptual set is a component that I have
added to the model (Holaday, 1982). The conceptual
set is a process of ordering that serves as the mediating 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 processingan inadequate conceptual set, a developing conceptual set,
and a sophisticated conceptual set.
89
TABLE 7-1
The Subsystems of Behavior*
Achievement Subsystem
Goal
Mastery or control of self or the environment
Function
To set appropriate goals

To direct behaviors toward achieving a desired goal
To perceive recognition from others
To differentiate between immediate goals and long-term goals
To interpret feedback (input received) to evaluate the achievement of goals
Affiliative Subsystem
Goal
To relate or belong to someone or something other than oneself; to achieve intimacy and inclusion
Function
To form cooperative and interdependent role relationships within human social systems
To develop and use interpersonal skills to achieve intimacy and inclusion
To share
To be related to another in a definite way
To use narcissistic feelings in an appropriate way
Aggressive/Protective Subsystem
Goal
To protect self or others from real or imagined threatening objects, persons, or ideas, to achieve selfprotection and self-assertion
Function
To recognize biological, environmental, or health systems that are potential threats to self or others
To mobilize resources to respond to challenges identified as threats
To use resources or feedback mechanisms to alter biological, environmental, or health input or human
responses in order to diminish threats to self or others
To protect ones achievement goals
To protect ones beliefs
To protect ones identify or self-concept
Dependency Subsystem
Goal
To obtain focused attention, approval, nurturance, and physical assistance; to maintain the environmental
resources needed for assistance; to gain trust and reliance
Function
To obtain approval, reassurance about self

To make others aware of self
To induce others to care for physical needs
To evolve from a state of total dependence on others to a state of increased dependence on the self
To recognize and accept situations requiring reversal of self-dependence (dependence upon others)
To focus on another or oneself in relation to social, psychological, and cultural needs and desires
90
TABLE 7-1
Continued
Eliminative Subsystem
Goal
To expel biological wastes; to externalize the internal biological environment
Function
To recognize and interpret input from the biological system that signals readiness for waste excretion
To maintain physiological homeostasis through excretion
To adjust to alterations in biological capabilities related to waste excretion while maintaining a sense of
control over waste excretion
To relieve feelings of tension in the self
To express ones feelings, emotions, and ideas verbally or nonverbally
Ingestive Subsystem
Goal
To take in needed resources from the environment to maintain the integrity of the organism or to achieve
a state of pleasure; to internalize the external environment
Function
To sustain life through nutritive intake

To alter ineffective patterns of nutritive intake
To relieve pain or other psychophysiological subsystems
To obtain knowledge or information useful to the self
To obtain physical and/or emotional pleasure from intake of nutritive or nonnutritive substances
Restorative Subsystem
Goal
To relieve fatigue and/or achieve a state of equilibrium by reestablishing or replenishing the energy
distribution among the other subsystems; to redistribute energy
Function
To maintain and/or return to physiological homeostasis

To produce relaxation of the self system
Sexual Subsystem
Goal
To procreate, to gratify or attract; to fulfill expectations associated with ones sex; to care for others and
to be cared about by them
Function
To develop a self-concept or self-identity based on gender

To project an image of oneself as a sexual being
To recognize and interpret biological system input related to sexual gratification and/or procreation
To establish meaningful relationships in which sexual gratification and/or procreation may be obtained
*Source: Based on J. Grubbs (1980). An interpretation of the Johnson behavioral system model. In J. P. Riehl & C. Roy
(Eds.), Conceptual models for nursing practice (2nd ed., pp. 217254). New York: Appleton-Century-Crofts; D. E.
Johnson (1980). The behavioral system model for nursing. In J. P. Riehl & C. Roy (Eds.), Conceptual models for nursing practice (2nd ed., pp. 207216). New York: Appleton-Century-Crofts; D. Wilks (1987). Operationalization of the
JBSM. Unpublished paper. University of California, San Francisco; and B. Holaday (1972). Operationalization of the
JBSM. Unpublished paper. University of California, Los Angeles.
91
The third and fourth components of each subsystem are choice and action. Choice refers to the individuals 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 behaviors 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 attainment. 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 notion of functional requirements of the behavioral system remains one of the cloudiest, and empirically,
one of the most debatable concepts of this model.
The concept of functional requirements tends to be
confined to conditions of survival of the system, and
it includes biological as well as psychosocial needs.
The problems are related to establishing the types of
functional requirements (universal versus 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 requires protection, from noxious stimuli
that threaten the survival of the behavioral system;
nurturance, which provides adequate input to sustain behavior; and stimulation, which contributes to
continued growth of the behavior and counteracts
stagnation. A deficiency in any or all of these func-
tional requirements threatens the behavioral system

as a whole, or the effective functioning of the particular subsystem with which it is directly involved.
In summary, the behavioral system is a complex
of observable features and actions of a person that
describe his interaction with the environment. It is
an integrative response system that adaptively relates
to various stimuli and communicates the status of internal processes to the surrounding environment.
Therefore, even though each of the subsystems has a
specialized function, the system as a whole depends
on an integrated performance of these subsystems.
Environment
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 also noted that there are forces in the environment that impinge on the person and to which
the person adjusts. Thus, the environment consists
of all elements that are not a part of the individuals
behavioral system but influence the system and can
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 specific definition of the environment, nor did she identify what she considered internal versus external
environment. But much can be inferred from her
writings, and system theory also provides additional
insights into the environment component of the
model. For those who choose to use this model, I encourage you to continue to define this domain.
I view the external environment as people, objects, and phenomena that can potentially permeate
your thoughts
92
the boundary of the behavioral system. This external

stimulus forms an organized or meaningful pattern
that elicits a response from the individual. The behavioral system attempts to maintain equilibrium in response to environmental factors by assimilating and
accommodating to the forces that impinge upon it.
Areas of external environment of interest to nurses
include the physical settings, people, objects, phenomena, and psychosocial-cultural attributes of an
environment.
No definition of internal environment was provided in Johnsons published material. However, she
provided detailed information about the internal
structure and how it functions. She also noted that
[i]llness or other sudden internal or external environmental change is most frequently responsible for
system malfunction (Johnson, 1980, p. 212). I focus
my attention on internal regulatory mechanisms.
Therefore, I view such factors as physiology, temperament, ego, age, and related developmental capacities, attitudes, and self-concept as 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 assessment.
For example, a nurse attempting to respond to the
needs of an acutely ill hospitalized 6-year-old would
need to know something about the developmental
capacities of a 6-year-old, and about self-concept
and ego development, to understand the childs
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 observed behavior that is
purposeful, orderly, and predictable. Such behavior
is maintained when it is efficient and effective in
managing the persons relationship to the environment.
Behavior changes when efficiency and effectiveness are no longer evident, or when a more optimal
level of functioning is perceived. Individuals are said
to achieve efficient and effective behavioral functioning when their behavior is commensurate with social
demands, when they are able to modify their behavior in ways that support biologic imperatives, when
they are able to benefit to the fullest extent during illness from the physicians 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 fol-
lowing statement to be a malfunction 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 predictable, the conditions and
resources necessary to their functional requirements are met, and the interrelationships
among the subsystems are harmonious. If
these conditions are not met, malfunction becomes apparent in behavior that is in part disorganized, erratic, and dysfunctional. Illness
or other sudden internal or external environmental change is most frequently responsible
for such malfunctions. (Johnson 1980, p. 212)
Thus, it can be inferred that behavioral system imbalance and instability are equated with illness. However, as Meleis (1991) has pointed out, we must consider that illness may
be separate from be- Nursing is viewed as a serhavioral system funcvice that is complementary
tioning. Johnson also
referred to physical to medicine and other
and social health, but
health professions, but
did not specifically define wellness. Just as which makes distinctive
the inference about ill- contributions to the health
ness may be made, it
may be inferred that and well-being of people.
wellness is behavioral
system balance and stability, as well as efficient and
effective behavioral functioning.
Nursing and Nursing Therapeutics

Nursing is viewed as a service that is complementary 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) 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 restore, 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 include helping the person
achieve an optimal level of balance and functioning
when this is possible and desired.
The goal of action of the system is behavioral system balance. For the nurse, the area of concern is a
behavioral system threatened by the loss of order
and predictability through illness or the threat of ill-
93
ness. The goal of action of the nurses is to maintain

or restore the individuals 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 analyzing system functioning,
and provided diagnostic classifications to delineate
disturbances and guidelines for interventions.
Johnson (1980) expected the nurse to base judgements 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 judgement 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 functional problems develop when the system is unable 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 systems
control and regulatory mechanisms fail to develop or
become defective.
The model differentiates four diagnostic classifications to delineate these disturbances. A disorder originating within any one subsystem is classified as either an insufficiency, 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 behavior does not
meet the intended conceptual goal. Disorders found
between more than one subsystem are classified either as an incompatibility, which exists when the behaviors of two or more subsystems in the same situation conflict with each other to the detriment of the
individual, 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 additional diagnostic classifications
would be developed. Nursing therapeutics deal with
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
94
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 individuals set
and choice. The second would be for the nurse to
temporarily 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 external environment and the internal interactions of the subsystem
to create change and restore stability. The third, and
most common, treatment modality is to supply or to
help the client find his or her own supplies of essential functional requirements. The nurse may provide
nurturance (resources and conditions necessary for
survival and growth, train the client to cope with
new stimuli, encourage effective behaviors), stimulation (provision of stimuli that brings forth new behaviors or increases behaviors, motivation for a particular behavior, and that provides opportunities for
appropriate behaviors), and protection (safeguarding from noxious stimuli, defending from unnecessary threats, coping with a threat on the individuals
behalf). The nurse and the client negotiate the treatment plan.
ROLE OF THE MODEL IN NURSING

PRACTICE, ADMINISTRATION,
RESEARCH, AND EDUCATION
Fundamental to any professional discipline is the development of a scientific body of knowledge that can
be used to guide its practice. The Johnson Behavioral
System Model (JBSM) has served as a means for identifying, labeling, and classifying phenomena important to the discipline of nursing. The JBSM model has
been used by nurses since the early 1970s and has
demonstrated its ability to provide a medium for theoretical growth; provide organization for nurses
thinking, observations, and interpretations of what
was observed; provide a systematic structure and rationale for activities; provide direction to the search
for relevant research questions; provide solutions for
patient care problems; and, finally, provide criteria
to determine if a problem had been solved. Rather
than provide a cursory overview of many articles, I
have reviewed the work of nurses who have used the
JBSM to guide a program of study over time.
Research
Stevenson and Woods (1986, p. 6) state: Nursing science is the domain of knowledge concerned with
the adaptation of individuals and groups to actual or

potential health problems, the environments that influence health in humans and the therapeutic interventions that promote health and affect the consequences of illness. This position focuses efforts in
nursing science on the expansion of knowledge
about clients health problems and nursing therapeutics. Nurse researchers have demonstrated the usefulness of Johnsons model in a clinical practice in a
variety of ways. The majority of the research focuses
on clients functioning 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 provide care that influences behavioral system
balance.
Dr. Anayis Derdiarians program of research involves both the client and the nurse as agents of action. Derdiarians early research tested an instrument
designed to measure and describe, using the JBSM
perspective, the perceived behavioral changes of
cancer patients (Derdiarian, 1983; Derdiarian &
Forsythe, 1983). The research was based on Johnsons premise that illness is a noxious stimulus that
affects the balance of the behavioral system. The results demonstrated by the instrument possessed content validity, strong internal consistency, and thus
strong reliability. A later study (Derdiarian, 1988) explained the effects of the variables of age, site, and
stage of cancer on set behaviors of the eight behavioral subsystems of the Johnson model. The study
also served to further validate her instrument.
These studies were important for two reasons.
First, Derdiarian examined the impact of three moderator variables on set behavior. The scores and subscores from her instrument were used to summarize
commonalities and not a specific behavior. Thus, the
measure can be taken as an indicator of the construct
of behavioral set. The construct was defined by a
network of relations that were tied to observables
and were therefore empirically testable. Thus, this
validation study linked a particular measure, the Derdiarian Behavioral System Model (DBSM), to the
more general theoretical construct, behavioral set,
that was embedded in the more comprehensive theoretical network of the JBSM.
The results indicated significant differences in
some mean factor scores in the subsystems among
the groups stratified by age, site of cancer, and stage
of cancer. Therefore, this study extended the development of the nomological network (Cronbach &
Meehl, 1955) of the Johnson model. It provided evidence that the measure exhibited, at least in part,
the network of relations derived from the theory of

the construct. It also elaborated the nomological network by increasing the definiteness of the components of the model (e.g., connections between the
moderator variables, behavioral set, and subsystem
behaviors). The linking of instrument behaviors to a
more general attribute provided not only an evidential basis for interpreting the process underlying the
instrument scores, but also a basis for inferring researchable implications of the scores from the
broader network of the constructs meaning. A further test of the instrument (Derdiarian & Schobel,
1990) indicated a rank order among the subsystems
response frequency counts as well as among their importance values. Derdiarian also found that changes
in the aggressive/protective subsystem made both direct and indirect effects on changes in other subsystems (Derdiarian, 1990).
Derdiarian also examined the nurse as an action
agent within the practice domain. She focused on
the nurses assessment of the patient using the DBSM
and the effect of using this instrument on the quality
of care (Derdiarian, 1990, 1991). This approach expanded the view of nursing knowledge 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 DBSM was
used. Derdiarian also found that a model-based valid
and reliable instrument could improve the comprehensiveness and the quality of assessment data, the
method of assessment, and the quality of nursing diagnosis, interventions, and outcomes.
Derdiarians body of work reflects the complexity
of nursings knowledge as well as the strategic problem-solving capabilities of the JBSM. Her article (Derdiarian, 1991) demonstrated the clear relationship
between Johnsons theory and nursing practice.
My program of research has examined normal and
atypical patterns of behavior of children with a
chronic illness and the behavior of their parents, and
the interrelationship between the children and the
environment. My goal was to determine the causes
of instability within and between subsystems (e.g.,
breakdown in internal regulatory or control mechanisms), and to identify the source of problems in behavioral system balance.
My first study (Holaday, 1974) compared the
achievement behavior of chronically ill and healthy
children. The study showed that chronically ill children differed in attributional tendencies when compared with healthy children, and that the response
patterns differed within the chronically ill group
when compared to certain dimensions (e.g., gender,
95
your thoughts
age at diagnosis). Males and children diagnosed at

birth attributed both success and failure to the presence or absence of ability and little to effort. This is
a pattern found in children with low achievement
needs. The results indicated behavioral system imbalance and focused my attention on interventions directed toward set, choice, and action.
The next series of studies used the concept of
behavioral set and examined how mothers and
their chronically ill infants interacted (Holaday, 1981,
1982, 1987). Patterns of maternal response provided
information related to the setting of the set goal or
behavioral set, that is, the degree of proximity and
speed of maternal response. Mothers with chronically ill infants rarely did not respond to a cry indicating a narrow behavioral set. Further analysis of the
data led to the identification of a new structural component of the model-conceptual set. A persons conceptual set was defined as an organized cluster of
cognitive units that were used to interpret the content information from the preparatory and preservatory sets. A conceptual set may differ both in the
number of cognitive units involved and in the degree
of organization exhibited. Thus, the various cognitive units that make up a conceptual set may vary in
complexity depending on the situation. Three levels
of conceptual set have been identified, ranging from
a very simple to a complex setwith a high degree of
connectedness between multiple perspectives (Holaday, 1982). Thus, the conceptual set functions as an
information collection and processing unit. Examining a persons set, choice, and conceptual set offered
a way to examine issues of individual cognitive patterns and its impact on behavioral system balance.
The most recent study (Holaday, Turner-Henson,
& Swan, 1997) drew from the knowledge gained
96
from previous studies. This study viewed the JBSM as

holistic, in that it assumed that all part processes
biological, physical, psychological, and socioculturalare interrelated; developmental, in that it assumed that development proceeds from a relative
lack of differentiation toward a goal of differentiation
and hierarchic integration of organismic functioning;
and system-oriented, in that a unit of analysis was the
person in the environment where the physical and/
or biological (e.g., health), psychological, interpersonal, and sociocultural levels of organization of the
person are operative and interrelated with the physical, interpersonal, and sociocultural levels of organization in the environment. Our results indicate that it
was possible to determine the impact of a lack of
functional requirements on a childs actions, to identify behavioral system imbalance and the need for
specific types of nursing intervention.
The goal of my program of research has been to
describe the relations both among and within the
subsystems that make up the integrated whole as
well as to identify the type of nursing interventions
that restore behavioral system balance. The process
of clinical assessment to attain such information is
described elsewhere (Holaday, 1997). The program
of research is linked to systems as well as developmental aspects of the JBSM. The research problems
were selected with the systems-based assumption
that a disturbance in any part of the behavioral system or the environment that supplies sustenal imperatives would impact the system as a whole. Moreover, with respect to development, we are touching
on a set of conditions that has developmental relevance, namely the functioning of the person under
stressful (e.g., diagnosis and management of a chronic
illness) versus more optimal conditions of function-
ing. Changes in the person, in the environment, or

in the relations between them can cause behavioral
system imbalance, which may, in turn, depending on
the nursing interventions, make for developmental
progression (change). Thus, my approach has been
to use the complementarity of explication (description) and causal explanation (condition under which
cause-effect relations occur) rather than being restricted to one approach.
Other nurse researchers have demonstrated the
utility of Johnsons model for clinical practice. Wilke,
Lovejoy, Dodd, and Tesler (1988) used the JBSM to
examine cancer pain control behaviors. Their findings supported the assumption that aggressive/protective subsystem behaviors are developed and modified over time. Lovejoy (1983) found that leukemic
children were affected by their perceptions of family
behavioral disturbances. Lewis and Randell (1990)
used the JBSM to identify the most common nursing
diagnoses of hospitalized geopsychiatric patients.
They found that 30% were related to the achievement subsystem. They also found that the JBSM was
more specific than NANDA (North American Nursing
Diagnosis Association) diagnoses, which demonstrated
considerable overlap. Poster, Dee, and Randell (1997)
found the JBSM was an effective framework to use to
evaluate patient outcomes. All of these studies have
tested the JBSM and have increased nursings body of
knowledge.
Education
Johnsons model was used as the basis for undergraduate 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 Johnsons model and provided some idea of
the content of that curriculum. Later, in the 1980s,
Harris (1986) described the use of Johnsons theory
as a framework for UCLAs curriculum. The Universities of Hawaii, Alaska, and Colorado also used the
JBSM as a basis for their undergraduate curricula.
Loveland-Cherry and Wilkerson (1983) analyzed
Johnsons model and concluded that the model
could be used to develop a curriculum. The primary
focus of the program would be the study of the person as a behavioral system. The student would need
a background in systems theory and the biological,
psychological, and sociological sciences.
Nursing Practice and Administration

Johnson has influenced nursing practice because 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 the
goal of nursing. Nurs- Nursings objective is to
ings specific objective
is to maintain or re- maintain or restore the
store the persons be- persons behavioral system
havioral system balbalance and stability, or
ance and stability, or
to help the person help the person achieve a
achieve a more optimore optimum level of
mum level of functioning. The model pro- functioning.
vides 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 use of the model
in practice has been at the University of California,
Los Angeles, Neuropsychiatric Hospital (UCLA
NPI). Auger and Dee (1983) designed a patient classification system using the JBSM. Each subsystem of
behavior was operationalized in terms of critical
adaptive and maladaptive 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 impact on all phases of the nursing process, including a
more systematic assessment process, identification
of patient strengths as well as problem areas, and an
objective means for evaluating the quality of nursing
care (Dee & Auger, 1983).
The early works of Dee and Auger lead 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
& Randell, 1989; Dee, 1990). Based on behavioral
data, each subsystem is assigned a behavioral category score ranging from 1 to 4 (1 = effective; 2 = inconsistently effective; 3 = ineffective; and 4 = severely ineffective). In addition, data is gathered to
determine the degree to which the internal and external environments protect, nurture, and/or stimulate the behavioral subsystems. The diagnostic process is based on the degree of effectiveness or on the
effectiveness of each behavioral subsystem. An overall behavioral category score is determined for the
entire behavioral system ranging from 1 to 4 (1 =
health, 2 = potential for health deviation; 3 = illness;
and 4 = critical illness). Priorities are established and
mutual goal-setting is conducted between patient/
family and nurse (Dee & Randell, 1989). Nursing
97
98
12.0
12.2
1.2
1.2
1.5
7.3
7.3
7.1
3.6
3.4
3.5
Totals
0.1
0.2
0.1
Levels of Nursing Interventions

II
III
IV
10.55
3.82
4.24
2.49
# Stf
7.11
2.55
2.91
1.65
Patient
Hours
722950
183008
358208
181734
763025
270855
338014
154156
79.1
40.4
159.7
87847
40075
40.2
176.7
61.9
79.6
35.2
16.9
21.5
0.4
5.0
Cost per Patient

Budget
Actual
Var
20194
27578
Total Cost
Budget Actual
Var
Source: V. Dee & B. Randell (1989). NPH Patient Classification System: A theory-based nursing practice model for staffing. Paper presented at the UCLA Neuropsychiatric Institute and Hospital.
12.3
Nursing Staffing Budget Unit: 2South
Actual No.
Patients
Shift
TABLE 72
interventions are ranked according to frequency, intensity, and nature of nursing contract. Predicted
outcomes and short-term goals are measured to determine whether increased behavioral effectiveness
was achieved.
The scores serve as an acuity rating system and
provide a basis for allocating resources. Resources
are allocated based on the assigned levels of nursing
intervention, and resource needs are calculated
based on the total number of patients assigned according to levels of nursing interventions and the
hours of nursing care associated with each of the levels (Dee & Randell, 1989) (see Table 72). The development of this system has provided nursing administration with the ability to identify the levels of staff
needed to provided care (licensed vocational nurse
versus registered nurse), bill patients for actual 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, Dee, & Randell, 1997) and the effectiveness of using a model to identify the characteristics of a large hospitals managed behavioral health
population in relation to observed nursing care
needs, level of patient functioning on admission and
discharge, and length of stay (Dee, Van Servellen, &
Brecht, 1998).
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 established a systematic framework for patient assessment and nursing interventions, provided
a common frame of reference for all practitioners in
the clinical setting, provided a framework 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.
Summary
The Johnson Behavioral System Model captures the
richness and complexity of nursing. While the perspective presented here is embedded in the past,
there remains the potentiality for the further development of the theory, as well as the uncovering and
shaping of significant research problems that have
both theoretical and practical value. There are a variety of problem areas worthy of investigation that are
suggested by the JBSM assumptions and from previous studies. Some examples include examining the
levels of integration (biological, psychological, 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 ones biological system (e.g., unstable, problems breathing), ones psychological self
(e.g., achievement goals, need for assistance, selfconcept), self in relation to the physical environment (e.g., allergens, being away from home), and
transactions related to the sociocultural context
(e.g., attitudes and values about the sick). The study
of transitions (e.g., the onset of puberty, menopause,
death of a spouse, onset of acute illness) also represents 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 conceptualization of the JBSM
but also information about nursing interventions.
The JBSM approach leads us to seek common organizational parameters in every scientific explanation
and does so using a shared language about nursing
and nursing care.
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101
Chapter 8
Myra Levine
Conservation Model:
A Model for the Future
Introduction to the Foundations of Clinical Nursing
The Conservation Model Informed by the Adjunctive Sciences
The Composition of the Conservation Model
Philosophical Notes
The Models Fit with Practice
Research Based on the Conservation Model
The Conservation Model in the Twenty-first Century
Summary
References
Bibliography
Karen Moore Schaefer
Nursing is human interaction. . . . Nursing knowledge, thoroughly grounded in modern scientific

concepts, allows for a sensitive and productive relationship between the nurse and the individual entrusted to her care. In the care of the sick, this has
always been true, but never before has there been
available to the nurse so rich and demanding a
body of knowledge to use in the patients behalf
Myra Levine (1973, p. 1)

Myra Levine has been called a Renaissance woman
highly principled, remarkable, and committed to
what happens to the quality of life of patients. She
was a daughter, sister, wife, mother, friend, educator, administrator, student of humanities, scholar, enabler, and confidante. She was amazingly intelligent,
opinionated, quick to respond, loving, caring, trustworthy, and global in her vision of nursing. She was
committed to her Jewish faith; she planted a tree in
Israel in memory of my father. What a precious gift
she was! In the Talmudic tradition of her ancestors,
she was a forthright spokesperson for social justice
and the inherent dignity of the human person as a
child of God (Mid-Year Convocation, 1992). She
lives on in my heart, as I hope she will in yours, as
you learn about her and the model she unknowingly
created to develop nursing knowledge.
Myra was born in Chicago and raised with a sister
and brother with whom she shared a close, loving relationship (Levine, 1988b). She was also very fond of
her father, who was a hardware man. He was often ill
and frequently hospitalized with gastrointestinal
problems. She thinks that this might have been why
she had such a great interest in nursing. Myras
mother was a strong woman who kept the home
filled with love and warmth. She was very supportive of Myras choice to be a nurse. [My mother]
probably knew as much about nursing as I did,
(Levine, 1988b) because she was devoted to caring
for her father when he was ill.
Myra completed most of her education in Chicago
schools. She went to elementary and high school in
the windy city. She started undergraduate work at
the University of Chicago, but after 2 years she left
the university and had to consider other options. She
claimed that she originally wanted to be a physician
but she was discouraged from pursuing this career
because she was a woman and Jewish. In her last
year of high school she had an emergency appendectomy and fell in love with nursing. When she could
104
no longer afford the University of Chicago, she chose

to attend Cook County School of Nursing.
Being in nursing school was a new experience for
her; she called it a great adventure (Levine, 1988b).
She had never before been away from home. At Cook
County she had a room all to herself with a desk, a
bed, and a chair. Before this time in her life she had
always shared a room with her sister. She received
her diploma from Cook County in 1944. She later received her bachelor of science degree from the University of Chicago in 1949 and her master of science
in nursing from Wayne State University in 1962.
Myra married Edwin Levine in 1944. They had
three children. Their first son, Benjamin, died 3 days
after birth. Bill and Pat were born several years later.
Myra talked of the difficulty of living with the loss
of her child, Benoni, but soon found that even this
sad event became a blessing to her (Levine, 1988b).
She said of her children: Bearing, nurturing, and
growing with children creates parent as person. My
childrenall threecreated me (Levine, 1988b,
p. 223).
Education was always Myras primary interest, although she had clinical experience in the operating
room and in oncology nursing. She was a civilian
nurse at the Gardiner General Hospital, director of
nursing at Drexel Home in Chicago, clinical instructor at Bryan Memorial Hospital in Lincoln, Nebraska,
and administrative supervisor at University of Chicago Clinics and Henry Ford Hospital in Michigan.
She was chairperson of clinical nursing at Cook
County School of Nursing and a faculty member at
Loyola University, Rush University, and University of
Illinois. She was a visiting professor at Tel Aviv University in Israel and Recanti School of Nursing at Ben
Gurion University of the Negev in Beer Sheeva, Israel. She was professor emeritus in Medical Surgical
Nursing, University of Chicago, a charter fellow of
the American Association of Nurses (FAAN), and a
member of Sigma Theta Tau, from which she received the Elizabeth Russell Belford Award as distinguished educator. She received an honorary doctorate from Loyola University in 1992. Dr. Jacqueline
Fawcett, Jane Benson Pond, and I were thrilled to
share this momentous event with her. This is when
I first met her and learned that she loved pizza as
much as I did. I also learned that her hugs were
warm fuzzies.
Myra passed away on March 20, 1996. It was comforting to know that many of her friends were able to
spend time with her in her final days. This was a sad
day for all those who loved her, especially her family
and friends.
INTRODUCTION TO
THE FOUNDATIONS FOR
CLINICAL NURSING
F. A. Davis Company published the first edition of
Myra Levines textbook, Introduction to Clinical
Nursing, in 1969, and the second and last edition in
1973. In discussing the first edition of her book,
Levine (1969a, p. 39) said: I decided against using
holistic in favor of organismic, largely because the
term holistic had been appropriated by pseudoscientists endowing it with the mythology of transcendentalism. I used holism in the second edition in
1973 because I realized it was too important to be
abandoned to the mystics. I believed that it was the
proper description of the way the internal environment and the external environment were joined in
the real world. In the introduction to the second edition, she wrote (Levine, 1973, p. vii):
There is something very final about a printed
page, and yet books do have a life all their
own. They gather life from the use to which
they are put, and when they succeed in communicating among many individuals in many
places, then their intent is most truly served.
The most remarkable fact about the first edition of this book has been the exchange of interests that has resulted from the willingness
with which its readers and users have communicated with its author.
This passage suggests that Levines original book
(1969) provided a model to teach medical surgical
nursing and created a dialogue among colleagues

about the plan itself. The text has continued to create
dialogue about the art and science of nursing with
ongoing research serving as a testament to its value.
Myras original reason for writing the book was to
find a way to teach the foundations of nursing that
would be focused on nursing and organized in such
a way that nursing students would learn the skill as
well as the rationale for the skill. She felt that too
often the focus was on skill and not on the reasons
why the skill is performed. She felt that nursing research was generally ignored. Her intent was to bring
practice and research together to establish nursing as
an applied science. The book was used as a beginning nursing text by by Myra and many of her colleagues.
The first chapter of her text was entitled the Introduction to Patient Centered Nursing Care, a
model of care delivery that is now acclaimed to be
the answer to cost-effective delivery of health-care
services today. She believed that patient-centered
care was individualized nursing care (Levine, 1973,
p. 23). She was truly visionary. She discussed the theory of causation, a unified theory of health and disease, the meaning of the conservation principles,
the hospital as environment, and patient-centered intervention. The nursing care chapters in her text focus on nursing care of the patient with:
1. failure of the nervous system,
2. failure of the integration resulting from hormonal
imbalance,
3. disturbance of homeostasis: fluid and electrolyte
imbalance,
4. disturbance of homeostasis: nutritional needs,
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Chapter 8 Myra Levine Conservation Model:A Model for the Future
105
5. disturbance of homeostasis: systemic oxygen

needs,
6. disturbance of homeostasis: cellular oxygen
needs,
7. disease arising from aberrant cellular growth,
8. inflammatory problems, and
9. holistic response.
Her way of organizing the material was a shift from
teaching nursing based on the disease model. Her final chapter on the holistic response represented a
major shift away from disease to the systems way of
thinking. Informed by other disciplines, she discusses the integrated system, the interaction of systems creating the sense of well-being, energy exchange at the organism level as well as the cellular
level, perception of self, the affect of space on selfperception, and the circadian rhythm.
As Myra wrote her book, major changes took
place in the curriculum at Cook County Hospital
(Levine, 1988b). She and her colleagues began to focus on the importance of nursing research, and
taught perception, sleep, distance (space), and periodicity as a factor in health and disease.
THE CONSERVATION
MODEL INFORMED BY
THE ADJUNCTIVE SCIENCES
4.
5.
6.
7.
8.
9.
Levine used the inductive method to develop her

model. She borrowed information from other disciplines while retaining the basic structure of nursing
in the model (Levine 1988a). As she continued to
write about her model, she integrated information
from other sciences and increasingly cited personal
experiences as evidence of the validity of her work.
The following is a list of the influences in the development of her philosophy of nursing and the conservation model.
1. Myra Levine credited Florence Nightingale
(1859) with the importance of observation to
the process of nursing. Observation is a
guardian activity (Levine, 1992). Levine indicated that Nightingale provided great attention
to energy conservation and recognized the need
for structural integrity. Levine relates Nightingales discussion of social integrity to Nightingales concern for sanitation, which she says implies an interaction between the person and the
environment.
2. Irene Beland was Myras teacher and thesis advisor. Beland influenced her thinking about nursing as a compassionate art and rigid intellectual
106
3.
10.
11.
12.
pursuit (Levine, 1988b). Levine also credited Beland (1971) for the theory of specific causation
and multiple factors.
Feynman (1965) provided support for Myras position that conservation was a natural law, arguing that the development of theory cannot deny
the importance of natural law (Levine, 1973).
Bernard (1957) is recognized for his contribution in the identification of the interdependence
of bodily functions (Levine, 1973).
Levine (1973) emphasized the dynamic nature
of the internal milieu, using Waddingtons
(1968) term homeophoresis.
Use of Batess (1967) formulation of the external
environment as having three levels of factors
perceptual, operational, and conceptualchallenging the integrity of the individual, helped to
emphasize the complexity of the environment.
The description of illness is based on Wolfs
(1961) description of disease as adaptation to
noxious environmental forces.
Selyes (1956) definition of stress is included in
Levines (1989c, p. 30) description of her organismic stress response as being recorded over
time and . . . influenced by the accumulated experience of the individual.
The perceptual organismic response incorporates Gibsons (1966) work on perception as a
mediator of behavior. His identification of the
five perceptual systems, including hearing,
sight, touch, taste, and smell, contributed to the
development of the perceptual response.
The notion that individuals seek to defend their
personhood is grounded in Goldsteins (1963)
explanation of the soldiers who, despite brain
injury, sought to cling to some semblance of
self-awareness.
Duboss (1965) discussion of the adaptability of
the organism helped support Levines explanation that adaptation occurs within a range of responses.
Levines personal experiences influenced her
thinking in several ways. When hospitalized,
the experience of wholeness is universally acknowledged, she said (Levine, 1996, p. 39).
THE COMPOSITION OF
THE CONSERVATION MODEL
As an organizing framework for nursing practice, the
goal of the Conservation Model is to promote adaptation and maintain wholeness using the principles of
conservation. The model guides the nurse to focus
on the influences and responses at the organismic

level. The nurse accomplishes the goals of the model
through the conservation of energy, structure, and
personal and social integrity (Levine, 1967). Interventions are provided in order to improve the patients condition (therapeutic) or to promote comfort (supportive) when change in the patients
condition is not possible. The outcomes of the interventions are assessed through the organismic
response.
Although Levine identified two concepts critical
to the use of her modeladaptation and wholenessconservation is fundamental to the outcomes
expected when the model is used. Conservation is
therefore handled as the third major concept of the
model.
Adaptation is the process of change, and conservation is the outcome of adaptation. Adaptation is
the process whereby the patient maintains integrity
within the realities of the environment (Levine,
1966, 1989a). Adaptation is achieved through the
frugal, economic, contained, and controlled use of
environmental resources by the individual in his or
her best interest (Levine, 1991, p. 5). In her view:
The environmental fit that underscores successful adaptation suggests that every species
has fixed patterns of response uniquely designed to ensure success in essential life activities, demonstrating that adaptation is both
historical and specific. However, tremendous
opportunities for individual accommodations
are locked into the gene structure of each
species; every individual is one of a kind.
Every individual has a unique range of adaptive responses. These responses will vary based on heredity, age, gender, or challenges of an illness experience. For example, the response to weakness of the
cardiac muscle is an increased heart rate, dilation of
the ventricle, and thickening of the myocardial muscle. While the responses are the same, the timing and
the manifestation of the organismic response (e.g.,
pulse rate) will be unique for each individual.
Redundancy, history, and specificity characterize
adaptation. These characteristics are rooted in history and awaiting the specific circumstances to
which they respond (Levine, 1991, p. 6). The genetic structure develops over time and provides the
foundation for these responses. Specificity, while
sharing traits with a species, has individual potential
that creates a variety of adaptation outcomes. For example, diabetes has a genetic component, which explains the fundamental decrease in sugar metabolism. However, the organismic responses vary (renal
perfusion, blood vessel integrity), for example, based

on genetic alterations, age, gender, and therapeutic
management techniques.
Redundancy represents the fail-safe options available to the individual to ensure continued adaptation. Levine (1991)
believed that health is The nursing practice goal
dependent on the ability to select from re- of the Conservation Model
dundant options. She is to promote adaptation
hypothesized that aging may be the result and maintain wholeness
of the failure of redun- using principles of conserdant systems. If this is
the case, then survival vation.
is dependent on redundant options, which are often challenged and
limited by illness, disease, and aging. When the compensatory response to cardiac disease is no longer
able to maintain an adequate blood flow to vital organs during activity, survival becomes increasingly
difficult. Adaptation represents the accommodation
between the internal and external environments.
Conservation is the product of adaptation and is
a common principle underlying many of the basic
sciences. Conservation is critical to understanding
an essential element of human life:
Implicit in the knowledge of conservation is the
fact of wholeness, integrity, unityall of the
structures that are being conserved . . .
conservation of the integrity of the person is
essential to ensuring health and providing the
strength to confront disability . . . the importance
of conservation in the treatment of illness is
precisely focused on the reclamation of
wholeness, of health . . . Every nursing act is
dedicated to the conservation, or keeping
together, of the wholeness of the individual.
(Levine, 1991, p. 3)
Individuals are continuously defending their wholeness to keep together the life system. Individuals defend themselves in constant interaction with their
environment, choosing the most economic, frugal,
and energy-sparing options that safeguard their integrity. Conservation seeks to achieve a balance of
energy supply and demand that is within the unique
biological capabilities of the individual (Schaefer,
1991a).
Maintaining the proper balance involves the nursing intervention coupled with the patients participation to assure the activities are within the safe limits
of the patients ability to participate. Although energy cannot be directly observed, the consequences
107
of energy exchanges are predictable, recognizable,

and manageable (Levine, 1973; 1991).
Wholeness is based on Eriksons (1964, p. 63) description of wholeness as an open system: Wholeness emphasizes a sound, organic, progressive mutuality between diversified functions and parts within
an entirety, the boundaries of which are open and
fluid. Levine (1973, p. 11) stated that the unceasing
interaction of the individual organism with its environment does represent an open and fluid system,
and a condition of health, wholeness, exists when
the interaction or constant adaptations to the environment, permit easethe assurance of integrity . . .
in all the dimensions of life. This continuous dynamic, open interaction between the internal and external environment provides the basis for holistic
thought, the view of the individual as whole.
Using the model in practice requires that the
nurse understand the commonplaces (Barnum,
1994) of health, person, environment, and nursing.
Health and disease are patterns of adaptive
change. From a social perspective, health is the ability to function in soConservation is the product cial roles. Health is
culturally determined:
of adaptation and is critical [I]t is not an entity,
to understanding but rather a definition
imparted by the ethos
human life. and beliefs of the
groups to which the
individual belongs (personal communication, February 21, 1995). Health is an individual response that
may change over time in response to new situations,
new life challenges, aging; or social, political, economic, and spiritual factors. Health is implied to
mean unity and integrity. The goal of nursing is to
promote health. Levine (1991, p. 4) clarified what
she meant by health as:
. . . the avenue of return to the daily activities
compromised by ill health. It is not only the insult or the injury that is repaired but the person himself or herself. . . . It is not merely the
healing of an afflicted part. It is rather a return
to self hood, where the encroachment of the
disability can be set aside entirely, and the individual is free to pursue once more his or her
own interests without constraint.
In all of life challenges, individuals will constantly attempt to attain, retain, maintain, or protect their integrity (health, wholeness, and unity).
The person is a holistic being who is sentient,
thinking, future-oriented, and past-aware.The whole-
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ness (integrity) of the individual demands that the

individual life has meaning only in the context of social life (Levine, 1973, p. 17). The person responds
to change in an integrated, sequential, yet singular
fashion while in constant interaction with the environment. Levine (1996, p. 40) defined the person
as a spiritual being, quoting Genesis 1:27: And God
created man in his own image, in the image of God
created He him. Male and female created He
them. . . . Sanctity of life is manifested in everyone.
The holiness of life itself [testifies] to its spiritual reality. Person can be an individual, a family, or a
community.
The environment completes the wholeness of
the individual. The individual has both an internal
and external environment. The internal environment
combines the physiological and pathophysiological
aspects of the individual and is constantly challenged
by the external environment.
The external environment includes those factors
that impinge on and challenge the individual. The
environment as described by Levine (1973) was
adapted from the three levels of environment identified by Bates (1967). The perceptual environment includes aspects of the world that individuals are able
to seize or interpret through the senses. The individual seeks, selects, and tests information from the environment in the context of his [her] definition of
himself [herself], and so defends his [her] safety, his
[her] identity, and in a larger sense, his [her] purpose (Levine, 1971, p. 262). The operational environment includes factors that may physically affect
individuals but are not directly perceived by them
such as radiation, microorganisms, and pollution.
The conceptual environment includes the cultural
patterns characterized by spiritual existence and mediated by language, thought, and history. Factors
that affect behaviorsuch as norms, values, and beliefsare also part of the conceptual environment.
Nursing is human interaction (Levine, 1973, p.
1). The nurse enters into a partnership of human experience where sharing moments in timesome
trivial, some dramaticleaves its mark forever on
each patient (Levine, 1977, p. 845). The goal of
nursing is to promote adaptation and maintain wholeness (health). The goal is accomplished through the
use of the conservation principles: energy, structure,
personal, and social.
Energy conservation is dependent on the free exchange of energy with the internal and external environment to maintain the balance of energy supply
and demand. Conservation of structural integrity is
dependent on an intact defense system (immune sys-
tem) that supports healing and repair to presponse that may change serve the structure and
function of the whole
over time in new situa- being.
The conservation of
tions. The goal of nursing is
personal integrity acto promote adaptation and knowledges the individmaintain health. ual as one who strives
for recognition, respect,
self-awareness, humanness, self-hood, and self-determination. The conservation of social integrity recognizes the individual as a social being who functions
in a society that helps to establish boundaries of the
self. The value of the individual is recognized, but it
is also recognized that the individual resides within a
family, a community, a religious group, an ethnic
group, a political system, and a nation (Levine,
1973).
The outcome of nursing involves the assessment
of organismic responses. The nurse is responsible for
[responding to a request for health care] and for recognizing altered health and the patients organismic
response to altered health. An organismic response is
a change in behavior or change in the level of functioning during an attempt to adapt to the environment. The organismic responses are intended to
maintain the patients integrity. The levels of organismic response include (Levine, 1973):
Health is an individual re-
1. Response to fear (flight/fight response). This is

the most primitive response. It is the physiological and behavioral readiness to respond to a sudden and unexpected environmental change; it is
an instantaneous response to real or imagined
threat.
2. Inflammatory response. This is the second level
of response intended to provide for structural integrity and the promotion of healing. Both are defenses against noxious stimuli and the initiation
of healing.
3. Response to stress. This is the third level of response, which is developed over time and influenced by each stressful experience encountered
by the patient. If the experience is prolonged,
the stress can lead to damage to the systems.
4. Perceptual response. This is the fourth level of response. It involves gathering information for the
environment and converting it to a meaningful
experience.
The organismic responses are redundant in the sense
that they coexist. The four responses help individuals
protect and maintain their integrity. They are integrated by their cognitive abilities, wealth of previous
experiences, ability to define relationships, and the
strength of their adaptive abilities.
Nurses use the scientific process and creative abilities to provide nursing care to the patient (Schaefer,
1997). The nursing process incorporates these abilities, thereby improving the care of the patient (Table
81).
PHILOSOPHICAL NOTES
Assumptions
1. The person is viewed as a holistic being: The
experience of wholeness is the foundation of all
human enterprises (Levine, 1991, p. 3).
2. Human beings respond in a singular yet integrated fashion.
3. Each individual responds wholly and completely
to every alteration in his or her life pattern.
4. Individuals cannot be understood out of the
context of their environment.
5. Ultimately, decisions for nursing care are based
on the unique behavior of the individual
patient. . . . A theory of nursing must recognize
the importance of unique detail of care for a single patient within an empiric framework which
successfully describes the requirements of all patients (Levine, 1973, p. 6).
6. Patient centered care means individualized
nursing care. It is predicated on the reality
of common experience: every man is a
unique individual, and as such requires a
unique constellation of skills, techniques, and
ideas designed specially for him (Levine, 1973,
p. 23).
7. Every self sustaining system monitors its own
behavior by conserving the use of resource required to define its unique identity (Levine,
1991, p. 4).
8. The nurse is responsible for recognizing the
state of altered health and the patients organismic response to altered health.
9. Nursing is a unique contributor to patient care
(Levine, 1988a).
10. The patient is in an altered state of health
(Levine, 1973). A patient is one who seeks
health care because of a desire to remain
healthy or identifies a known or possible risk
behavior.
11. A guardian angel activity assumes that the nurse
accepts responsibility and shows concern based
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on knowledge that makes it possible to decide

on the patients behalf and in his [or her] best
interest (Levine, 1973).
Values
1. All nursing actions are moral actions.
2. Two moral imperatives are the sanctity of life and
the relief of suffering.
3. Ethical behavior is the day-to-day expression of
ones commitment to other persons and the ways
in which human beings relate to one another in
their daily interactions (Levine, 1977, p. 846).
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4. A fully informed individual should make decisions regarding life and death in advance of
the situations. These decisions are not the role
of the health care providers or families (Levine,
1989b).
5. Judgments by nurses or doctors about quality of
life are inappropriate and should not be used as a
basis for the allocation of care (Levine, 1989b).
6. Persons who require the intensive interventions
of critical care units enter with a contract of
trust. To respect trust . . . is a moral responsibility (Levine, 1988b, p. 88).
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THE MODELS FIT WITH PRACTICE

The universality of the model is supported by the use
of the model in a variety of situations and patients
conditions across the life span. A growing body of research is providing the support for the development
of scientific knowledge related to the model.
Use of the Conservation

Model in Practice
The model has been used to guide patient care in settings such as critical care (Brunner, 1985; Langer,
1990; Littrell & Schumann, 1989; Lynn-McHale &
Smith, 1991; Tribotti, 1990), acute care (Foreman,
1989, 1991, 1996; Molchany, 1992; Schaefer, 1991a;
Schaefer & Shober-Potylycki, 1993; Schaefer, Swavely,
Rothenberger, 1996), emergency room (Pond &
Taney, 1991), primary care (Pond, 1991), operating
room (Crawford-Gamble, 1986), long-term/extended
care (Cox, 1991), homeless (Pond, 1997), and the
community (Dow & Mest, 1997; Pond, 1991).
This model has been used with a variety of patients across the life span, including the neonate (Tribotti, 1990), infant (Newport, 1984; Savage & Culbert, 1989), young child (Dever, 1991), pregnant
woman (Roberts, Fleming, & Yeates-Giese, 1991),
young adult (Pasco & Halupa, 1991), long-term ventilator patient (Higgins, 1998), and older adult and
elderly patients (Cox, 1991; Foreman, 1991, 1996;
Hirschfeld, 1976), including the frail elderly patient.
(M. Happ, personal communication, January 31,
1995; Roberts, Brittin, Cook, & deClifford, 1994).
The model has been used as a framework for
wound care (Cooper, 1990), managing respiratory
illness (Dow & Mest, 1997; Roberts, Brittin, Cook, &
deClifford, 1994), managing sleep in the patient
with a myocardial infarction (Littrell & Schumann,

1989), developing nursing diagnoses (MacLean,
1989; Taylor, 1989), practicing enterostomal therapy
(Neswick, 1997), assessing for changes in bladder
function in posthysterectomy women (OLaughlin,
1986); for developing plans of care for women with
chronic illness (Schaefer, 1997), care of intravenous
sites (Dibble, Bostrom-Ezrati, & Rizzuto, 1991), and
skin care (Burd et al., 1994); for developing day
room admission (Clark, Fraaza, Schroeder, & Maddens, 1995); and for care of patients undergoing
treatment for cancer (Webb, 1993). Universities and
colleges are considering continued and new use of
the model as the framework for undergraduate
(Grindley & Paradowski, 1991) and graduate programs (Schaefer, 1991b). Current work on the model
is in process in the areas of community health. The
following is a brief summary of beginning clarification of the models use in community-based care.
The Conservation Model as

a Model for Community-based Care
A Modification of the Model
The principles of community health nursing that are
fundamental to community-based care can be practiced in any setting. This particular discussion focuses on community-based care using Levines Conservation Model to provide a foundation for the
future of nursing practice and dispel the myth that
the model is inappropriate for the community.
The focus of health in the community is based on
the assumption that community-based care is informed often by the one-to-one care provided to individuals. Using Levines Conservation Model, community was initially defined as a group of people living
111
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together within a larger society, sharing common

characteristics, interests, and location (National
League for Nursing Self Study Report, 1978). Clark
(1992) provides examples of the use of the conservation principles with the individual, family, and community as a testament to the models flexibility/
universality.
The approach to community begins with the collection of facts and a thorough assessment (provocative facts). The internal environment assessment directs the nurse to examine the patterns of health and
disease among the people of the community and
their use of programs available to promote a healthy
community. The assessment of the external environment directs the nurse to examine the perceptual,
operational, and conceptual levels of the environment in which the people live. The perceptual
environment incorporates those factors that are
processed by the senses. On a community basis
these factors might include an assessment of:
1. how the media affect the health of the people,
2. how the quality of the air influences health patterns and housing development,
3. the availability of nutritious and affordable foods
throughout the community,
4. noise pollution, and
5. relationships among the subcultures of the community.
The operational environment would encourage a
more detailed assessment of the factors in the environment that affect the health of the individual but
are not perceived by the people. These might include assessment for the use of toxins in industry,
disposal of waste products, consideration for expo-
112
sure to radiation from electrical lines, and examination of buildings for asbestos and radon.
The conceptual environment will focus the assessment on the ethnic and cultural patterns in the
community. An assessment of types of houses of worship and health-care settings might be included. In
this area, the effect of the communities external to
the one being assessed would be addressed in order
to determine factors that may influence the function
of the target community.
The novice nurse will benefit from using the conservation principles to guide continued assessment
to assure a thorough understanding of the community. When considering energy conservation, areas to
assess might include:
1. hours of employment
2. water supply
3. community budget
An assessment of structural integrity might include:
1.
2.
3.
4.
city planning
availability of resources
transportation
public services
Assessment of personal integrity might include:

1. community identity
2. mission of the government
3. political environment
Assessment of the social integrity might include:
1. recreation
2. social services
See Table 82, Levines Conservation ModelNursing Process in the Community.
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tested. Following is a summary of the conclusions of

research using the Conservation Model as a framework.
RESEARCH BASED ON THE

CONSERVATION MODEL
Nurses are constantly testing what they propose
will work in their practice based on what they
know (Schaefer, 1991a, p. 45). This continuous testing expands what is known about practice and offers
new insights to improve the practice of nursing.
Levine (1973) maintained that research is critical to
the development of a scientifically sound body of
knowledge for nursing. She felt that the conservation
principles offer an approach to nursing that is scientific, research-oriented, and universal in practice.
She said that the focus of research should be on the
maintenance of wholeness and the interface between the internal and external environments of the
person (Levine, 1978). For the purpose of discovery,
and contrary to the notion of wholeness, Levine supported the testing of variables that represent a single
integrity. For example, Lane and Winslow (1987) focused on energy conservation, whereas Roberts,
Fleming, and (Yeates) Giese (1991) focused on energy conservation and structural integrity. To be true
to the model, investigators can explain their findings
within the framework and consider how the findings
support the goal of promoting adaptation and maintaining wholeness.
Because the model supports understanding and
description, both qualitative and quantitative approaches are appropriate to develop the model and
theories derived from the model. The qualitative approach helps to explain how the patient experiences
the challenges to their internal and external environments. The quantitative approach helps to test the relationships between the variables, and, in some
cases, provides for the testing of causal models.
These predictive models help clinicians alter the environments to promote adaptation and maintain
wholeness.
Combining qualitative and quantitative (triangulation) approaches to the study concepts using
Levines model helps to preserve the art and the science of nursing. Interactions with patients are both
predictive and creative. Qualitative research helps to
provide a way for the nurses to share the creative aspects of their work in a way that they can be shared
again and again. Qualitative data help to explain the
quantitative data and provide a more holistic perspective regarding the data experience.
Several investigators have contributed significant
research to the support and expansion of the Conservation Model as a model for nursing practice. Theories developed from the model will provide propositions from which hypotheses can be developed and
114
1. Responding to involuntary urges was as efficient

as, and resulted in less perineal damage than,
sustained breath holding during the second
stage of labor (Yeates & Roberts, 1984). There
were no differences in the mean duration of the
second stage of labor between the two groups.
2. Interventions that are employed as a course of
routine rather than based on individual needs actually increase the physiological burden of healing following birth and act as a significant threat
to the psychological adjustments of the postpartum period (Fleming, 1988).
3. Conservation of energy can be maintained by
placing the infant skin to skin on the mothers
chest, covered with a warm blanket (Newport,
1984).
4. Ludington (1990) found that simple skin-to-skin
contact was effective in reducing activity and
state-related energy expenditure in the newborn
of 34 to 36 weeks gestation.
5. An initial study of patients with rheumatoid
arthritis who engaged in a balance of physical
activity and rest increased their activity more
than patients in the control group. Rest served
as a restorative measure.
6. There is no significant difference in energy expenditure between basin, tub, or shower
bathing 5 to 17 days postmyocardial infarction
(Winslow, Lane, & Gaffney, 1985). The differences that did exist were related more to subject
variability than the type of bathing. The experimental group had significantly lower oxygen
consumption than did the control group.
7. There are no significant differences in oxygen
consumption when comparing unoccupied and
occupied bed making, but it was significantly
higher than when at rest. Heart rate differed significantly between rest and unoccupied bed
making. The researchers concluded that the
findings provide no basis for restricting either
bed-making technique (Lane & Winslow, 1987).
8. Generally the use of water beds for preterm infants produces a soothing effect and reduces activity. However, the expected reduction in heart
rate as a measure of energy cost does not occur.
The use of heart rate as a measure of energy use
needs further investigation. The high variability
among and within subjects raises questions
about the value of heart rate as a measure of energy cost.
9. Age, arterial pressure on bypass, and body temperature on the first and third postoperative days
best predicts delirious patients (Foreman, 1989).
Acutely confused patients were differentiated
best from those not confused by 10 variables representing all four conservation principles.
10. Foreman (1996) is in the process of analyzing
measures of cognition and psychophysiological
variables associated with delirium in the elderly.
The four conservation principles provided the
basis for the selection of variables. The results,
as of 1996, supported the conclusion through
confirmatory factor analysis that the model explained 87.3% of the variance in cognition. The
results also support that the Conservation Model
of Nursing is a framework with which to examine complex clinical phenomena, and for deriving effective plans of care for preventing and
treating delirium in this vulnerable population.
11. Higgens (1998) found that fatigue was present in
ventilator patients 100% of the time, and that fatigue and depression were significantly correlated. Despite the fact that sleep disturbances
were present and nutrition was compromised,
there were no significant relationships with fatigue.
12. Boomerang pillows used to provide comfort are
safe for individuals who are healthy and do not
have respiratory problems (Roberts, Brittin,
Cook, & deClifford, 1994). The use of the pillows does not interfere with energy conservation. A secondary finding was that vital capacity
was significantly lower in the semi-Fowlers position than in a straight chair.
13. After 10 minutes on boomerang pillows, frail elderly patients experienced a significant reduction in vital capacity (Roberts, Brittin, & deClifford, 1995). Boomerang pillows interfere with
energy conservation in women whose respiratory capacity is compromised by age.
14. Schaefers (1991b; Schaefer & Shober-Potylycki,
1993) research supports the finding that the experience of fatigue in congestive heart failure is
an experience that affects ones whole sense of
being.
Winslow (personal communication, October 14,
1993) indicated that an important outcome of her
studies of bathing and toileting was that hospitalized
patients had a significantly lower oxygen consumption during these activities than did healthy subjects.
Patients moved more slowly and deliberately than
did the healthy subjects. Consistent with Levines
(1973, p. 7) notion that we reduce activity to that
which is absolutely necessary, patients seem to reduce activity on their own to promote healing.
Levine (1989, p. 332) later stated that:
The conservation of energy is clearly evident
in the very sick, whose lethargy, withdrawal,
and self-concern are manifested while, in its
wisdom, the body is spending its energy resource on the processes of healing.
Many of the studies using the Conservation Model
as the basis for the investigation are single studies or
the beginning research program development. There
is no replication and little consistency in how the
variables are measured. The results of the studies are
therefore not sufficient to change nursing practice
but they do cluster in two areas that with continued
study could have a major influence on how nurses
practice.
In general, the studies support that energy can be
conserved with nursing interventions and can be
measured through the assessment of organismic responses. Patients inherently conserve their own
energy when confronted with environmental challenges. The second important finding is that Three major concepts of
attention to the conservation principles ex- Levines model are critical
plains the organismic to health-care delivery of
response of confusion
(delirium) better than the future: adaptation,
does any single princi- wholism, and conserple alone. This supports the assumption vation.
that using the conservation principles to guide interventions will promote
adaptation and maintain wholeness.
Investigators are encouraged to continue their excellent work with Levines model. New investigators
are encouraged to consider the Conservation Model
as a basis for study and to test the propositions developed from the theories discussed later in this chapter. It is only with continued research that a scientific
basis for nursing will be developed.
THE CONSERVATION MODEL IN

THE TWENTY-FIRST CENTURY
Nurses of the future will continue to build on the basic principles of nursing established by Florence
Nightingale (1859). Nightingale was a visionary
woman who knew that nurses should be prepared
professionals in institutions of higher education.
Myra Levine continued in this tradition and focused a
115
great deal of her professional career on preparing advanced practice nurses as clinical nurse specialists.
Nurses of the future will be leaders in health care.
Their leadership will increasingly provide direction
for care in community settings and less in acute care
settings. The skills and knowledge required of these
nurses will include:
1. an understanding of the predicaments associated
with health promotion, health restoration, health
maintenance, and illness prevention;
2. a working knowledge of health care and information systems, marketing and financial management, strategic planning, and program development and evaluation;
3. the ability to practice as professionals in a variety
of settings, and to direct and manage personnel;
4. the ability to assess the value of and provide complementary therapies to appropriate patients;
and
5. the ability to make contributions to the understanding and the maintenance of quality care delivery systems through program evaluation and
research to support evidence based practice.
Levines Conservation Model and the theories developed from the model provide a basis for the future of professional nursing. The model includes a
method for assessment; identification of problems;
development of a hypothesis about the problem; the
identification, selection, and application of an intervention; and an evaluation of the response. The interventions are provided based on the assumption that
if the intervention attends to the conservation of energy, structural, social, and personal integrities, the
patient will return to wholeness (health). Health is a
goal for individuals, families, communities, and populations at large. From a global perspective, health
for all is an appropriate metaphor. Wholeness is universally understood. The model includes three major
concepts that are critical to understanding the healthcare delivery systems of the future: adaptation, wholism (health), and conservation (balance of energy
supply and demand within the capabilities of the patient [organization, community, and universe]).
The Conservation Model provides the conceptual
basis for the development of three theories: the
Theory of Conservation, the Theory of Redundancy,
and the Theory of Therapeutic Intention. About theory, Levine said:
1. The serious study of any discipline requires a
theoretical baseline which gives it substance and
meaning (Levine, 1969a, p. xi).
2. The essential science concepts develop the rationale [for nursing actions], using ideas from all
116
3.
4.
5.
6.
7.
8.
areas of knowledge that contribute to the development of the nursing process in the specific
area of the model(cited in Fawcett, 1995, p. 136).
Nursing theory should define the boundaries of
nursing.
Nursing theory is too important an enterprise to
be undertaken without the strictest rules of scientific discovery and explanation. . . . It is the researcher who should challenge the cherished
ideas and find the data that will support or refute
the theorists claims. The practitioner must provide the ultimate test of relevance to the theorists work. Unless the theory can be interpreted
by the nurse who reaches the patient wherever
nursing is practiced, theory will remain a questionable entity . . . theory should teach nurses
what they are (Levine, 1988a, pp. 2021).
It is essential that concepts that are shared
from other disciplines are accurately reproduced
and used appropriately (Levine, 1996). The sharing of concepts from other disciplines has enhanced nursing scholarship and provided nurses
with the knowledge and skills to provide holistic
care.
At every level where theory is taught . . . the
content of courses in nursing theory ought to excite what Brunner (1985) called the effective surprise, where the combination of recognition and
discovery adds new dimensions to nursing practice (Levine, 1995, p. 12).
[I]t is imperative that there be a variety [of nursing theories]for there is no global theory of
nursing that fits every situation (Levine, 1995,
p. 13).
Not everything that is accepted as theory now
cannor shouldsurvive, but serious intellectual inquiry will create new theories, and nursing can only prosper when it does (Levine, 1995,
p. 14).
In summary, Levine proposed that nursing theory

is an adjunctive science, provides for the development of the intellectual component of nursing essential for understanding the why of nursing actions, is
tested through use by practitioners, is not universal
in the sense that there is no one global theory of
nursing that will fit all situations, and should be refined and further developed by new researchers. She
noted that some theories might be time limited and
new theories would be developed. Levines work
continues to encourage the intellectual pursuits of
her students. We learn and grow as we continue to
review and reinterpret her work in preparation for
the future of nursing.
Alligood (1997) first made the Theory of Conservation explicit. The Theory of Conservation is rooted
in the concept of conservation and is based on the
assumption that all nursing actions are conservation
principles (Levine, 1973, p. 13). Conservation is natural law that is fundamental to many basic sciences.
The purpose of conservation is to keep together.
To keep together means to maintain a proper balance between active nursing interventions coupled
with patient participation on the one hand and the
safe limits of the patients abilities to participate on
the other. The Theory of Conservation is based on
the universal principle of conservation, which provides the foundation for the conservation principles
in the model. Conservation assures wholeness, integrity, and unity.
The conservation principles form the major propositions (Levine, 1973, pp. 444, 446, and 13):
1. The individual is always within an environment
milieu, and the consequences of his awareness of
his environment persistently influence his behavior at any given moment.
2. The individual protects and defends himself
within his environment by gaining all the information he can about it.
3. The nurse participates actively in every patients
environment, and much of what she does supports his adaptations as he struggles in the
predicament of illness.
4. Even in the presence of disease, the organism
responds wholly to the environment interaction
in which it is involved, and considerable element
of nursing care is devoted to restoring the symmetry of responsesymmetry that is essential to
the well-being of the organism (Levine, 1969b,
p. 98).
The Theory of Therapeutic Intention was developed with the intent of providing a way to organize
nursing interventions out of the biological realities
that nurses had to confront (Fawcett, 1995). The biological realities faced by nurses include areas of concern that focus on living organisms; their structure,
form, function, behavior, growth, and development;
and relationships to their environment and organisms like and unlike themselves. Given the biological
realities of health, illness, and disease, nurses are organizing interventions across the life span, in a variety of settings, and based on the principles drawn
from nursing and other disciplines (epidemiology,
psychology, sociology, theology, etc.). The Theory of
Therapeutic Intention is directly related to the biological realities. Therefore, the guiding assumptions
for this theory are:
1. Conservation is the outcome of adaptation.

2. Change associated with therapeutic intervention
results in adaptation.
3. The proper application of conservation (conservation principles) results in the restoration of
health.
4. Activities directed toward the preservation of
health include health promotion, surveillance, illness prevention, and follow-up activities.
According to Fawcett, Levine (cited in Fawcett,
1995) identified the following goals of the Theory of
Therapeutic Intention:
1. Facilitate integrated healing and optimal restoration of structure and function [by supporting and
enhancing] the natural response to disease. This
goal can be reached if the nurse caring for a patient with burns changes dressing as ordered,
provides medication to reduce the pain associated with treatment, offers complementary painreducing techniques, listens carefully to the concerns the patient may have regarding self related
to scarring from the burns, refers to appropriate
counseling, and works closely with the family or
support persons to maintain connections for the
patient.
2. Provide support for a failing autoregulatory portion of the integrated system (e.g., medical/surgical treatments).
3. Restore individual integrity and well-being (e.g.,
work with children with ADHDattention deficit
hyperactivity disorder).
4. Provide supportive measures to assure comfort
and promote human concern when therapeutic
measures are not possible (e.g., care of the dying).
5. Balance a toxic risk against the threat of disease
(e.g., nurses who facilitate immunization).
6. Manipulate diet and activity to correct metabolic
imbalances and to stimulate physiological processes (e.g., care of the anorexic young woman).
7. Reinforce or antagonize usual response to create
a therapeutic change (e.g., enhance pain relief
with music therapy).
The expected outcome of therapeutic intentions
would be a therapeutic response measured by the organismic change (e.g., adaptation resulting in conservation).
The Theory of Redundancy is grounded in the
concept of adaptation. Change is the process of
adaptation and conservation is the outcome of adaptation. The Theory of Redundancy assumes that there
are fail-safe options available in the physiological, anatomical, and psychological responses of individuals
117
that are employed in the development of patient

care. The body has more than one way for its function to be accomplished. It involves a series of adaptive responses (cascade of integrated responses
simultaneous, not separate) available when the
stability of the organism is challenged (Schaefer,
1991b). The selection of an option rests with the
knowledge of the health-care provider in consultation with the patient. When redundant choices are
lost, survival becomes difficult and ultimately fails
for lack of fail-safe optionseither those that the patient possesses (e.g., two lungs) or those that can be
employed on his or her behalf (e.g., medications or a
pacemaker) (Levine, 1991).
Summary
Levines notion of the environment as complex provides an excellent basis for continuing to develop an
improved understanding of the environment. Studying the interactions between the external and the internal environment will provide for a better understanding of adaptation. This focus will provide for
additional information about the challenges in the
external environment and how they change over
time. It is important that we understand the changes
that occur and how the person who adapted before
now changes the adaptive response in order to maintain balance or integrity. This adaptive response will
inform the organismic response. With an improved
repertoire of organismic responses we can test how
to predict these responses, hence assure that the responses that are adaptive will occur. This is said with
the understanding that nurses recognize when the
goal is to maintain comfort only (e.g., supportive
interventions).
Moving to a more global perspective, the environment as defined according to Levine (1973) provides
nurses with the opportunity to enhance their understanding of it and to provide interventions for communities that suffer from environmental disasters. An
assessment of the internal environments response to
the challenge of the external environment (e.g., destruction from hurricanes) will identify the altered
health status of the community and the community
needs immediately. An assessment of the external environment will provide an understanding of the
changes occurring due to the assault on the internal
environment and a more detailed assessment of the
perceptive, organismic, and conceptual levels of the
environmental challenges. There is no question that
this approach to describing, defining, and planning
for environmental challenges will identify (1) the
118
perceptual challenges, (2) the organismic challenges

that may not be immediately known to the residents
(e.g., pollution of air and water), and (3) the conceptual issues that increase the nurses awareness of the
social, political, and economic impact on the predicament. This provides the nurses with the opportunity to develop a political agenda and perhaps design
public policy that might improve interventions in the
context of a disaster. The Conservation Model has the
components needed to provide nurses with a global
perspective of the environment.
Future practitioners and researchers are encouraged to continue to focus on studies that will develop and enhance the model as well as the theories
of conservation, therapeutic intention, and redundancy. Schaefer (1991a, p. 223) expressed excitement about the development of the Theory of Therapeutic Intention because, [n]ot only will the nurse
have a repertoire of tested interventions, given that a
theory provides specific information about care delivery, but [the nurse] also . . . should have information about the expected responses. With this in
mind, the theory provides the direction for quality
[improvement] activities and measure of cost effectiveness. Nurses are encouraged to test interventions
guided by the propositions of the theory to define
further the boundaries of nursing practice.
Development of the theories of conservation and
redundancy is also encouraged. It is suggested that
the natural law of conservation be thoroughly examined in all disciplines with attention to the implications for nursing practice. A brief search revealed
that many studies address the issue of conservation
without the use of the Conservation Model as a foundation. It is possible that the completed studies will
provide parameters for the issue of conservation in
nursing and substantiate its significance to a Theory
of Conservation for nursing.
Two areas appropriate to the Theory of Redundancy are important to nursing practice and warrant
further investigation: the importance of choice in
the management of an individuals health and the significance of availability of fail-safe options. Although
there is evidence that patients benefit from a feedback system, compensatory systems, and two kidneys, lungs, and eyes, the value of this knowledge
for the practice of nursing must be carefully investigated. This theory will benefit all health-care providers and perhaps provide a foundation for collaborative practice (e.g., consider the context in which
kidney transplantation takes place). As more choices
become available for patients, development of this
theory becomes imperative. To enhance the development of knowledge, scientists may want to consider
an integrated theory that considers the principles associated with redundancy and moral theory. Levines
perspective on ethical and moral care has been made
explicit (Levine, 1977, 1982a, 1982b, 1989b, 1989c,
1989d).
Levines (1968a, 1968b, 1973) discussion of the
person includes recognition that the person is defined to a certain degree based on the boundaries
defined by Hall (1966) as personal space. Levine rejected the notion that energy can be manipulated
and transferred from one human to another as in
therapeutic touch. Yet a person is affected by the
presence of another relative to his or her personal
space boundaries. Admittedly some of this is defined
based on cultural ethos, yet what is it about the bubble that results in a specific organismic response? It
may be that the energy involved in the interaction is
not clearly defined. Scientists are challenged to examine this. Levine encouraged creativity such as
therapeutic touch but rejected activities that are not
scientifically sound.
And finally, the practice of nurses and advanced
practice nurses is changing rapidly to keep up with
the current speed of health-care system changes.
Levines Conservation Model provides an approach
that educates good nurses and provides a foundation
for their practice, whatever the role or the setting.
Nurse practitioners, case managers, program planners, nurse midwives, nurse anesthetists, and nurse
entrepreneurs are encouraged to test the model as a
basis for improving and guiding their practice. Whatever the results, they should publish them to assure
the continued development of the art and science of
nursing. Myra will applaud their efforts.
Theory is the poetry of science. The poets
words are familiar each standing alone, but
brought together they sing, they astonish,
they teach. The theorist offers a fresh vision,
familiar concepts brought together in bold,
new designs . . . the theorist and poet seek excitement in the sudden insights that make ordinary experience extraordinary, but theory
caught in the intellectual exercises of the academy becomes alive only when it is made a true
instrument of persuasion. (Levine, 1995, p. 14)
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123
Chapter 9
Ida Jean Orlando (Pelletier)
The Dynamic Nurse-Patient
Relationship
A Conversation with the Theorist
Assumptions of the Theory
Major Theoretical Concepts
Relevance of the Theory for Nursing Practice
Applicability in Todays Health-Care System
Summary
References
Maude R. Rittman

Nursing is responsive to individuals who suffer or
anticipate a sense of helplessness; it is focused on
the process of care in an immediate experience; it is
concerned with providing direct assistance to individuals in whatever setting they are found for the
purpose of avoiding, relieving, diminishing or curing the individuals sense of helplessness.
Ida Jean Orlando (1972)
The above quotation summarizes Ida Jean Orlandos theoretical contributions in defining what
nursing is and what constitutes effective nursing
practice. Her theory, dubbed the dynamic nursepatient relationship, has also been called a theory of
effective nursing practice (George, 1990; MarinerTomey, 1994; Schmieding, 1993) and will be reviewed from the perspective of its application in
clinical practice. Before applying a theory, whether
for practice, research, or education, the user needs
to know the origins of the theory, as well as the underlying assumptions or beliefs embedded in the theory, and assess its adequacy and appropriateness for
the context in which it will be used. Following a discussion of these points, an exploration of the applicability of Orlandos work to clinical practice in todays nursing environment is presented.
Although the focus of this chapter is on application of Orlandos theory to practice, the theory has
been used to guide nursing research. Probably the
most extensive review of Orlandos theory was written by Norma Jean Schmieding (1993). Orlando
directed me to Schmiedings book and other published materials. Orlando stated that Schmiedings
work most accurately describes her theory. In her
book, entitled Ida Jean Orlando: A Nursing Process
Theory, Schmieding summarizes the research that
was completed shortly after Orlandos theory was
published, including her own research applying the
theory to nursing administration.
Ida Jean Orlando was born August 12, 1926, in
New York. She received a diploma in nursing from
the New York Medical College, Lower Fifth Avenue
Hospital, School of Nursing, New York, in 1947, and
a bachelor of science degree in public health nursing
from St. Johns University in Brooklyn, New York, in
1951. Orlando completed her masters degree at
Teachers College, Columbia University, in New York
in 1954, with emphasis on education and psychiatric-mental health nursing. Her masters degree was
completed during the era when nurse leaders were
concerned about defining nursing as a profession
and separating nursing functions from the traditional
role of physicians handmaid.
126
In understanding the evolution of Orlandos theoretical developments, it is interesting to note that her
early education is firmly grounded in clinical practice. Her background
experiences culminated
Orlandos theory is
in an interest in and focus on the nurse-patient research-based, using
relationship. Her studnaturalistic inquiry
ies at Teachers College
contributed a strong ed- methods.
ucational perspective
with which she approached the study of nursing
practice. Schmieding attributes Orlandos focus on
the role of past experiences influencing the meaning
of present experiences to her graduate education.
She studied with Professor L. Thomas Hopkins, who
was teaching education courses at Columbia University (Schmieding, 1993).
Early in her nursing career, Orlando worked
briefly in clinical practice in obstetrics, medicine,
surgery, and emergency room nursing. Following her
masters degree in 1954, she went to Yale University,
where she completed research upon which she developed her theory. Her research blended her previous experience and interests in nursing practice,
psychiatric-mental health nursing, and nursing education. After completing her research and publishing
her first book in 1961, Orlando moved to Massachusetts, where she worked at McLean Hospital as a clinical nursing consultant. During the 1960s and early
1970s, she tested the applicability of her theory and
taught her theory to nurses. Later she was an assistant director of nursing for education and research at
the Metropolitan State Hospital in Waltham, Massachusetts. She has also been nationally and internationally recognized as a consultant and speaker on
nursing and health care issues. Her last public presentation was probably on the issue of independence
of nursing practice, an issue about which she continues to feel strongly.
Orlandos theory is research-based, evolving out
of a study funded by the National Institute of Mental
Health to improve the education of nurses. Specifically, the study was aimed at improving the education of nurses on psychiatric-mental health concepts
and probably at least partially accounts for the strong
emphasis on interpersonal relationships. Orlando
was one of the earliest qualitative nurse researchers.
She used an inductive method to obtain her data using naturalistic inquiry methods. The definitive text
of Orlandos theory is The Dynamic Nurse-Patient
Relationship: Function, Process, and Principles,
which was first published in 1961 and remained out
of print until 1990, when it was reissued by the Na-
tional League for Nursing. The book, dedicated to

her students, is a report of findings from a study to
identify factors that promoted or inhibited the integration of mental health principles in nursing educational programs.
Qualitative methods of participant observations
and interviews were used to collect data over a 3year period on experiences of nursing faculty,
nurses, students, and patients. Data were analyzed to
identify the content of instruction, the teaching process, and the learning environment important in
shaping students professional development. It is not
surprising that the dynamic nurse-patient relationship theory has it roots in psychiatric-mental health
nursing, clinical practice, and education. Orlandos
theory was originally developed to provide professional nurses with a theory of effective nursing practice with a focus on the patients experience with illness and what is required from the nurse to meet the
needs of the patient. The theory reflects Orlandos
strong belief in the nurse-patient relationship, meeting the needs of patients as they perceive them, and
the power of communication in clinical practice.
Over the next 10 years, Orlando continued to develop her theory while she was a clinical nursing
consultant at McLean Hospital in Belmont, Massachusetts. In this position, she continued to study interactions between patients and nurses. Using her theory
as a framework for nursing practice at McLean Hospital, she developed a training program for nurses and
reorganized the nursing service around her theory.
She also received federal funding to evaluate the
training program. She published findings from this
phase of her work in her second book, The Discipline and Teaching of Nursing Process: An Evaluative Study (1972).
A CONVERSATION
WITH THE THEORIST
In October 1998, I contacted Ida Jean Orlando. She
agreed to talk with me about her theory but warned
me that her health would not allow her to talk very
long (she was 72 years old). We made an appointment and talked for about 20 minutes a few weeks
later about her life and her work. I was thrilled to be
able to speak directly with one of the early nurse theorists and felt a sense of awe in being able to talk
with a nurse who had made a significant contribution to the nursing profession before I had even entered college. I immediately felt a sense of respect
and admiration for her and for all of the early theorists in nursing as I reflected on their work and contributions to the nursing profession.
My impression of Orlando was that she still

holds very strong beliefs about nursing and what
nursing is. She emphasized in our talk about
nursing that todays nurses need to reconnect with
the patient, to learn about what the patient perceives his or her needs to be, and to address those
needs. She vividly described her own recent experiences with the health-care system that were both
positive and negative. She attributed the difference
to the quality of care provided by the nurse who assisted her. She spoke eloquently about the need today for nurses to serve as advocates for patients, and
stay focused on what is valued and needed by the patient. She stated that if nurses do not ensure that patients get what they need, there is no one else who
will help guide them through the system. When I
asked her to tell me about significant life experiences
that might have influenced her in developing her
theory, she quipped, Who knows? I dont, and I am
not sure it is so important. She went on to
Nurses must stay conexplain that when she
became a nurse, she nected to patients and astried to make sense sure that patients get what
out of what it meant
to be a nurse and real- they need. There is no one
ized that, as a profes- else who will help guide
sion, nursing needed
to define itself and its them through the system.
unique contribution in
health care and to patients. The quest for answering
these questions is what influenced Orlando and
shaped her career in nursing.
I asked her if there were any misconceptions about
her or her work that she would like to address. She
stated that some authors have presented a misconception about the origins of her work by saying that Hildegard Peplau influenced her thinking. She said that this
was absolutely incorrect: Although Orlando and Peplau were of the same generation of theorists, Orlandos work was not influenced by Peplaus thinking.
It seemed important to her to set the record straight.
She told me how she came to know Peplau. She and
Peplau became acquainted while she was at Yale and
Peplau consulted with her while she was at McLean
Hospital. Peplau made a presentation at McLean Hospital while Orlando was working as a clinical nurse
consultant there. Orlando stated that she enjoyed
knowing Peplau and that they had similar interests.
Peplau authored her theory of interpersonal relationships in nursing in 1952. Peplau and Orlando enjoyed
a collegial relationship for several years.
Orlando stressed the need for nurses to stay connected to patients and to advocate to make sure that
Chapter 9 Ida Jean Orlando (Pelletier) The Dynamic Nurse-Patient Relationship
127
your thoughts
patients receive what they need from the health-care

system in order to recover. She expressed concern
about nurse practitioners, because she said many of
them practice in a manner that is closer to physician
practice than it is to nursing practice. For example,
she said that she did not support the idea of nurses
ordering medicationsshe believed that ordering
medications should be the responsibility of physicians. Nonetheless, she went on to describe the
wonderful assistance she and her husband received
from a nurse practitioner who, according to her,
functioned in an independent role. She stated that
the nurses who are her heroes are the nurses in Appalachia, who sometimes deliver care on horseback
and must function independently. She strongly believed that nurses should take care of the patients
and think for themselves.
We also talked about the role of nursing theory today. She laughed about the interest in all this theory
stuff and stated that students must hate having to
learn all these theories. Orlando said that educators
should let nursing students take care of patients and
that it is only in engaging in practice that one can
learn how to be a nurse. As she talked, I realized that
many of the issues important in her era are still with
us today and remain largely unresolved. Nurses continue to define and redefine nursing as a profession,
and the many issues involved in the overlap between
medicine and nursing are still important.
ASSUMPTIONS OF THE THEORY

Defining the assumptions, or givens, inherent in a
theory is important in order to develop an understanding of the theory. Underlying assumptions can
also influence a decision regarding the appropriate-
128
ness of using the theory in a particular clinical setting. Orlandos theory reflects her belief that nursing
practice should be based on the needs of the patient.
Hence, communication with the patient was foundational to understanding the needs and providing effective nursing care. The essence of her theory is its
focus on the patient and his or her needs and the
communicative interface between the nurse and the
patient. The following assumptions are identified in
her writings:
1. The nursing process includes identifying the
needs of patients, the response of the nurse, and
nursing actions. The nursing process described
by Orlando is not the linear nursing process
model taught today in nursing education but is
more reflexive and circular, occurring during encounters with patients.
2. Understanding the meaning of the patients behavior is influenced by the nurses perceptions,
thoughts, and feelings requiring deliberative responses. Orlando argued that this deliberative
process can be taught in educational programs
and nursing students can learn to use it in patient
care situations.
3. Patients experience
Nursing is an interpersonal
distress when they
process aimed at assisting
cannot cope with
their needs.
patients when they are ex4. The nurse must take
the initiative in help- periencing distress. It is a
ing the patient exdeliberative process that
press the meaning
can be learned.
of behavior to ascertain distress. The basis for nursing action is determined by the distress experienced by the patient.
5. Direct and indirect observations of patient behavior can be used to determine its meaning, and
thus provide knowledge about the patient in
planning nursing care.
6. Interactions with patients are unique, complex,
and dynamic processes.
7. Professional nurses function in an independent
role separate from physicians and others.
MAJOR THEORETICAL CONCEPTS

The major concepts included in Orlandos theory are
person, needs, perceptions, thoughts, and feelings
of the nurse, and deliberative action. The four major
theoretical concepts in nursing are client (or patient),
nursing action, environment, and health (Kim, 1983).
Orlandos theory addresses all but environment, and
the concept of health is implicit in the theory. The
domain of environment includes the physical, social,
and symbolic environment of the patient and is an essential concept for holistic nursing practice.
RELEVANCE OF THE THEORY

FOR NURSING PRACTICE
Meleis (1985) stated that to be useful in practice, a
theory has to be evaluated in terms of its goals. In addition to goals of the theory, and in order to judge
the practical value of Orlandos theory, I will use four
criteria recommended by Glaser and Strauss regarding evaluating theory: whether it fits, its understandability, whether it is sufficiently general, and whether
it provides at least partial control over situations that
it addresses (Glaser, 1967). Each of these criteria is

discussed below.
Goals
Orlando conceptualized nursing practice as an interactive process focused on the patients needs and/or
responses to the environment. She defined nursing
as a deliberative interaction process that is learned
and includes the patients needs, the nurses reactions, and the nursing interventions to assist the patient. In Orlandos view, the major goal of nursing as
an interpersonal process is to assist patients when
they are experiencing distress.
Fit
According to Glaser (1967), a theory must closely fit
the area in which it will be used. The strength of Orlandos theory is that it was developed inductively
from the study of nursing practice. This grounding in
the clinical world is evident in its emphasis on recognizing the patients needs, on the nurse-patient relationship as the vehicle for achieving the goals of nursing practice, and on the nursing process. The theory
was developed prior to the high technology that we
take for granted in todays health-care settings. Information that influences the assessment of patient
needs comes from a variety of sources. The patient is
one source but not the only source of information.
Understandability
Glasers second criterion (1967) is that the theory
must be readily understood. Understandability is a
hallmark of this theory because Orlando used words
that are common to the practice of nursing and that
are easy to comprehend.
your thoughts
Chapter 9 Ida Jean Orlando (Pelletier) The Dynamic Nurse-Patient Relationship
129
Sufficiently General
Third, the theory must be sufficiently general in order to be applicable to multiple and diverse situations. The applicability of Orlandos theory to multiple and diverse nursing care situations is strong in
that almost all nursing practice situations depend on
nurse-patient relationships to some extent. However,
in complex health-care settings, the theory is an important aspect of the nursing situation but does not
sufficiently address all of the functions and responsibilities that nurses encounter in their work. In this
sense, Orlandos theory is sufficient for understanding the interactions between nurses and patients but
fails to address other important areas of practice.
Summary
Control
The last criterion (Glaser, 1967), is that theory
should provide at least partial control over situations
as they change over time. Orlandos theory is a general approach to nursing interactions and interpersonal relationships with patients and is not focused
on a particular patient population. Hence, control
over specific clinical situations is weak.
APPLICABILITY IN TODAYS
HEALTH-CARE SYSTEM
The health-care system as we know it today is vastly
different from the health-care system that existed
during Ida Jean Orlandos era. Today we are faced
with health-care systems that are largely operating in
an economic paradigm, in which costs are driving
the way hospitals and health maintenance organizations (HMOs) do business. Emphasis today is on outcomes that demonstrate cost reductions or costeffectiveness. Price squeezing has led to altered
staffing patterns. Nurses are expected to deliver
nursing care to patients who are short stay with
fewer and fewer resources. In todays context, every
contact with a patient has to contribute to improved
outcomes.
As hospitals move into the periphery of the
health-care scene, more care is provided in the home
or at other sites. Little concern is focused on nursepatient relationships. Even as health-care systems
strive to improve customer service, the connection
between nurse-patient relationships and satisfied
customers seems to be glossed over. Health-care administrators are looking to the business community
to improve efficiency of operations and are losing
sight of the purpose of the industry: to provide care.
As a nurse-scientist in a clinical setting, I have considered the usefulness of Orlandos theory in todays
130
practice setting. Almost 40 years have passed since

this theory was developed from the study of clinical
nursing practice. It was before the era of intensive
care units, life-sustaining technologies, electronic
monitoring, and many aspects of modern nursing as
we know it today. With all of the benefits that modern
technology and modern health care bringand there
are manywe need to pause and ask the question,
What is at risk in health care today? I believe the answer to that question leads us to reconsider the value
of Orlandos theory in nursing and the critical link between meaningful relationships and the preservation
of humankinda risk with high stakes.
The most important contribution of Orlandos nursing theory is what it says about the values underpinning our profession. Inherent in this theory is a
strong value that what transpires between the patient and the nurse is of the highest value. Orlandos
theory reveals and bears witness to the essence of
nursing as a practice discipline. I believe the true
worth of Orlandos theory of nursing is that it clearly
states what nursing is or should be. Regardless of the
changes in the health-care system, the human transaction between the nurse and the patient in any setting that nurses have ever practiced holds the greatest value, not only for nursing but for society at large.
Orlandos theory can serve as a philosophy as well as
a theory, because it is the foundation upon which
our profession has been built.
References
George, J. B. (1990). Nursing theories:The base for
professional nursing practice (3rd ed.). Norwalk,
CT: Appleton & Lange.
Glaser, B. G., & Strauss, A. L. (1967). The discovery of
grounded theory. Chicago: Aldine Publishing Co.
Kim, H. S. (1983). The nature of theoretical thinking
in nursing. Norwalk, CT: Appleton-Century-Crofts.
Mariner-Tomey, A. (1994). Nursing theorists and their
work (3rd ed.). St. Louis: Mosby.
and progress. Philadelphia: J. B. Lippincott.
Orlando, I. J. (1961/1990). The dynamic nurse
patient relationship: Functions, process, and principles. New York: National League for Nursing.
(reprinted from 1961 edition, New York: G. P. Putnams Sons).
Orlando, I. J. (1972). The discipline and teaching of
nursing process:An evaluative study. New York:
G. P. Putnams Sons.
Schmieding, N. J. (1993). Ida Jean Orlando:A nursing
process theory. Newbury Park, CA: Sage.
Chapter 10
Lydia Hall
The Care, Core,
and Cure Model
Historical Background
Vision of Nursing
Care, Core, and Cure
The Loeb Center for Nursing and Rehabilitation
Implications for Nursing Practice
Implications for Nursing Research
Summary
References
Bibliography
Theris A. Touhy and Nettie Birnbach

Lydia Hall and her conceptual model of nursing will
be described in this chapter, along with her work at
the Loeb Center for Nursing and Rehabilitation, the
implications of her work for practice and research,
and, finally, our views about how Hall might reflect
on the future of nursing in the twenty-first century.
Our purpose in writing this chapter is to share the
story of Lydia Halls life and her contribution to professional nursing rather than to critique a nursing
theory.
Visionary, risk-taker, and consummate professional, Lydia Hall touched all who knew her in a special way. She inspired commitment and dedication
through her unique conceptual framework for nursing practice that viewed professional nursing as the
key to the care and rehabilitation of patients.
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 consultation and joined a community of
nurse leaders. At the same time, she was involved in
research activities for the U.S. Health Service. Active
in nursings professional organizations, Hall also provided volunteer service to the New York City Board
of Education, Youth Aid, and other community associations (Birnbach, 1988).

Halls most significant contribution was to nursing practice in the form of the model she designed
and put into place in the Loeb Center for Nursing
and Rehabilitation at Montefiore Medical Center in
New York. Opened in 1963, the Loeb Center was
the culmination of 5 years of planning and construction under Halls direction. The circumstances that
brought Hall and the Loeb Center together date back
to 1947, when Dr. Martin Cherkasky was named director of the new hospital-based home care division
of Montefiore Medical Center in Bronx, New York. At
that time, Hall was employed by the Visiting Nurse
Service at its Bronx office and had frequent contact
with the Montefiore home care program. Hall and
Cherkasky shared congruent philosophies regarding
health care and the delivery of quality service, which
served as the foundation for a long-standing professional relationship (Birnbach, 1988).
In 1950, Cherkasky was appointed director of the
Montefiore Medical Center. During the early years of
his tenure existing traditional convalescent homes
fell into disfavor. Convalescent treatment was undergoing rapid change due largely to medical advances,
new pharmaceuticals, and technological discoveries.
One of the homes that closed as a result of the
emerging trends was the Solomon and Betty Loeb
Memorial Home in Westchester County, New York.
Cherkasky and Hall collaborated in convincing the
board of the Loeb Home to join with Montefiore in
founding the Loeb Center for Nursing and Rehabilitation. Using the proceeds realized from the sale of the
Loeb Home, plans for construction of the Loeb Center proceeded over a 5-year period, from 1957 to
your thoughts
132
1962. Although the Loeb Center was, and still is, an

integral part of the Montefiore physical complex, it
was separately administered, with its own board of
trustees that interrelated with the Montefiore board.
Under Halls direction, patients for the Loeb Center were selected by nurses based on their potential
for rehabilitation. Qualified professional nurses provided direct care to patients and coordinated needed
services. Hall frequently described the center as a
halfway house on the road home, where the nurse
worked with the patients as active participants in
achieving desired outcomes (Hall, 1963a, p. 2). Over
time, the effectiveness of Halls practice model was
validated by the significant decline in the number of
readmissions among former Loeb patients as compared with those who received other types of
posthospital care (Montefiore cuts, 1966).
In 1967, Hall received the Teachers College Nursing Alumni Award for Distinguished Achievement in
Nursing Practice. She shared her innovative ideas
about the practice of nursing with numerous audiences around the country and contributed articles to
nursing journals. In those articles, she referred to
nurses using feminine pronouns. Because genderneutral language was not yet an accepted style, and
women comprised 96 percent of the nursing workforce, the feminine pronoun was used almost exclusively.
Hall died of heart disease on February 27, 1969,
at Queens Hospital in New York. In 1984, she was inducted into the American NursesAssociation Hall of
Fame. Following Halls death, her legacy was kept
alive at the Loeb Center, until 1984, under the capable leadership of her friend and colleague Genrose
Alfano.
Remembered by her colleagues for her passion
for nursing, her flamboyant personality, and the excitement she generated, Hall was indeed a force for
change. At a time when task-oriented team nursing
was the preferred practice model in most institutions, she implemented a professional patientcentered framework whereby patients received a
standard of care unequaled anywhere else. At the
Loeb Center, Lydia Hall created an environment in
which nurses were empowered, in which patients
needs were met through a continuum of care, and in
which, according to Genrose Alfano, nursing was
raised to a high therapeutic level (personal communication, January 27, 1999).
HISTORICAL BACKGROUND
During the 1950s and 1960s, the health-care milieu
in which Lydia Hall functioned was undergoing
tremendous change. As previously stated, the type of

nursing home model then in use failed to meet expectations, and care of the elderly was a growing
problem. Increasing recognition that the elder population was in the greatest need of health-care insurance generated years of debate among legislators,
the medical profession, and the public. Finally, in
1965, Medicare legislation was enacted that provided hospital, nursing home, and home care for
those citizens age 65 and over. Medicaid was established to provide health-care services for the medically indigent irrespective of age. These programs
provided a source of revenue for the nations hospitals and, as public confidence in hospitals grew,
there was concomitant growth in the need for more
hospitals. Subsequent congressional legislation provided for construction of new facilities, which, in
turn, created more opportunities for the employment of nurses. Undoubtedly, all of these factors
were relevant to Hall as she proceeded to implement
her vision.
With respect to nursing, the 1960s witnessed the
growth of specialization, the movement toward
preparation of nurse practitioners and clinical nurse
specialists, and the emergence of new practice fields
such as industrial nursing. Although most nurses
worked in hospitals at that time, a beginning trend to
community-based practice was evolving. In regard to
nursing education, the advent of degree-granting,
2-year programs in community colleges proved to be
an attractive alternative to the apprenticeship
modelhospital-based, diploma school education
through which most nurses had previously been prepared. And, with publication of the American
Nurses Associations position statement on educational preparation in 1965, baccalaureate education
was receiving renewed recognition as the preferred
method for preparing professional nurses. The correlation between higher education and professional
practice seems to agree with Halls ideas and probably elicited her support. Her model of nursing at the
Loeb Center clearly required nurses to be educated,
professional, and caring. Its success depended upon
the ability of the nurses to relate to each patient with
sensitivity and understanding. Hall was clear in her
vision of the registered professional nurse as the appropriate person to fulfill that role.
Scholars and practitioners today continue to grapple with questions about how to define nursing and
to demonstrate the unique contribution of professional nursing to the health and well-being of people.
Lydia Halls belief that the public deserves and can
benefit from professional nursing care was not only
articulated in her theory of nursing but also demon-
Chapter 10 Lydia Hall The Care, Core, and Cure Model
133
strated in practice at the Loeb Center under her guidance. Hall stated (1963c, p. 805):
The program at the Loeb Center was designed
to alleviate some of the growing problems
which face our health-conscious public today:
the complex and long-term nature of illnesses
besetting all age groups; the high cost of services utilized in overcoming these illnesses;
the negative reactions of the public and the
health professions to patient care offered by
institutions; and the confusion among all
groups about the definition of nursing, its organization for service, and the kind of educational preparation it requires.
These questions and concerns are as relevant today
as they were when Hall articulated her ideas over
30 years ago. Perhaps
they are even more
Hall believed that in spite relevant now, as we
of successes in keeping face a rapidly increasing older population
people alive, there was
with needs for longfailure in helping them term care and an era
of cost containment
live fully with chronic
that often limits acpathology. cess to professional
care and services.
VISION OF NURSING
Lydia Hall would not have considered herself a nursetheorist. She did not set out to develop a theory of
nursing but rather to offer a view of professional
nursing. Wiggins (1980, p. 10) reflected on the status of nursing theory during this time and stated:
[T]he excitement of the possibility of development
by nurses of nursing theories was in its barest beginnings. Halls observations of hospital care at the time
led her to articulate her beliefs about the value of
professional nursing to patient welfare. She observed
that care was fragmented; patients often felt depersonalized; and patients, physicians, and nurses were
voicing concern about the lack and/or poor quality
of nursing care. She reflected that in the early part of
the twentieth century, a person came to the hospital
for care. In the 1950s and 1960s, the focus changed,
and a person came to the hospital for cure. However,
the health problems of the time were long-term in
nature and often not subject to cure. It was Halls belief that in spite of successes in keeping people alive,
there was a failure in helping patients live fully with
chronic pathology. After the biological crisis was stabilized, Hall believed that care should be the primary
134
focus and that nurses were the most qualified to provide the type of care that would enable patients to
achieve their maximum potential. In fact, she questioned why medicine would want the leadership and
suggested that the patient with a long-term illness
would come to nursing (Hall, 1965).
Hall described the two phases of medical care
that she saw existing in hospitals at the time. The
first phase is when the patient is in biological crisis
with a need for intensive medicine. Phase 2 begins
when the acute crisis is stabilized and the patient is
in need of a different form of medicine. Hall labeled
this as follow-upevaluative medicineand felt
that it is at this point that professional nursing is
most important. She criticized the practice of turning over the patients care to practical nurses and
aides at this point while the professional nurse attended to new admissions in the biological crisis
phase. Hall (1969, p. 87) stated:
Now when the patient reaches the point
where we know he is going to live, he might
be interested in learning how to live better before he leaves the hospital. But the one nurse
who could teach him, the one nurse who has
the background to make this a truly learning
situation, is now busy with the new patients in
a state of biological crisis. She rarely sees those
other patients who have survived this period,
unless there is something investigative or potentially paining to do! The patients in the second stage of hospitalization are given over to
straight comforters, the practical nurses and
aides. No teaching is available and the patient
doesnt change a bit. No wonder so many people keep coming back for readmission. Theyve
never had the invitation nor the opportunity to
learn from this experience. So I say, if thats
the way it is, take [the patient] from the medical center at this point in his follow-up evaluative medical care period and transfer him to
the Loeb Center, where nurturing will be his
chief therapy and medicine will become an ancillary one.
Hall also opposed the concept of team nursing,
which was being implemented in many acute care
settings at the time. According to Hall (1958), team
nursing viewed nursing as a set of functions, ranging
from simple to complex. Simple functions were considered those in which few factors were taken into
consideration before making a nursing judgement.
The tasks or activities of nursing were divided among
nursing personnel, simply or complexly educated,
with the highest educated leading the nursing team.
Hall believed that the concept of team nursing was

detrimental to nursing and reduced nursing to a vocation or trade. Hall (1958, p. 1) stated: There is
nothing simple about patients who are complex human beings, or a nurse who is also complex and who
finds herself involved in the complexities of disease
and health processes in a complex helping relationship. Hall was convinced that patient outcomes are
improved when direct care is provided by the professional nurse.
CARE, CORE, AND CURE
Hall enumerated three aspects of the person as patient: the person, the body, and the disease. These aspects were envisoned as overlapping circles that influence each other. Hall stated:
Everyone 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)
She believed that medicines responsibility was the
area of pathology and treatment. The area of person,
which, according to Hall, has been sadly neglected,
belongs to a number of professions, including psychiatry, social work, and the ministry, among others.
She saw nursings expertise as the area of body as
body, and also as influenced by the other two areas.
Hall clearly stated that
Nursing is required when the focus of nursing is
the provision of intipersons are not able to pro- mate bodily care. She
vide intimate bodily care reflected that the public has long recognized
for themselves. The nursing this as belonging excluintent of this care is to sively to nursing (Hall,
1958, 1964, 1965). Becomfort. ing expert in the area of
body involved more
than simply knowing how to provide intimate bodily
care. To be expert, the nurse must know how to
modify the care depending on the pathology and
treatment while considering the unique needs and
personality of the patient.
Based on her view of the person as patient, Hall
conceptualized nursing as having three aspects, and
delineated the area that is the specific domain of
nursing, as well as those areas that are shared with
other professions (Hall, 1955, 1958, 1964, 1965)
(Figure 101). Hall believed that this model reflected
the nature of nursing as a professional interpersonal

process. She visualized 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 medical crisis to the rehabilitative phase of the illness. In the acute care phase, the
cure circle is the largest. During the evaluation and
follow-up phase, the care circle is predominant.
Halls framework for nursing has been described as
the Care, Core, and Cure Model (Chinn & Jacobs,
1987; Marriner-Tomey, Peskoe, & Gumm, 1989;
Stevens-Barnum, 1990).
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 healthful environment)
belongs exclusively to nursing. Nursing is required
when people are not able to undertake these activities for themselves. This aspect provided the opportunity for closeness and required seeing the process
as an interpersonal relationship (Hall, 1958). Hall labeled this aspect care, and identified knowledge in
the natural and biological sciences as foundational to
practice. The intent of bodily care is to comfort the
patient. Through this comforting, the person of the
patient, as well as his or her body, responds to the
physical care. Hall cautioned against viewing inti-
135
mate bodily care as a task that can be performed by

anyone when she stated:
To make the distinction between a trade and a
profession, 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 patientyou 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 feels close to the comforting
one. At this time his person talks out and acts
out those things that concern himgood, bad
and indifferent. If nothing more is done with
these, what the patient gets is ventilation or
catharsis, if you will. This may bring relief of
anxiety and tension but not necessarily learning. If the individual who is in the comforting
role has in her preparation all of the sciences
whose principles
Cure is an aspect of nurs- she can offer a
teaching-learning
ing that is shared with experience around
medicine. The nurse may his concerns, the
ones that are most
assume medical functions, effective in teachor help the patient with ing and learning,
then the comforter
these through comforting proceeds to someand nurturing. thing beyondto
what I call nurturersomeone who fosters learning, someone who fosters growing up emotionally,
someone who even fosters healing. (Hall,
1969, p. 86)
Cure
The second aspect of the nursing process is shared
with medicine and is labeled the cure. During this
aspect, the nurturing process may be modified as
this aspect overlaps it. Hall (1958) comments on the
two ways that this medical aspect of nursing may
be viewed. It may be viewed as the nurse assisting
the doctor by assuming medical tasks or functions.
The other view of this aspect of nursing is to see the
nurse helping the patient through his or her medical,
surgical, and rehabilitative care in the role of comforter and nurturer. Hall felt that the nursing profession was assuming more and more of the medical aspects of care while at the same time giving away the
136
nurturing process of nursing to less well-prepared

persons. Hall stated:
Interestingly enough, physicians do not have
practical doctors. They dont 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 feels
better in this role, why not? One good reason
why not for more
and more nurses is
The nurse who knows self
that with this increasing trend, pa- can love and trust the patients receive from tient enough to work with
professional nurses
second class doctor- him professionally, rather
ing; and from practi- than for him technically, or
cal nurses, second
class nursing. Some at him vocationally.
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 personal closeness
provides to further [the] patients growth and
rehabilitation. (Hall, 1958, p. 3)
Core
The third area that nursing shares with all of the
helping professions is that of using relationships for
therapeutic effectthe core. This area emphasizes
the social, emotional, spiritual, and intellectual
needs of the patient in relation to family, institution,
community, and the world (Hall, 1955, 1958, 1965).
Knowledges foundational to the core were based
on the social sciences and 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 is, where
he is, where he wants to go and will take or refuse
help in getting therethe patient will make amazingly more rapid progress toward recovery and rehabilitation (Hall, 1958, p. 3). Hall believed that
through this process, the patient would emerge as a
whole person.
Knowledge and skills important for the nurse to
be able 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 therapeutic 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 professionally, rather than for him
technically, or at him vocationally. Her 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 participates 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 invited the patient to learn to get at the core of his difficulties
while seeing him through the cure that is possible.
Through the professional nursing process, the patient has the opportunity of making the illness a
learning experience from which he may emerge
even healthier than before his illness (Hall, 1965).
THE LOEB CENTER FOR

NURSING AND REHABILITATION
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
major orientation of the center was rehabilitation
and subsequent 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 patients need for rehabilitation nursing. What made the Loeb Center uniquely
different was the model of professional nursing that
was implemented under Lydia Halls guidance. The
guiding philosophy of the center was Halls belief
that during the rehabilitation phase of an illness ex-
perience, professional nurses were the best prepared to foster the rehabilitation process, decrease
complications and recurrences, and promote health
and prevent new illnesses. She saw this 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.
At the Loeb Center, nursing was the chief therapy,
with medicine and the other disciplines ancillary to
nursing. A new model of organization of nursing services was implemented and studied at the center.
Hall stated:
Within this proposed organization of services,
the chief therapeutic agent for the patients rehabilitation and progress will be the special
and unique way the nurse will work with the
individual patient. She will be involved not
only in direct bedside care but she will also be
the instrument to bring the rehabilitation service of the Center to the patient. Specialists in
related therapies will be available on staff as resource persons and as consultants. (Hall,
1963b, p. 4)
Nursing was in charge of the total health program
for the patient and responsible for integrating all
aspects of care. Only
registered professional The chief focus of the panurses were hired.
tients rehabilitation at the
The 80-bed unit was
staffed with 44 pro- Loeb Center was the spefessional nurses emcial and unique way the
ployed around the
clock.
Professional nurse worked with each
nurses gave direct pa- patient. Patients particitient care and teaching and were responsi- pated in all care decisions.
ble 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 messengerattendant.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, 1969).
Additionally, there were four ward secretaries. Morning and evening shifts were staffed at the same ratio.
Night-shift staffing was less; however, Hall (1965,
p. 2) 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. In most institutions of that
time, the number of nurses was decreased during the
137
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
participated actively in all care decisions. Families
were free to visit at any hour of the day or night.
Rather than strict adherence to institutional 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 transition to home. There was no chart section
labeled Doctors 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. Additionally, there were no doctors progress notes or nursing notes. Instead, all
charting was done on a form entitled Patients Progress Notes. These notes included the patients reaction to care, his concerns and feelings, his understanding of the problems, the goals he has identified,
and how he sees his progress toward those goals.
Hall believed that what was important to record was
the patients progress, not the duties of the nurse or
the progress of the physician. Patients were also encouraged to keep their own notes to share with their
caregivers.
Referring back to Halls care, core, and cure
model, the care circle enlarges at Loeb. The cure circle becomes smaller, and the core circle becomes
very large. It was Halls belief that the nurse reached
the patients person through the closeness of inti-
mate bodily care and comfort. The interpersonal process established by the professional nurse during the
provision of care was the basis for rehabilitation and
learning on the part of the patient. Alfano (1982, p.
213) noted that Halls process for nursing care was
based upon a theory that incorporated the teachings
of Harry Stack Sullivan, Carl Rogers, and John
Dewey. Nurses were taught to use a nondirective
counseling approach that emphasized use of a reflective process. Within this process, it was important
for nurses to learn to know and care for self so that
they could use the self therapeutically in relationship
with the patient (Hall, 1965, 1969). Hall reflected:
If the nurse is a teacher, she will concern herself with the facilitation of the patients verbal
expressions and will reflect these so that the
patient can hear what he says. Through this
process, he will come to grips with himself
and his problems, in which case, he will learn
rapidly, i.e. he will change his behavior from
sickness to wellness. (Hall, 1958, p. 4)
Lydia Hall directed the Loeb Center from 1963 until her death in 1969. Genrose Alfano succeeded her
in the position of director until 1984. At this time,
the Loeb Center became licensed to operate as a
nursing home, providing both subacute and longterm care (Griffiths, 1997b). The philosophy, structure, and organization of services established under
Hall, and continued under the direction of Genrose
Alfano, changed considerably in response to changes
in health-care regulation and financing. Hall and others have provided detailed desciptions of the planning and design of the original Loeb Center, its daily
operations, and the nursing work that was done
from 1963 to 1984 (Alfano, 1964, 1969, 1982;
your thoughts
138
Bowar, 1971; Bowar-Ferres, 1975; Englert, 1971;

Hall, 1963a, 1963b; Henderson, 1964; Isler, 1964;
Pearson, 1984).
IMPLICATIONS FOR
NURSING PRACTICE
The stories and case studies written by nurses who
worked at Loeb provide the best testimony of the implications for nursing practice at the time (Alfano,
1971; Bowar, 1971; Bowar-Ferres, 1975; Englert,
1971). Griffiths and Wilson-Barnett (1998, p. 1185)
noted: The series of case studies from staff at the
Loeb illustrate their understanding of this practice
and describe a shift in the culture of care both between nurses and patient and within the nursing
management structure. Alfano (1964) discussed the
nursing milieu, including the orientation, education,
mentoring, and expectations of the nurses at the
Loeb Center. Before hiring, the philosophy of nursing and the concept of professional practice were
discussed with the applicant. Alfano stated: If she
agrees to try the nondirective approach and the reflective method of communication, and if shes willing to exercise all her nursing skills and to reach for a
high level of clinical practice, then were ready to
join forces(1964, p. 84). Nurses were given support
in learning and developing their professional practice. Administration worked with nurses in the same
manner in which they expected nurses to work with
patients, emphasizing growth of self. Bowar (1971,
p. 301) described the role of senior resource nurse
as enabling growth through a teaching-learning process grounded in caring and respect for the integrity
of each nurse as a person.
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 knowlege of
the two professions led to more effective team planning (Isler, 1964). The nursing stories published by
nurses who worked at Loeb describe nursing situations that demonstrate the effect of professional
nursing on patient outcomes. Additionally, they reflect the satisfaction derived from practicing in a
truly professional role (Alfano, 1971; Bowar, 1971;
Bowar-Ferres, 1975; Englert, 1971). Alfano stated:
The successful implementation of the professional
nursing role at Loeb was associated with an institutional philosophy of nursing autonomy and with considerable authority afforded clinical nurses in their
practice (Alfano, 1982, p. 226). The model of professional nursing practice developed at Loeb has
been compared to primary nursing (Griffiths & Wilson-Barnett, 1998).

Questions arise about why the concept of the
Loeb Center was not replicated in other facilities. Alfano (1982) identified several deterrents to replication of the model. Foremost among these was her belief that many people were not convinced that it was
essential for professional nurses to provide direct patient care. Additionally, she postulated that others
did not share the definition of the term professional
nursing practice that was espoused by Hall. She
noted that those who have tried to replicate the program, but have employed nonprofessional or lessskilled persons, have not produced the same results
(Alfano, 1982, p. 226). Other factors included economic incentives that favored keeping the patient in
an acute care bed, and the difficulties encountered
in maintaining a population of short-term rehabilitation patients in the extended care unit. Pearson
(1984, p. 54) suggested that the philosophy of the
center may have been
threatening to estab- Research findings suglished hierarchies and
power relationships. gested that patients at the
Alfano (1982, p. 226) Loeb Center achieved betspeculated that the
Loeb Center may have ter outcomes at less overbeen an idea ahead of all cost. These findings are
its time and that dissatisfaction with nurs- consistent with recent
ing homes, the na- research.
tions excess hospital
bed capacities, and an increasing emphasis on rehabilitation might contribute to replication of the Loeb
model in the future.
Interestingly, the Loeb model was the prototype
for the development of several Nursing-Led InPatient Units (NLIUs) in the United Kingdom. Two
British nurses, Peter Griffiths and Alan Pearson, both
traveled to the Loeb Center in preparation for the development of NLIUs in the United Kingdom. Both
have done extensive writing in the literature describing the units and are involved in active outcome research. In a comprehensive review of the literature,
Griffiths and Wilson-Barnett (1998) identify several
nursing-led in-patient units, including Loeb; describe
their structure; and discuss the research that was
conducted to evaluate the centers. The operational
definition of nursing-led in-patient units derived from
this study includes the following characteristics:
1. in-patient environment offering active
treatment;
2. case mix based on nursing need;
139
3. nurse leadership of the multidisciplinary clinical

team;
4. nursing is conceptualized as the predominant active therapy; and
5. nurses have authority to admit and discharge patients. (Griffiths & Wilson-Barnett, 1998, p. 1185)
Unencumbered at the present time by the financial constraints of the American health-care system,
the potential for the further development of nursingled in-patient centers in the United Kingdom seems
promising. However, Griffiths (1997b) suggested
that future development of NLIUs in the United Kingdom may soon be influenced by financial constraints
similar to those in the United States.
IMPLICATIONS FOR
NURSING RESEARCH
In addition to case study research by nurses who
worked at Loeb, an 18-month follow-up study of the
outcomes of care was funded by the Department of
Health, Education and Welfare. Alfano (1982) presents a detailed description of the study. The purpose
of the longitudinal study was to compare selected
outcomes of two groups of patients exposed to different nursing environments (the Loeb program and
a control group). Outcomes examined were cost of
hospital stay, hospital readmissions, nursing home
admissions, mortality, and return to work and social
activities. Overall, findings suggested that the Loeb
group achieved better outcomes at less overall cost.
The findings of several other studies in nurse-led
units lend further support to the benefit of the structure to patient outcomes, including prevention of
complications (Daly, Phelps, & Rudy, 1991; Griffiths,
1996; Griffiths & Wilson-Barnett, 1998; Rudy, Daly,
Douglas, Montenegro, Song, & Dyer, 1995). There is
a critical need for research examining the effect of
professional nursing care on patient outcomes in all
settings. In a recent study involving 506 hospitals in
10 states, Kovner and Gergen (1998) reported that
patients who have surgery done in hospitals with
fewer registered nurses per patient run a higher risk
of developing avoidable complications following
their operation. There was a strong inverse relationship between registered nurse staffing and adverse
patient events. Patients in hospitals with fewer fulltime registered nurses per in-patient day had a greater
incidence of urinary tract infections, pneumonia,
thrombosis, pulmonary congestion, and other lungrelated problems following major surgery. The authors suggested that these complications can be prevented by hands-on nursing practices and that this
140
should be considered when developing strategies to

reduce costs. Griffiths (1996) suggested the need for
further research and cautioned that although clinical
outcomes are important, it is equally important to
study the processes of care in these units. In doing
so, we will begin to understand the resources and
methods of nursing care necessary to ensure positive
patient outcomes.
Summary
Currently, nurses practice in a health-care environment driven by financial gain, where quality is sacrificed and the patient is lost in a world of mismanaged
care. More than ever, these alarming trends indicate a
need to return to the basic premise of Halls philosophypatient-centered, therapeutic care. According
to Griffiths (1997a), however, the Loeb Center
presently reflects little resemblance to its former image. It now provides part subacute and part long-term
care and, in fact, appears remarkably like the kind of
system that Hall was trying to alter. Nursing is bogged
down in a morass of paperwork, and the enthusiasm
generated by the Hall model is no longer evident.
How would Lydia Hall react to these conditions,
and what response might we expect if she spoke
with us today? We believe she would be appalled by
the diminished presence of professional nurses in
health-care facilities and the impediments confronting those who remain. She would encourage us
to explore new ways to provide needed nursing care
within an existing chaotic climate. She would lead us
in challenging the status quo and speak of the necessity for nursing leaders to have a clear vision of nursing practice as well as a willingness to advocate for
nursing irrespective of external forces seeking to undermine the profession.
She would foster scientific inquiry that addresses
outcomes of care and validates the impact of professional nursing, particularly in long-term care settings. She would agree that the improvement of care
to elders in nursing homes is a significant ethical issue for society and that nurses, the largest group of
providers of care to elders in nursing homes, play a
vital role in the improvement of care. She would call
upon us to develop professional models of care and
demonstrate the positive outcomes for the health
and well-being of elders. She would challenge the
widely held belief that provision of care to this population consists only of bed and body care that can be
effectively delivered by nonprofessional staff.
She would applaud the movement toward advanced nursing practice but would probably envi-
sion it as a means for highly educated nurses to use

their expertise more effectively in providing direct
patient care outside the hospital. She would encourage advanced practice nurses to continue to develop
knowledge related to the discipline of nursing and
the unique contribution of nursing to the health of
people. And she would identify community nursing
organizations as an opportunity for nurses to coordinate and deliver continuity of care in the ambulatory
setting and in the home.
Finally, she would urge nurses to recapture the aspects of nursing practice that have been relinquished
to othersthose nurturing aspects that, according
to Hall (1963a), provide the opportunity for nurses
to establish therapeutic, humanistic relationships
with patients and make it possible for them to work
together toward recovery.
References
Alfano, G. (1964). Administration means working
with nurses. American Journal of Nursing, 64,
8386.
Alfano, G. (1969). The Loeb Center for Nursing and Rehabilitation. Nursing Clinics of North America, 4,
487493.
Alfano, G. (1971). Healing or caretakingwhich will it
be? Nursing Clinics of North America, 6, 273280.
Alfano, G. (1982). In Aiken, L. (Ed.), Nursing in the
1980s (pp. 211228). Philadelphia: J. B. Lippincott.
Birnbach, N. (1988). Lydia Eloise Hall, 19061969. In
Bullough, V. L., Church, O. M., & Stein, A. P. (Eds.),
American Nursing:A biographical dictionary (pp.
161163). New York: Garland Publishing.
Bowar, S. (1971). Enabling professional practice
through leadership skills. Nursing Clinics of North
America, 6, 293301.
Bowar-Ferres, S. (1975). Loeb Center and its philosophy of nursing. American Journal of Nursing, 75,
810815.
Bullough, V. L., Church, O. M., & Stein, A. P. (Eds.).
(1988). American Nursing:A biographical dictionary. New York: Garland Publishing.
Chinn, P. L., & Jacobs, M. K. (1987). Theory and nursing. St. Louis: Mosby.
Daly, B. J., Phelps, C., & Rudy, E. B. (1991). A nursemanaged special care unit. Journal of Nursing Administration, 21, 3138.
Englert, B. (1971). How a staff nurse perceives her role
at Loeb Center. Nursing Clinics of North America,
6 (2), 281292.
Griffiths, P. (1996). Clinical outcomes for nurse-led inpatient care. Nursing Times, 92, 4043.
Griffiths, P. (1997a). In search of the pioneers of nurseled care. Nursing Times, 93, 4648.
Griffiths, P. (1997b). In search of therapeutic nursing:
Subacute care. Nursing Times, 93, 5455.
Griffiths, P., & Wilson-Barnett, J. (1998). The effectiveness of nursing beds: A review of the literature.
Hall, L. E. (1955). Quality of nursing care. Manuscript of an address before a meeting of the Department of Baccalaureate and Higher Degree Programs
of the New Jersey League for Nursing, February 7,
1955, at Seton Hall University, Newark, New Jersey.
Montefiore Medical Center Archives, Bronx, New
York.
Hall, L. E. (1958). Nursing:What is it? Manuscript.
Montefiore Medical Center Archives, Bronx, New
York.
Hall, L. E. (1963a, March). Summary of project report:
Loeb Center for Nursing and Rehabilitation. Unpublished report. Montefiore Medical Center Archives, Bronx, New York.
Hall, L. E. (1963b, June). Summary of project report:
Loeb Center for Nursing and Rehabilitation. Unpublished report. Montefiore Medical Center Archives, Bronx, New York.
Hall, L. E. (1963c). A Center for Nursing. Nursing Outlook, 11, 805806.
Hall, L. E. (1964). Nursingwhat is it? Canadian
Nurse, 60, 150154.
Hall, L. E. (1965). Another view of nursing care and
quality. Address delivered at Catholic University,
Washington, D.C. Unpublished report. Montefiore
Medical Center Archives, Bronx, New York.
Hall, L. E. (1969). The Loeb Center for Nursing and Rehabilitation, Montefiore Hospital and Medical Center, Bronx, New York. International Journal of
Nursing Studies, 6, 8197.
Henderson, C. (1964). Can nursing care hasten recovery? American Journal of Nursing, 64, 8083.
Isler, C. (June, 1964). New concept in nursing therapy:
Care as the patient improves. RN, 5870.
Kovner, C., & Gergen, P. (1998). The relationship between nurse staffing level and adverse events following surgery in acute care hospitals. Image: Journal
of Nursing Scholarship, 30, 315321.
Marriner-Tomey, A., Peskoe, K., & Gumm, S. (1989).
Lydia E. Hall Core, Care, and Cure Model. In Marriner-Tomey, A. M. (Ed.), Nursing theorists and
their work (pp. 109117). St. Louis: Mosby.
Montefiore cuts readmissions 80%. (1966, February
23). The New York Times.
ObituariesLydia E. Hall. (1969). American Journal of
Nursing, 69, 830.
Pearson, A. (1984, July 18). A centre for nursing. Nursing Times, 5354.
Rudy, E. B., Daly, B. J., Douglas, S., Montenegro, H. D.,
Song, R., & Dyer, M. A. (1995). Patient outcomes
for the chronically critically ill: Special care unit versus intensive care unit. Nursing Research, 44,
324331.
Stevens-Barnum, B. J. (1990). Nursing theory analysis,
application, evaluation (3rd ed.). Glenview, IL:
Scott, Foresman/Little Brown.
Wiggins, L. R. (1980). Lydia Halls place in the development of nursing theory. Image, 12, 1012.
Bibliography
Hall, L. E. (1955). Quality of nursing care. Public
Health News (New Jersey State Department of
Health), 36, 212215.
141
Hall, L. E. (1960). Report of a work conference on

nursing in long-term chronic disease and aging.
National League for Nursing as a League Exchange
#50. New York: National League for Nursing.
Hall, L. E. (1963, June). Report of Loeb Center for
Nursing and Rehabilitation project report (pp.
15151562). Congressional Record Hearings before
the Special Subcommittee on Intermediate Care of
the Committee on VeteransAffairs. Washington, DC.
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Hall, L. E. (1965). Nursingwhat is it? In Baumgarten

(Ed.), Concepts of nursing home administration.
New York: Macmillan.
Hall, L. E. (1966). Another view of nursing care and
quality. In Straub, M. K. (Ed.), Continuity of patient
care:The role of nursing. Washington, DC: Catholic
University of America Press.
Levenson, D. (1984). Montefiorethe hospital as social instrument. New York: Farrar, Straus & Giroux.
Chapter 11
Virginia Avenel Henderson
Definition of Nursing
Personal Background
The Search for a Personal Definition of Nursing
Influence on International Nursing
Influence on Nursing Education
Influence on Practice
Influence on Library Research and Development
Summary
References
Shirley Countryman Gordon

Virginia Avenel Henderson presented her definition
of the nature of nursing in a era when few nurses had
ventured into describing the complex phenomena of
modern nursing. Henderson wrote about nursing the
way she lived it: focusing on what nurses do, how
nurses function, and on nursings unique role in
health care. Her works are beautifully written in jargon-free, everyday language. However, Henderson
refused to have her definition of nursing endowed as
a theory or concept (Smith, 1998). She believed that
so-called nursing theories did not make a direct impact on the quality of nursing care delivered to real
patients (Smith, 1998).
Virginia Henderson is often referred to as the
twentieth-century Florence Nightingale (Halloran,
1991). Her search for a definition of nursing ultimately influenced the practice and education of
nursing around the world. Her pioneer work in the
area of identifying and structuring nursing knowledge has provided the foundation for nursing scholarship for generations to come.
PERSONAL BACKGROUND
Virginia Avenel Henderson was born in Kansas City,
Missouri, on November 30, 1897. She was the fifth
of eight children born to Lucy Abott Henderson and
Daniel B. Henderson. The family relocated to Virginia
in 1901 when her father, an attorney, took a position
representing Native-Americans before the government in Washington, D.C.
Hendersons early education was received at
home and at a school for boys run by her uncle,
Charles Abott. With two of her brothers serving in
the armed forces during World War I and in anticipation 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 regimentalization of patient care and
the concept of nursing as ancillary to medicine (Henderson, 1991). She described her introduction to
nursing as a series of almost unrelated procedures,
beginning with an unoccupied bed and progressing
to aspiration of body cavities (Henderson, 1991, p.
9). It was also at Walter Reed Army Hospital that she
met Annie W. Goodrich, the dean of the School of
Nursing. Henderson admired Goodrichs intellectual
abilities and stated: Whenever she visited our unit,
she lifted our sights above techniques and routine
(Henderson, 1991, p. 11). Henderson credited Goodrich with inspiring her with the ethical significance
of nursing (Henderson, 1991, p. 10).
144
Henderson learned to serve in an atmosphere

where nurses felt indebted to their patients. During
her training, there was a war going on. As a member
of society, she considered it a privilege to care for
sick and wounded soldiers (Henderson, 1960). This
experience forever influenced her ethical understanding of nursing and her appreciation of the importance and complexity of the nurse-patient relationship. She continued to explore the nature of
nursing as her student experiences exposed her to
different ways of being in relationship with patients
and their families.
A pediatric experience as a student at Boston
Floating Hospital introduced Henderson to patientcentered care. In this setting nurses were assigned to
patients instead of tasks, and, in contrast with the
atmosphere of Walter Reed Army Hospital, warm
nurse-patient relationships were encouraged. Nurses
in this setting were able to come to know the children but were unfamiliar with their parents or home
environments (Henderson, 1991).
Following 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 environments. She enjoyed the less formal approach to patient care and
become skeptical of the ability of hospital regimes to
successfully alter patients unhealthy ways of living
upon returning home (Henderson, 1991).
Based on her experience at Henry Street, Henderson became a visiting nurse after earning her
diploma in 1921. Responding to a need for nursing
instructors, she left nursing in homes to take a teaching position at Norfolk Protestant Hospital School of
Nursing in Norfolk, Virginia. After 5 years of what
Henderson (1966) referred to as learning through
teaching, she went back to school to gain more
knowledge and to clarify her ideas about the nature
of nursing.
THE SEARCH FOR A PERSONAL

DEFINITION OF NURSING
Henderson entered Teachers College at Columbia
University, earning her baccalaureate degree in 1932
and her masters degree in 1934. She continued at
Teachers College as an instructor and associate professor of nursing for the next 20 years.
While at Teachers College, Henderson studied
with several people who were influential in clarifying her thoughts about nursing and in developing an
analytical approach to patient care. She credits Caroline Stackpole for her understanding of the principle
of physiological balance and Edward Thorndike for

providing her with a framework focusing on the fundamental needs of humans in which routine nursing
activities could be designed and evaluated (Henderson, 1966). Henderson saw the ideas she had been
formulating implemented in the rehabilitation work
of Dr. George Deaver. She stated: Nothing made my
concept of nursing more concrete that the demonstrations and writings of these rehabilitation experts
with their insistence on individualized programs and
constant evaluation of the patients needs and his
progress towards the goal of independence(Henderson, 1966, p. 17).
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 chapter 1 with the
following question: What is nursing and what is the
function of the nurse?
What is the unique function (Harmer & Henderson,
1955, p. 1) Henderson
of the nurse? believed this question
was fundamental to anyone choosing to pursue the study and practice of
nursing.
Her often-quoted definition of nursing first appeared in the fifth edition of Textbook 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 would perform unaided if he had the necessary strength, will, or
knowledge. It is likewise the unique contribu-
tion of nursing to help people be independent

of such assistance as soon as possible.
Similar definitions later appeared in Basic Principles
of Nursing Care (Henderson, 1960), The Nature of
Nursing (Henderson, 1966), and Principles and
Practice of Nursing, sixth edition (Henderson &
Nite, 1978). The subsequent definitions of nursing
contain minor wording changes, but the essence of
Hendersons definition of nursing has remained consistent with her earliest definition.
In presenting her definition of nursing, Henderson hoped to encourage others to develop their own
working concept of nursing and nursings unique
function in society. She believed the definitions of
the day were too general and failed to differentiate
nurses from other members of the health team. From
experience she knew that the functions of healthteam members at times overlapped but believed in
recognizing the unique function of each member.
This knowing led her to consider 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 the definition identified
above, Henderson described the unique function of
the nurse as follows:
To assist the individual (sick or well) in the
performance of those activities contributing to
health or its recovery (or to a peaceful death),
that he would perform unaided if he had the
necessary strength, will, or knowledge. It is
likewise her function to help the individual
gain independence as rapidly as possible.
(Harmer & Henderson, 1955, p. 4)
your thoughts
Chapter 11 Virginia Avenel Henderson
145
In addition to declaring nursing functions as unique,

Hendersons definition provides a rationale for legitimate nursing activities. Nursing activities are to be
performed when an individual lacks part or all of the
necessary strength, will, or knowledge to reach the
goal of recovery, independence, or peaceful death.
One of Hendersons many contributions to nursing
was the introduction of the term basic nursing care.
She identified 14 components that encompassed basic
nursing care (Henderson, 1966, pp. 1617):
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
breathe normally
eat and drink adequately
eliminate body wastes
move and maintain desirable postures
sleep and rest
select suitable clothesdress and undress
maintain body temperature within normal range
by adjusting clothing and modifying the environment
keep the body clean and well groomed and protect the integument
avoid dangers in the environment and avoid injuring others
communicate with others in expressing emotions, needs, fears, or opinions
worship according to ones faith
work in such a way that there is a sense of accomplishment
play or participate in various forms of recreation
learn, discover, or satisfy the curiosity that leads
to normal development and health and use the
available health facilities.
The 14 components reflect needs pertaining to

personal hygiene and healthful living, including
helping the patient carry out the physicians therapeutic plan (Henderson, 1960, 1966). The focus is
on helping individual patients perform patterns of
daily living and health-related activities. The definition of nursing and the fourteen components together outline the functions the nurse can initiate
and control (Furukawa & Howe, 1995, p. 72). They
also provide the boundaries for nursing. Patients are
returned to independence or health when they are
able to perform the 14 components unaided. Henderson (1960) eloquently describes the basic nursing
care components in her publication, Basic Principles of Nursing Care.
INFLUENCE ON
INTERNATIONAL NURSING
Based on the success of Textbook of the Principles
and Practice of Nursing (fifth edition), Henderson
146
was asked by the International Council of Nurses

(ICN) to prepare a short essay that could be used as a
guide for nursing in any part of the world. Despite
Hendersons belief that it was difficult to promote a
universal definition of nursing, Basic Principles of
Nursing Care (Henderson, 1960) became an international sensation. To date, it has been published in 29
languages and is referred to as the twentieth-century
equivalent of Florence Nightingales Notes on Nursing. Henderson continued to question the usefulness
of a universal definition of nursing. As recently as
1991, she stated: Perhaps we should accept the conclusion that it [nursing]
depends on the re- Hendersons definition of
sources of the country
involved and the needs nursing called for the
of the people it serves nurse to be an expert in
(Henderson, 1991, p. 8).
basic nursing and to be an
After visiting countries
worldwide, she con- independent practitioner.
cluded that nursing varied from country to country and that rigorous attempts to define it have been unsuccessful, leaving
the nature of nursing largely an unanswered question (Henderson, 1991).
INFLUENCE ON
NURSING EDUCATION
Henderson used the term nurse to refer to a man
or woman with a minimum general education represented by graduation from high school, having been
prepared for nursing in a recognized basic program
of from two and a half to three years (Harmer &
Henderson, 1955, p. 9). Her definition of nursing,
which called for the nurse to be an expert in basic
nursing care and to be an independent practitioner,
required a move from training to education in order
to promote nurses knowing the why of their practice over adhering to memorized rules (Henderson,
1966).
Henderson outlined basic programs of nursing
that included the study of biological and physical sciences, social sciences, medical sciences, and the
nursing arts (Harmer & Henderson, 1955). For Henderson, knowledge of the biological and physical sciences was necessary in order for the nurse to understand body functions and to distinguish normal
activity from subnormal or pathological activity
(Harmer & Henderson, 1955). For this purpose, she
recommended study of scientific principles in the
areas of biology, chemistry, physics, physiology, and
pathology. Without knowing the scientific principles
underlying their practice, Henderson believed nurses

would be limited in their ability to offer patients help
in making healthful decisions and in developing practices or assisting others in developing practices leading to good health (Harmer & Henderson, 1955).
Study in the social sciences was intended to provide the nurse with a better understanding of herself
and therefore her patients. In addition, Henderson
believed that the nurse must have knowledge of personality development and of the beliefs and customs
of different groups in order to assess individual needs
accurately (Harmer & Henderson, 1955).
Henderson referred to the following as the medical sciences: all that is known about the cause; the
signs and symptoms; and the occurrence, prevention, treatment, and probable outcome of disease
(Harmer & Henderson, 1955). She believed knowledge of the medical sciences was necessary for the
nurse to cooperate effectively with the physicians
therapeutic plan for the patient.
The nursing arts were described by Henderson as
the application of knowledge of the sciences and
development of skills related to nursing activities
(Harmer & Henderson, 1955). She stated: It may be
that knowledge of the general with application to
the specific is central to artistic performances in
all artsincluding the art of nursing (Henderson,
1966, p. 62).
In addition to recommendations about curricular
content, Henderson had thoughts on the sequencing
of learning experiences, tools to facilitate learning,
and evaluation of nursing practice. She believed basic programs of nursing should begin with learning
the fundamentals of nursing care and progress
through a sequence of increasingly complex experiences involving mildly ill adults; medical and surgical
services; and maternity, pediatrics, and mental health
divisions while working beside an older nurse
(Harmer & Henderson, 1955). She believed that
working with an older nurse enabled the student to
develop the ability to size up or analyze a nursing
situation. For Henderson, this analysis began with an
assessment of patient health needs and culminated in
a developed plan of care.
Hendersons 1955 revision of Harmers Textbook
of the Principles and Practice of Nursing included a
chapter on the plan of care for the patient. She
placed the responsibility for studying the patient and
planning his or her nursing care on the individual
nurse assigned to the patient or on the nurse team
leader. Henderson stated: In order to meet the persons health needs it is necessary to know him and
his family, and this can only be accomplished by being with them and studying them (Harmer & Hen-
derson, 1955, p. 3). Studying the patient involved an

analysis of factors influencing nursing care that included having knowledge of the patients age, sex,
race, nationality, and religion, along with an estimate
of the patients native intelligence, previous experiences, occupation, and economic status. The nurse
also required information about the physicians diagnosis and plan of therapy. Henderson referred to the
collection of information about the patient as a case
study (Harmer & Henderson, 1955). Without the
preparation of a case study, Henderson believed that
the nurse could not analyze individual needs of the
patient required to develop an effective plan of care.
She believed that failure to prepare an adequate patient case study would result in a routine pattern of
care.
Virginia Henderson also believed in evaluating the
quality of basic nursing care provided to patients.
She was interested in developing tools that would
assist instructors, students, and graduate nurses to
evaluate the quality of their care continually. Birnbach (1998, p. 45) recalled Henderson discussing
the following three questions that nurses could use
to determine how patients perceived their quality of
care: What did I do that helped you? What did I do
that didnt help you? and What did I not think of that
might have helped you?
INFLUENCE ON PRACTICE
Hendersons definition of nursing has had a lasting
influence on the way nursing is practiced around the
globe. She was one of the first nurses to articulate
that nursing had a unique function that made a valuable contribution to the health care of individuals. In
writing reflections on the nature of nursing, Henderson (1966) states that her concept of nursing implies
universally available health care and a partnership relationship between doctors, nurses, and other healthcare workers.
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 Henderson has been
functions of nursing
provided the initial heralded as the greatest
groundwork for intro- advocate for nursing
ducing the concept of
independent nursing libraries worldwide.
practice. In her 1966
publication, The Nature of Nursing, Henderson
stated: It is my contention that the nurse is, and
147
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
physicians functions (Henderson, 1966, p. 22).
Furthermore, Henderson believed that functions
pertaining to the care of patients could be categorized as nursing and non-nursing. She believed that
limiting nursing activities to nursing care was a useful method of conserving professional nurse power
(Harmer & Henderson, 1955). She defined functions
that are not a service to the person (mind and body)
as non-nursing functions (Harmer & Henderson,
1955). For Henderson, examples of non-nursing
functions included ordering supplies, cleaning and
sterilizing equipment, 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 level of complexity. For Henderson, all nursing care . . . is essentially complex
because it involves constant adaptation of procedures to the needs of the individual (Harmer & Henderson, 1955, p. 9).
As the authority on basic nursing care, Henderson
believed the nurse has the responsibility to assess the
needs of the individual patient, help individuals meet
their health needs, and/or provide an environment
in which the individual can perform activities unaided. It is the nurses role, according to Henderson,
to get inside the patients skin and supplement his
strength, will or knowledge according to his needs
(Harmer & Henderson, 1955, p. 5). Conceptualizing
the nurse as a substitute for the patients 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.
INFLUENCE ON LIBRARY
RESEARCH AND DEVELOPMENT
Henderson has been heralded as the greatest advocate for nursing libraries worldwide. Following the
completion of her revised text in 1955, Henderson
moved to Yale University. It was here that she began
what would become a distinguished career in library
science research.
Of all her contributions to nursing, Virginia Hendersons 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
practice of nursing. It was also recognized that the
body of nursing knowledge was unstructured and
therefore inaccessible to practicing nurses and educators. Henderson encouraged nurses to become active in the work of classifying the nursing literature.
Virginia Henderson and Leo W. Simmons, an anthropologist at Yale University, were asked to make a
survey of existing nursing research (Simmons & Henderson, 1964). Working on a grant awarded to Yale
University, Henderson went to 30 states to determine what nursing research had been done there,
what individuals knew about, and what studies they
would do if they had the necessary resources (Henderson, 1991). The results of the survey indicated
that awareness of nursing research was limited and
that nurse researchers were conducting studies from
the perspective of the social sciences (Henderson,
1991).
your thoughts
148
Florence Wald, dean of Yale University School of

Nursing, recognized the value of the bibliography developed from the survey and pursued a grant from
the U.S. Public Health Service to publish the bibliography. An advisory committee and what would become the Interagency Council on Library Resources
for Nursing were formed to support the project. At
its completion, the 11-year project was published by
J. B. Lippincott Company as the four-volume annotated index to the analytical and historical literature
on nursing from 1900 through 1959, known as the
Nursing Studies Index (NSI).
The success of the NSI and the efforts of the Interagency Council on Library Resources for Nursing led
to the creation of the International Nursing Index
(INI) in 1966. The INI is published collaboratively by
the American Journal of Nursing and the National
Library of Medicine and continues to be a major
scholastic resource in nursing. The INI includes articles selected from nursing and non-nursing journals,
publications of organizations and agencies, nursing
books published, and nursing dissertations. In an effort to help nurses use the index more easily, the
nursing thesaurus was revised to include commonly
used nursing terms as cross-references to the Medical
Subject Headings in 1968.
Virginia Henderson remained a strong advocate
for nursing resource development throughout her
lifetime. In 1990, the Sigma Theta Tau International
Library was named in her honor. Henderson insisted
that if the library were to bear her name, the electronic networking system would have to advance the
work of staff nurses by providing them with current,
jargon-free information wherever they were based
(McBride, 1997).
Summary
Virginia Hendersons life was devoted to the promotion of nursing and nursing care. Embodied in her
writings is a deep sense of obligation to serve others.
Hendersons definition of nursing and the 14 basic
nursing care components have been widely read and
frequently used in guiding the direct nursing care of
real patients around the world. Her conceptualizations have empowered others to see nursing from a
new perspective and continue to ask questions about

the nature of nursing. She has influenced curriculum
development and inspired nurses to be clinical scholars by promoting the accessibility and importance of
research in day-to-day practice. Miss Hendersons lifetime achievements have provided essential stepping
stones in the recognition of nursing as a scientific
discipline and profession. But more important, she
served by sharing the beauty of nursing with the
world.
I think the beauty of medicine and nursing
is the combination of your heart, your head
and your hands and where you separate them,
you diminish them, diminish the service.
(McBride, 1997)
References
Birnbach, N. (1998). Three questions. In Hermann,
E. K. (Ed.), Virginia Avenel Henderson:
Signature for nursing. Indianapolis: Center
Nursing Press.
Furukawa, C. Y., & Howe, J. K. (1995). Virginia Henderson. In George, J. B. (Ed.), Nursing theories:The
base for professional nursing practice (4th ed.).
Halloran, E. (1991). Virginia Henderson. [On-line].
Available: http://www.son.washington.edu/news
l.html.
Harmer, B., & Henderson, V. A. (1955). Textbook of the
principles and practice of nursing. New York:
Macmillan.
Henderson, V. A. (1960). Basic Principles of nursing
care. Geneva: International Council of Nurses.
Henderson, V. A. (1966). The nature of nursing. New
York: The National League for Nursing Press.
Henderson, V. A. (1991). The nature of nursing: Reflections after 25 years. New York: The National League
for Nursing Press.
Henderson, V. A. & Nite, G. (1978). Principles and
practices of nursing (6th ed.). New York:
Macmillan.
McBride, A. B. (Narrator). (1997). Celebrating Virginia
Henderson. (Video). (Available from Center for
Nursing Press, 550 West North Street, Indianapolis,
IN 46202.)
Simmons, L. W., & Henderson, V. A. (1964). Nursing research:A survey and assessment. New York: Appleton & Lange.
Smith, J. P. (1998). In my opinion. In Hermann, E. K.
(Ed.), Virginia Avenel Henderson: Signature for
nursing. Indianapolis: Center Nursing Press.
149
Chapter 12
Josephine Paterson
and Loretta Zderad
Humanistic Nursing Theory
with Clinical Applications*
Introducing the Theorists
Humanistic Nursing Theory
Clinical Applications of Humanistic Nursing Theory
References
Susan Kleiman
*Reprinted with permission of the National League for Nursing, New York.
INTRODUCING THE THEORISTS

While I was struggling to write about Humanistic
Nursing Theory, I received a phone call from a registered nurse from the Midwest. She was a graduate student taking her first course in nursing theory and had
chosen the Theory of Humanistic Nursing as the topic
of her term paper. She was being discouraged by her
instructor and dissuaded by some other academic
nursing professionals that she had contacted. The reasons given ranged from lack of clarity of the theory, to
not enough mention in the literature about clinical or
research applications, to the assertion that Humanistic Nursing Theory is a theory that has had its day.
I have heard these criticisms before, both personally
and related by other students. The purpose of this
section is to clarify these and other relevant issues.
The applications presented in the next section are directed toward enhancing the understanding of the
practical applications of Humanistic Nursing Theory.
As for Humanistic Nursing Theory having had its
day, I still believe that it was before its time and it is
only recently, in an atmosphere of theory-based nursing, that it is being received and understood in its full
range of meaning. Why now?, you may ask, as this
student did. I truly believe that it is related to the
changing worldview. There is an increasing acceptance of a worldview that does not embrace the reductionist mind-set as the touchstone of explanatory
power. More and more there is an awareness of interrelatedness or, in terms of Humanistic Nursing
Theory, the all-at-once quality of existence. It includes a temporal component that provides a spacetime immediacy to the phenomenon in the here and
now. According to this view, patients and nurses
bring all that they are, all at once, as they engage in
a dialogue that is the essence of nursing. It is a theory that does not reduce either the patient or the
nurse to needs, pathology, or culture. It is an inclusive theory that provides a method for managing the
complexities that are the reality of being in the
world.At the same time, it offers a means of prioritizing and focusing, which allows for growth and enrichment. I will show how Humanistic Nursing Theory provides an umbrella; in other words, that it is a
meta-theory, under which other nursing theories are
subsumed and can be explained.
Questions that students of Humanistic Nursing
Theory ask are not only related to the concepts and
the application of the theory itself. There are also important questions about how we might use this
newly found awareness and understanding of the essential characteristics of nursing to enhance nursing
as a profession.
Martin Buber (1965, p. 71) has eloquently said
that humans have a basic need to be confirmed by
others of their kind: [S]ecretly and bashfully [they]
watch for a Yes which allows [them] to be. In Humanistic Nursing Theory we experience that yes as
we encounter outward expression of that which
we have inwardly known. We are uplifted by the
poiesis, the bringing forth and bursting open of the
blossom of possibilities that this brings (Heidegger,
1977, p. 10).
The Theorists
Who are the theorists who authored Humanistic
Nursing Theory? Dr. Josephine Paterson is originally
from the East Coast and Dr. Loretta Zderad is from
the Midwest. Each attended different diploma
schools of nursing and different undergraduate pro-
your thoughts
152
grams, both receiving their bachelors degree in nursing education. In their graduate work, Dr. Zderad
majored in psychiatric nursing at the Catholic University of America and Dr. Paterson in public health
nursing at Johns Hopkins University. They met in the
mid-1950s, when they both worked at Catholic University. Their task was to create a new program that
would encompass the community health component
and the psychiatric component of the graduate program. That started a process of collaboration and dialogue and friendship that has lasted for over 35 years.
Dr. Zderad earned her doctorate in philosophy
from Georgetown University and Dr. Paterson
earned her doctor of nursing science degree from
Boston University. Dr. Zderads dissertation was on
empathy and Dr. Patersons was on comfort. They
shared and developed their concepts, approaches,
and experiences of existential phenomenology,
which evolved into the formal Theory of Humanistic
Nursing. They incorporated these into their work as
educators and shared them across the country in
seminars and workshops on Humanistic Nursing
Theory. This theory may be considered a prototype
for some of the more recent experiential-based nursing theories (Benner, 1984; Parse, 1981; Watson,
1988).
My first contact with Humanistic Nursing Theory
was when I was a graduate student in psychiatric
mental health nursing. Josephine Patersons name
was given to me as a possible preceptor for my clinical placement. At that time, Dr. Paterson was working as a psychotherapist at the Veterans Hospital in
Northport, Long Island, in the Mental Hygiene Clinic
and was also adjunct associate professor at Adelphi
University. Loretta Zderad was at that time the associate chief of nursing service for education at the same
Veterans Hospital.
Dr. Paterson and Dr. Zderad came to the Veterans
Administration (VA) Hospital in Northport in 1971.
They were hired for their original positions as nursologists by a forward-thinking administrator who recognized the need for staff support during a period of
change in the VA system. The position of nursologist
involved a three-pronged approach to the improvement of patient care through clinical practice, education, and research. These functions were integrated
within the framework of humanistic nursing. They
worked with the nurses at Northport in this manner
from 1971 until 1978. At that time they assumed the
positions they held when I met them.
My initial interview with Dr. Paterson went well
and she agreed to work with me over the next 2
years. Perhaps she had an attraction to the all at
onceness of my multidimensional life. At that time, I
was working full time, a graduate student, a wife, a

mother, and a homemaker. I am eternally grateful to
her for those sunrise hours of supervision before I
went off to work. The following week I had the privilege of meeting Loretta Zderad.
When I first met Dr. Paterson and Dr. Zderad, I
had no awareness of Humanistic Nursing Theory.
During our discussions, however, it became apparent that we shared an interest in certain writers. For
example, we spoke about Martin Buber and the I
and Thou concept and dialogue as the process of
intersubjective relating. We also spoke about Rollo
May (1995) and his work on creativity. At some point
Dr. Paterson casually mentioned that I might be interested in reading a book that she and Dr. Zderad had
written. She indicated that the book referenced
these writers as well as some existentialists such as
Marcel, Desan, and Popper. The book was Humanistic Nursing (1988). The following 2 years brought
me a world of enrichment. For Dr. Paterson and Dr.
Zderad the next 2 years culminated in their retirement and relocation to the South. I, on the other
hand, continue the work that they started, as a fellow theorist, and as a friend and colleague in nursing.
Since their retirement, Dr. Zderad and Dr. Paterson refer inquiries about Humanistic Nursing Theory
to me. The reasons for this honor I have been told are
that they believe I have a real grasp of what the
theory is about. They also appreciate how alive it
is in my everyday practice of nursing. It has given me
the opportunity to speak individually to students or
to present and discuss the theory with groups of
nurses. At these times I am aware of the disappointment that nurses feel in not being able to have more
direct access to the theorists themselves. I feel privileged to have had a professional and a personal relationship in which I have been able to dialogue with
Dr. Paterson and Dr. Zderad about Humanistic Nursing Theory. With this privilege I also experience a responsibility to share what that dialogue has offered
me. I do, however, have concerns when they refer
people to me that I represent Humanistic Nursing
Theory accurately and adequately.
My call to Dr. Paterson and Dr. Zderad for validation of my representation of their theory in discourse
and in writing has been responded to with confirmation that I have done what they had hoped nurses
would do. That is, I have taken Humanistic Nursing
Theory and made it my own, expanded it, and articulated it to others. And so while I may use a different
style, and in our world scholars at times may differ, I
am confident based on their validation that the core
concepts of the theory have not been distorted. Per-
Chapter 12 Paterson and Zderad Humanistic Nursing Theory with Clinical Applications
153
haps my particular contribution is that I have taken

the basic theoretical concepts of Humanistic Nursing
Theory that were originally articulated and conceptualized through the shared experiences of nurses,
and shown how nurses can use those concepts to expand and enrich themselves, their patients, nursing,
and health care in general. Dr. Paterson and Dr.
Zderads response to my call was that it was now our
theory. Our theory to me means a theory in progress, to be owned, expanded upon, and hopefully articulated by all those nurses who embrace it as their
own.
HUMANISTIC NURSING THEORY

Humanistic Nursing Theory is multidimensional. It
speaks to the essences of nursing and embraces the
dynamics of being, becoming, and change. It is an interactive theory of nursing that provides a methodology for reflective articulation of nursing essences. It is
also a theory that provides a methodological bridge
between theory and practice by providing a broad
guide for nursing dialogue in a myriad of settings.
Nursing as seen through Humanistic Nursing Theory is the ability to struggle with another through
peak experiences related to health and suffering
in which the participants in the nursing situation are
and become in accordance with their human potential (Paterson & Zderad, 1976, p. 7). The struggle is
shared through a diaNursing is nurturing the logue between the
participants. This manwell-being and more-being
date to share strugof persons. It is the ability gles with is what
allows for each to beto enter into nursing situacome in relationship
tions and to struggle with with the other. In
another in his or her expe- nursing, the purpose
of this dialogue, or inriences of health and suf- tersubjective relating,
fering toward his or her according to Josephine Paterson and Loself-actualizing potential. retta Zderad, is, [n]urturing the well-being
and more-being of persons in need (p. 4). Humanistic Nursing Theory is grounded in existentialism and
emphasizes the lived experience of nursing. One of
the existential themes that it builds on is the affirmation of being and becoming of both the patient and
the nurse through the choices they make and the intersubjective relationships they engage in. This dynamic is expressed as nursings concern with the
struggle toward self-actualizing potential or morebeing.
154
The new adventurer in humanistic nursing theory

may at first find some of these terms and phrases awkward. When I spoke to a colleague of the moreness
and of relating all-at-once, she remarked, Oh, oh,
youre beginning to sound just like them, meaning
Dr. Paterson and Dr. Zderad. What was of note to her
has become natural to me. It is reflective of my grasp
of nursing as an ever-changing process. Think of your
nursing experiences, whatever the contexts may be.
Are these experiences of static settings? Or is there a
pervasive sense of activity associated with them? Just
as nursing in actual practice is never inert, so Humanistic Nursing Theory is in its essence dynamic. I reflect with a smile on Josephine Patersons description
of humanistic nursing: Our here and now stage of
humanistic nursing practice theory development at
times is experienced as an all-at-once octopus at a discotheque, stimulation personified gyrating in many
colors (1977, p. 4). It is a bonus when a theory not
only can be useful but also can be fun.
While this approach to theory may seem somewhat lighthearted, it addresses the need to feel comfortable with theory. Theory, like research, is not just
for those in ivory towers. Theory and research are a
part of every nurse and all that is nursing. If we look
at theory through R. D. Langs eyes as an articulated
vision of experience (Zderad, 1978, p. 4), we can
see that in one sense by looking at our own experience of nursing, as proposed in Humanistic Nursing
Theory, we all become theorists. I do not use the
term comfortable with in the generic sense, but
rather in the humanistic nursing sense. Comfort in
this view is that which allows persons to be all that
they can be in particular lived situations. Theory
should offer nurses comfort in their everyday nursing. In other words, theory should offer nurses assistance to be all that they can be in their particular
lived nursing situations.
If I were asked to succinctly conceptualize humanistic nursing theory, I would have to say, call
and response.These three words encapsulate for me
the core themes of this quite elegant and very profound theory. In what follows, you will come to understand that through this paradigm, Josephine Paterson and Loretta Zderad have presented a vision of
nursing that withstands variation in practice settings
and the changing patterns of nursing over time.
According to Humanistic Nursing Theory, there is
a call from a person, a family, a community, or from
humanity for help with some health-related issue. A
nurse, a group of nurses, or the community of nurses
hearing and recognizing that call responds in a manner that is intended to help the caller with the
health-related need. What happens during this dia-
logue, the and in the call-and-response, the between, is nursing.

In their book Humanistic Nursing (1976), Drs.
Paterson and Zderad share with other nurses their
method for exploring the between, again emphasizing that it is the between that they conNurses respond to calls
ceive of as nursing. The
from a person, family, or method is phenomenocommunity, or from human- logical inquiry (Paterson & Zderad, 1976 p.
ity for help with a health- 72). Engaging in pherelated issue. The nursing nomenological inquiry
sensitizes the inquiring
is what happens in this nurse to the excitedialogue between the ment, fear, and uncertainty of approaching
nurse and the one being the nursing situation
helped. The nursing is the openly. Through a spirit
of receptivity, a readibetween.
ness for surprise, and
the courage to experience the unknown, there is an opportunity for
authentic relatedness and intersubjectivity. The process leads one naturally to repeated experiencing of
and reflective immersion in the lived phenomena
(Zderad, 1978, p. 8). This immersion into the intersubjective experience and the phenomenological
process that one engages in helps guide the nurse in
the responsive interchange between the patient and
the nurse. During this interchange the nurse calls
forth all that she is (education, skills, life experiences, etc.) and integrates it into her response. A
common misconception that some students of Humanistic Nursing Theory have is that it asserts that
the nurse must provide what it is that the patient is
calling for. Remember the response of the nurse is
guided by all that she is. This includes her professional role, ethics, and competencies. And so although a response may not actually provide what is
being called for, the process of being heard according to this theory is in itself a humanizing experience.
This explanation of Humanistic Nursing Theory
calls for elaboration of some of its basic concepts and
assumptions. Lets look at the conceptual framework
of Humanistic Nursing Theory represented in Figure
121.
Humanistic nursing is a moving process that occurs in the living context of human beings, human
beings who interface and interact with others and
other things in the world. This conceptual framework represents a nonlinear process that, over time,
spirals upward. This fluidity may be somewhat dis-
turbing to the beginning explorer of Humanistic

Nursing Theory. It is this fluidity, however, that,
once grasped, allows for the generalization to a diversity of practice settings.
In the world of Humanistic Nursing Theory the
human beings identified are the patient (i.e., person,
family, community, or humanity) and the nurse (Figure 122). A patient becomes identified as the patient when he sends a call for help with some healthrelated problem. The person hearing and recognizing
the call is the nurse. The nurse is another human being who by intentionally choosing to become a nurse
has made a commitment to help others in relation to
their health needs.
It is important to emphasize that the nurse and
the patient are both first human beings, or groups of
human beings, with their own particular gestalts
(Figure 123). Gestalt, representing all that those human beings are, includes all their past experiences,
all their current being, and all their hopes, dreams,
and fears of the future that are experienced in their
own space-time dimension. This includes the environmental resources available to them, factors that
have increasing import in times of fiscal constraints.
In sum, using a humanistic nursing term, they exist
all-at-once. In the context of nursing, when these
two human beings encounter and interact with each
other, that interaction centers on the call from one
person, the patient, for a helpful response from another person, the nurse. Although the call and response is between the nurse and the patient, it is important to understand that all else that makes the
individual person who he or she is enters in this interaction too.
This gestalt includes the patients past and current
social relationships, such as the experiences of gender, race, and religion, as well as education, work,
and whatever individualized patterns for coping with
the experience of living the person has developed. It
also includes past experiences with helpers in the
health-care system and the patients image and expectation of what it is that he or she is calling to the
nurse for. As incarnate human beings, we exist in this
particular space at this particular time, in a physical
body that senses, filters, and processes our experiences.
The nurse too brings all that she is. Her expectation is, however, that she be able to respond to the
call for help as a nurse. The nurse then interweaves
her professional identity and professional education,
with all her other life experiences to create her own
tapestry, which she projects through her nursing responses. One has only to observe nurses going about
their nursing to see how individualized the ex-
155
ell-being a
a rd w
nd
tow
mo
g
re
ir n
tu
be
ing
nu
r
HUMANISTIC NURSING
Gestalt
Incarnate
in time
and space
PATIENT
Call
well-being and
more-being
NURSE
Response
Gestalt
Incarnate
in time
and space
DIALOGUE
being and becoming

through intersubjective relating
(being with and doing with)
The Body Knows

(a being in a body)
gut feeling
Figure 121 World of others and things.
pressed dialogue with a particular patient can be. A

very simple example of this may be two nurses performing the same task of suctioning a patient. Depending on the nurse and the patient, I have seen
this done with tenderness, with humor, and with
masterful technical skills that make the procedure almost unnoticeable. I noticed one nurse who, each
time she positioned and suctioned the person she
was working with, made sure that she also repositioned the little basket of flowers that the nurse had
placed by the patients bedside. It is this individuality
as human beings that makes us alike and provides
156
one of the threads that unite us throughout this process of living. Being alike in our differences is only
one of those core threads, however, and in nursing,
humanistic theory attempts to uncover the other unifying threads or essences that make up the human
fabric of nursing. The nurse must always be aware
thatbecause in existential theory human beings become through the choices they make and the intersubjective experiences they engage inthe choice
to intersubjectively engage and the level of that intersubjective relating are mutually determined by the
patient and nurse.
Nursing Is Transactional
age
e im
nurs ctations ess
n
expe of being
state
nu
ex rse
sta pec im a
te tati ge
of on
be s
ing
ne
ss
CALL--AND----RESPONSE
PATIENT
d
ive
ex
ie
er
nc
NURSE
liv
ed
ex
pe
r
ien
ce
ente
r into
I need help
the e
xper
ienc
e of
the
I am prepared to give you help
patie
nt
educational preparation
professional development
nursing
expressed in
being with-----------doing with
(presence)
(procedures)
bridges or barriers
Figure 122 Shared human experience.
Philosophical and
Methodological Background
The phenomenological movement of the nineteenth
century was in response to what its proponents
called the dehumanization and objectification of the
world by the scientific community. Phenomenologists proposed that human beings, the world, and
their experiences of their world are inseparable. You
can easily see that a nursing theory that is based in
the human context lends itself to phenomenological
inquiry rather than reductionism, which attempts to
remove subjective humanness and strives to achieve
detached objectivity. The early phenomenologists
saw their goal as the examination and description of
all things, including the human experience of those
things, in the particular way that they reveal themselves without preconceived ideas or assumptions.
In the early 1960s Josephine Paterson and Loretta
Zderad gravitated toward this method to first examine their own nursing. Later they used this method
to work with other nurses in examining their nursing
practice to explicate its essences. Today, nursing

phenomenologists use variations of phenomenological methods to examine the experiential phenomena
of nursing.
There are people, however, who profess that phenomenology is not a philosophy but is at best a
methoda method developed by applying phenomenological concepts. In other words, phenomenology is the experience of a method that can be integrated into a general approach or way of viewing the
world. As I mentioned before, nurses who can relate
to this method are inclined to cultivate it and make it
a part of their everyday approach to nursing. This
method is no less rigorous in its application than the
method used in experimental research to build theories. The phenomenological approach is based on description, intuition, analysis, and synthesis. Intuitive
openness and accurate description require some aptitude for this conceptual framework. Of importance
are training and conscientious self-criticism on the
part of the unbiased inquirer as the inquirer investigates the phenomenon as it reveals itself. In phenom-
157
pa
st e
on
ati
xpe
c
du
e
rie
nce
sw
ith
he
lpe
,
race
der,
rs
io
relig
gen
interweaves
"all-at-once"
past experiences
his current being
soc
du
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oth
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im
ag
ea
nd
ex
pe
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fea
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pe
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Figure 123 Patient and nurse gestalts.
enology a statements validity is based on whether or

not it describes the phenomenon accurately. The
truth of all the premises resulting from the critical
analysis of each phenomenon described can be verified by examining the phenomenon itself.
Dr. Paterson and Dr. Zderad describe five phases
to their phenomenological study of nursing. These
phases are presented sequentially, but actually in this
process they are interwoven, because, as with all of
Humanistic Nursing Theory, there is a constant flow
between, in all directions, and all-at-once emanating
toward a center that is nursing. The phases of humanistic nursing inquiry are:
preparation of the nurse knower for coming to
know
nurse knowing the other intuitively
nurse knowing the other scientifically
nurse complementarily synthesizing known
others
succession within the nurse from the many to
the paradoxical one
158
Enfolded in these five phases are three concepts

that are very basic to Humanistic Nursing Theory.
They are bracketing, angular view, and noetic loci.
These will be taken up as we discuss the phases of
inquiry.
Preparation of the Nurse

Knower for Coming to Know
In the first phase the inquirer tries to open herself up
to the unknown and possibly different. She consciously and conscientiously struggles with understanding and identifying her own angular view. Angular view involves the gestalt of the human that we
spoke about earlier. It includes the conceptual and
experiential framework that we bring into any situation with us, a framework that is usually unexamined
and casually accepted as we negotiate our everyday
world. Angular view is not judged. It is a component
of the process and needs to be recognized as such.
Later in the process it is called upon to help make
sense of and give meaning to the experience of
inquiry.
your thoughts
By identifying our angular view we are then able to

purposefully bracket it so that we do not superimpose
it on the experience we are trying to relate to. When
we bracket, we purposefully hold our own thoughts,
experiences, and beliefs in abeyance. I reemphasize
that this abeyance does not deny our unique selves
but suspends them, allowing us to experience the
other in its own uniqueness. This is primary to phenomenological inquiry, which calls on us to see that
which the phenomenon reveals itself in itself to be.
By becoming aware of and acknowledging what
we think is true, we can then attempt to hold these
assumptions in abeyance, so that they will not prematurely intrude upon ones attempts to describe the
experiences of another. A personal experience that
helped me to grasp the concept of bracketing occurred a few years ago when I was traveling in Europe. As I entered each new country, I experienced
the excitement of the unknown. I realized at the
same time how alert, open, and other directed I was
in this uncharted world as compared to my own daily
routine at home. Here at times I would kind of fill
in the blanks left by my inattentiveness to a routine
experience, sometimes anticipating and answering
questions even before they were asked. This alertness, openness, and other directedness is the goal of
bracketing. According to Husserl (1970), who is considered the father of modern phenomenology, the
state desired is that of the perpetual beginner.
Bracketing prepares the inquirer to enter the uncharted world of the other without expectations and
preconceived ideas. It helps one to be open to the
authentic, in other words to the true experience of
the other. Even temporarily letting go of that which
shapes our own identity as the self, however, causes
anxiety, fear, and uncertainty. Labeling, diagnosing,
and routines add a necessary and very valuable predictability, sense of security, and means of conserving energy to our everyday existence and practice. It
may also make us less open, however, to the new
and different in a situation. Being open to the new
and different is a necessary stance in being able to
know of the other intuitively.
Nurse Knowing the Other Intuitively

Knowing the other intuitively is described by Dr. Paterson and Dr. Zderad as moving back and forth between the impressions the nurse becomes aware of
impressions the
nurse becomes
aware of in
herself
sudden
insights
a new
overall grasp
recollected
real experience
At this time the nurse's general impressions

are in a dialogue with her unbracketed view
Figure 124 Nurse knowing the other intuitively. Adapted
from illustration in Briggs, J., & Peat, D. (1989). Turbulent Mirror
(p. 176). New York: Harper & Row.
159
Standing outside the phenomenon, the nurse

examines it through analysis
and comes to know
Concepts from
written literature
evaluation
mulls over
Alternative
elements
Structure
Mental and
written
information
Model
relates
compares
Discrepancies
contrasts
interprets
nurse conscious of herself
Figure 125 Nurse knowing the other scientifically. Adapted from illustration in Briggs, J., & Peat, D. (1989). Turbulent Mirror
(p. 176). New York: Harper & Row.
in herself and the recollected real experience of the

other (1976, pp. 8889), which was obtained
through the unbiased being with the other. This process of bracketing versus intuiting is not contradictory. Both are necessary and interwoven parts of the
phenomenological process. The rigor and validity of
phenomenology are based on the ongoing referring
back to the phenomenon itself. It is conceptualized
as a dialectic between the impression and the real.
This shifting back and forth allows for sudden insights on the part of the nurse, a new overall grasp
which manifests itself in a clearer or perhaps a new
understanding of. These understandings generate
further development of the process. At this time the
nurses general impressions are in a dialogue with
her unbracketed view (Figure 124).
Nurse Knowing the Other Scientifically

In the next phase, objectivity is needed as the nurse
comes to know the other scientifically. Standing out-
160
side the phenomenon the nurse examines it through

analysis. She comes to know it through its parts of elements that are symbolic and known. This phase incorporates the nurses ability to be conscious of herself and that which she has taken in, merged with,
made part of herself. This is the time when the
nurse mulls over, analyzes, sorts out, compares, contrasts, relates, interprets, gives a name to, and categorizes (Paterson & Zderad, 1976, p. 79). Patterns
and themes are reflective of and rigorously validated
by the authentic experience (Figure 125).
Nurse Complementarily
Synthesizing Known Others
At this point the nurse personifies what has been described by Dr. Paterson and Dr. Zderad as a noetic
locus, a knowing place (1976, p. 43). According to
this concept, the greatest gift a human being can
have is the ability to relate to others, to wonder,
search, and imagine about experience, and to create
your thoughts
out of what has become known. The ability of nurses

to see themselves as knowing places encourages
them to continue to develop their community of
world thinkers through their educative processes,
which then become a part of their angular view. This
self-expansion, through the internalization of what
others have come to know, dynamically interrelates
with the nurses human capacity to be conscious of
her own lived experiences. Through this interrelationship the subjective and objective world of nursing can be reflected upon by each nurse, who is
aware of and values herself as a knowing place (Figure 126).
themselves and dialectically reflect on their relationship to the universe. This dialectic process has a pattern similar to that of the call and response paradigm
of Humanistic Nursing Theory. This paradigm speaks
to the interactive dialogue between two different human beings from which a unique yet universal instance of nursing emerges. The nursing interaction is
limited in time and space, but the internalization of
Dialectic
a new overall grasp
sudden insights
Succession within the Nurse

from the Many to the Paradoxical One
This is the birth of the new from the existing patterns, themes, and categories. It is in this phase that
the nurse comes up with a conception or abstraction that is inclusive of and beyond the multiplicities
and contradictions (Paterson & Zderad, 1976, p. 81),
in a process that corrects and expands her own angular view.
This is the pattern of the dialectic process, which
is reflected throughout Humanistic Nursing Theory.
In the dialectic process there is a repetitive pattern
of organizing the dissimilar into a higher level (Barnum, 1990, p. 44). At this higher level differences
are assimilated to create the new. This repetitive dialectic process of humanistic nursing is an approach
that feels comfortable and natural for those who
think inductively. For me, the pervasive theme of dialectic assimilation speaks to universal interrelatedness from the simplest to the most complex level.
Human beings by virtue of their ability to be selfobserving have the unique capacity to transcend
Synthesizes
objective
subjective
Noetic Loci
"knowing place"
Figure 126 Nurse complementarily synthesizing known others
161
that experience adds

something new to
persons struggling together each persons angular
view. Neither is the
toward a center. A distin- same as before. Each
guishing concept of this is more because of
that coming together.
theory is the obligation of The coming together
nurses to each other in of the nurse and the
patient, the between
community.
in the lived world, is
nursing. Just as in the
double helix of the DNA molecule, this interweaving
pattern is what structures the individual. In the fabric of Humanistic Nursing Theory this intentional interweaving between patient and nurse is what also
gives nursing its structure, form, and meaning.
Dr. Paterson and Dr. Zderad used this method of
phenomenological inquiry and dialectic synthesis in
workshops with other nurses. Over 2000 descriptions of nursing were written by more than 120
nurses who shared their lived world of nursing with
each other. From the analysis and synthesis of these
descriptions, 11 phenomena of nursing were generated. These are awareness, openness, empathy, caring, touching, understanding, responsibility, trust,
acceptance, self-recognition, and dialogue. These
phenomena were envisioned as the constants in the
ever-changing world of patient and nurse interaction.
Community is two or more
The Concept of Community

The definition of community presented by Drs. Paterson and Zderad is: Two or more persons struggling together toward a center (1976, p. 131). They
and the other nurses from their workshops were
very much a community, a community of nurses
struggling toward a center that is nursing. Just as in
any community there is the individual and the collective known as the community. Plato points to the
microcosm and the macrocosm and proposes that
the one is reflective of the many. In unification theories the emphasis is on recurrent patterns that given
enough distance would be found in all the universe.
Humanistic Nursing Theory can be considered both a
micro- and macrotheory in which the nursing interaction of one is considered to be a reflection of the
recurrent pattern of nursing and is therefore worth
reflecting upon and valuing. All nurses are members
of a community of nurses struggling toward a center
that is nursing through dialogue and interaction.
A distinguishing concept of Humanistic Nursing
Theory is an inherent obligation of nurses to each
other in this community. That which enhances one
162
of us, enhances all of us. Through openness, sharing,

and caring, we each will expand our angular views,
each becoming more than before. Subsequently we
take back into our nursing community these expanded selves, which in turn will touch our patients,
other colleagues, and the world of health care.
CLINICAL APPLICATIONS OF
HUMANISTIC NURSING THEORY
Nurses Reflection on Nursing
As an introduction to the clinical applications of Humanistic Nursing Theory, I will share with you two
explorations from Dr. Patersons and Dr. Zderads
nursing experiences. These descriptive explorations
are related to the concepts of empathy, comfort, and
presence. Dr. Paterson (1977, p. 13) shared her experiences with a terminally ill cancer patient. She describes: For a while I really beat on myself. I felt
nothing, just a kind of indifference and numbness, as
Dominic expressed his miseries, fears, and anger. I
pride myself on my empathic ability. I felt so inadequate. I could not believe I could not feel with him
what he was experiencing. Intellectually I knew his
words, his expressions were pain-filled. My feelings
of inadequacy, helplessness, and inability to control
myself, came through strong. [As] I mulled reflectively about this, suddenly a light dawned amidst my
puzzlement. I was experiencing what Dominic was
expressing. At this time I was feeling his inadequacy,
helplessness, and inability to control his cancer.
This insight brought a greater understanding between Dr. Paterson and this patient, an understanding that brought them closer so that she could endure with him in his fear-filled knowing and
unknowing of dying. As his condition deteriorated,
she continued to visit at his bedside. Often after
greeting me and saying what he needed he would fall
asleep. First, I thought, It doesnt matter whether I
come or not. Then I noticed and validated that when
I moved his eyes flew open. I reevaluated his sleeping during my visit. I discussed this with him. He felt
safe when I sat with him. He was exhausted, staying
awake, watching himself to be sure he did not die.
When I was there I watched him, and he could sleep.
I no longer made any move to leave before my time
with him was up. I told him of this intention, so that
he could relax more deeply. To alleviate aloneness;
this is a most expensive gift. To give this gift of time,
and presence in the patients space, a person has to
value, the outcomes of relating.
This gift of presence is poetically described by Dr.
Zderad (1978, p. 48):
Death lifts his scythe

to swipe down the young man
misdressed in hospital gown
displaced in hospital bed.
The cruel cold blade slashes
the hard mask of his nurse
silently standing there
bleeding forth her presence.
The beauty of the articulation of this essence is that
it encourages other nurses to reflect, value, and further communicate the essences of their practice.
And so Dr. Patersons and Dr. Zderads accounts
brought back to mind an experience of mine that
had stayed with me for years but that I had not truly
reflected upon until exposed to the process of humanistic nursing.
Years ago I worked on the night shift in the nursing home portion of a hospital center. One of the patients I worked with was Mrs. W., an 84-year-old
woman who had had a major stroke 2 years earlier,
as well as several serious infections during that time.
Mrs. W. was becoming increasingly compromised in
her ability to move and provide any of her own selfcare.
Some of the staff had difficulty with Mrs. W. and
described her as ornery, nasty, and demanding. She
was known to scratch and pull hair if she was displeased with the way she was being positioned during the night. She could speak, but would do so sparingly and seemed to be able to express herself best
with four letter words.
One night as I walked through the rooms checking on the patients at the beginning of the shift, I experienced something different immediately upon entering Mrs. W.s room. It was intuitive. I wasnt sure
what it was at first, but upon making eye contact
with her I again immediately felt a different sense of
connectedness between us. I walked closer and was
able to sense a welcoming engagement and a previously not present softness about her. I instinctively
touched her hand and she did not respond in her
usual combative manner, as somehow I knew she
wouldnt. I asked her how she was feeling, and with
a barely visible smile, she said softly, Oh, okay, but
do you think I could stay for awhile? I said, Of
course, you can stay as long as you like. I then told
her Id be back. I went to her chart and there was
nothing different noted, but there was something different. I went back and casually did her vital signs,
which were all within normal limits for her. There
seemed to be no physical indication that she was in
any distress. I knew something was happening,
though. I felt that she was getting ready to leave.
I made it a point to spend a lot of time with Mrs.

W. that night. Fortunately, it was not particularly
busy. She let me comb her hair and fuss with her a
bit. While I did this she pointed to the picture of her
family and for the first time shared some family stories with me. As I was leaving to go home, I stopped
in to say good-bye to Mrs. W. She put her hand on
mine and weakly smiled good-bye. And I knew we
were really saying good-bye for good. Something special had happened between us, so instead of feeling
bad, we both seemed to feel quietly good.
Mrs. W. died 2 hours later. It may seem bizarre,
but I smiled when I heard. I was glad that we had
spent so much time together the night before. I truly
believe that I helped Mrs. W. with her inevitable passage with my presence. I know she helped me to experience dying as something that at times is quietly
welcome by allowing me to be with her at the beginning of that passage.
Upon reflecting and trying to understand this experience of the patient, I have become better able to
share in the final journeys of others. By allowing me
to be with her in her experience, she has given me a
better understanding of how to offer comfort to
those who are dying. I thank her for our experience.
Patients Reflection on Nursing

It is of great interest to me when I come across reflections by patients of their experiences with
nurses. These reflective experiences also help to
clarify the essences of nursing. Two years ago I attended a conference on love, intimacy, and connectedness. It was an interdisciplinary conference attended by 300 to 400 people.
One of the opening speakers described the experience that had been related to him by a dear friend.
This experience related to his friend, who had just
been diagnosed with a serious form of cancer. The
speaker described his friend telling him, In the early
evening the family was all around. We talked, but
there was the awkwardness of not knowing what to
say or what to expect. Later that night, I was in my
room all alone. No longer having to be concerned
about my family and what they were struggling with,
I began to experience some of my own feelings. I felt
so alone. Then the evening nurse who had been
working with me over the last 2 days of testing came
in. We looked at each otherneither of us said a
word and she just gently touched my hand. I cried.
She stayed there for . . . I dont know how long, until
I placed my other hand on top of hers and gently
gave it a pat. She left, and I was able to go to sleep.
This was one of the most intimate moments in my
life. This nurse offered to be with me in the known,
163
and somehow she also conveyed a reassurance that I

did not have to go through what was coming, whatever that was, alone.
This ability to be with and endure with the patient in the process of living is frequently taken for
granted by us, yet it is what many times differentiates
us from other professionals. In my practice as nursing care coordinator I frequently engage in the phenomenological process of humanistic nursing to help
me in my everyday interactions. On one occasion the
department heads of the day hospital where I work
were talking about a program evaluation. This evaluation was partially a result of a study that the nurses of
the day hospital had done. I was proposing that it
was important to have patients share with us their
experience of the groups that they attended. One of
the doctors of the day hospital voiced his skepticism
that the patients input was actually necessary. He
said that, after all, he was aware of their pathology
and diagnosis. Based on this, he believed he could
judge the effectiveness of a group by using his clinical skills to assess changes in symptomatology. I took
exception to this and must admit I got a little hot under the collar. Upon reflecting on this experience,
however, I had an insight related to the angular view.
I realized that this doctor was coming from the angular view of medicine rather than the angular view of
nursing, which emphasizes that the patients views
and experiences are
The ability to be with a primary to the treatment process. I felt
patient in his or her promore tolerant of this
cess of living is often doctor at that point.
But more important, I
taken for granted in nurshad an experience of
ing, yet it may be what dif- the difference beferentiates nursing from tween doctoring and
nursing. Nurses must
other professions. recognize the difference, respect these
differences in the health-care field, and accept the responsibility of meeting the challenges to nursing that
those differences entail.
Uses of the Theory

in Clinical Supervision
In my clinical supervision with the nurses in the day
hospital I use the humanistic nursing approach. In
the process of supervision I try to understand the
call of the nurse when she brings up a clinical issue. This usually is connected to the call of the patient to her and some issue that has arisen around the
nurses not being able to hear or respond to that call.
164
An illustration of this can be seen in one of my

nurse supervising experiences. Ms. L. was working
with a patient who had recently been told that her
HIV test was positive. Although she did not have
AIDS, she had been exposed to the AIDS virus, probably through her current boyfriend, who was purportedly an IV drug abuser. The original issue that
came up was that the nurse was very concerned that
the doctor on the interdisciplinary team, who was
also the patients therapist, was not giving the patient the support that the nurse felt the patient was
calling out for. This nurse and I explored her perception that the patient did in fact seem to be reaching
out. The nurse and I explored the reaching out in
terms of what the patient was reaching for. It had
been carefully explained to the patient that she did
not have AIDS, but that at some point she might
come down with the illness. The patient was told
that there were treatments to retard the disease but
that there were no cures yet. Given this, the doctor,
whose primary function is treatment and cure, was
feeling ill prepared to deal with this patient and it
was perhaps this sense of inadequacy that fostered
avoidant behavior on his part. The nurse and I, however, came to understand that, in fact, the patient
was not calling for doctoring; she was calling for
nursing care. She was calling for someone to help
her get through this experience in her life. When this
was clarified, the nurse and I began to explore the
nurses experience of hearing this call. The nurse
spoke of the pain of knowing that this young woman
who was close to her own age would die prematurely. She spoke of how a friend, who reminded her
of this patient, had also died and that when she associated the two she felt sad. This nurse also had had
some difficult personal experiences that had elicited
a will to survive. By touching on these, she also
could relate to this patient.
As we explored what really was the nurses angular view, we were able to identify areas that were unknown. The nurse had difficulty understanding the
need or the role of the patients relationship with her
current boyfriend. We worked on helping the nurse
to bracket her own thoughts and judgements, so that
she could be open to the patients experience of this
relationship. Subsequently the nurse was able to understand the patients intense fear of being alone. As
the nurse began to understand that choices are humanizing, she began to explore the need for support
systems. In the experience of her own angular view,
as a part of her being her own knowing place, the
nurse realized that she herself had things to learn in
this area. And so to expand her own capability of being a knowing place and expanding her angular
view, she sought out the help of the nurse practitioner in our gynecology clinic. They worked well together with this patient, who eventually was able to
leave our day hospital, get a part-time job, and be all
that she could in her current life situation.
The nurse in the day hospital grew from her experience of working with this patient. Although she is
usually quite reserved and shies away from public forums, with encouragement she was able to share the
experience with this patient in a large public forum.
She not only shared with other professionals the role
that she as a nurse played in the treatment of this patient, she also acknowledged herself in a group of
professionals as a knowing place. As for me, I was
touched by this nurses experience of struggling
through this difficult situation to become more in
her nursing realm, and I became more because of
her growth.
Another example of the application of Humanistic
Nursing Theory in clinical practice involves a nurse
working with a patient diagnosed with chronic schizophrenia. The patient had experienced several severe psychotic breaks, with subsequent deterioration
in functioning. For certain patients with schizophrenia who experience this downward course, it is
heartbreaking to the patient and the family alike. In
my supervision with this nurse, it became clear that
she was struggling with the threatened decompensation of this patient each time discharge came near.
She felt frustrated and at first like the patient was failing. Later she began to see that it was the team that
was projecting their own sense of failure at not being
able to get the patient to follow through with their
discharge plan. By helping this nurse to relate and reflect upon her experience with this patient, she was
able to see that he was not noncompliant, one of our
favorite labels. When she was with the patient she
began to see how hard he really was trying. When
asked what she thought he might be calling to her
for in their interactions, she suddenly became aware
that he was looking for someone to acknowledge
how hard he was trying and that he didnt want to
disappoint anyone but it was the best he could do.
With this new understanding, the nurse became
aware of her need to validate to the patient that she
understood. Her further nursing action was to take
this information back to the team to help them recognize their own inability to deal with the patients
loss of functioning. For if they were unable to recognize it and deal with it, how could they help the patient to deal with it? Subsequently both the nurses
actions and the teams actions were more attuned to
the patients call rather than their own expectations
and needs. This affected not only the attitude of the
staff toward the patient but also permitted them to

make an appropriate discharge plan that the patient
could follow through with. This nurse had the experience of herself as a knowing place. She exerted
her influence with new confidence in her interactions with the team. I, as her supervisor, had a renewed experience in the validity of the process of
humanistic nursing.
Although the examples of clinical supervision I
have cited were in the psychiatric setting, I do believe using the process enfolded in humanistic nursing theory is beneficial to supervisors and self-reflective practitioners in all areas of nursing. Patients call
to us both verbally and nonverbally, with all sorts of
health-related needs. It is important to hear the calls
and know the process that lets us understand them.
In hearing the calls and searching our own experiences of who we are, our personal angular view, we
may progress as humanistic nurses.
Use of the Theory in Research

Shifting the application of the theory from the individual nurse to a community of nurses, I would like
to share with you a group research project that was
conducted in the clinical setting of a psychiatric day
hospital. In an effort to better understand why some
patients stayed in the day hospital and others left,
the nursing staff conducted a phenomenological
study that investigated the experiences of patients as
they enter and become engaged in treatment in a day
hospital system. The initial step in the process, in Dr.
Patersons and Dr. Zderads terms, is to prepare the
nurse knower for coming to know.
Part of the process of preparing the nurses for this
study was to expand their angular view by educating
them in the phenomenological method and the unstructured interview style. Literature was handed out
on this and meetings were held to discuss the articles
and any questions about them. We also shared our
feelings about this method, our concerns, and other
experiences related to this study. As we did this, we
began to establish an atmosphere of openness and
trust. This open atmosphere was essential to the
preparation for gathering descriptions of the patients experiences. In order to further promote the
openness of the interviewers to the experience of
the patients, we used our group nursing meetings for
the purpose of bracketing our angular views. In
these group meetings we raised our consciousness
through articulation of our own angular views. In addition, by opening ourselves to each others experiences and points of view, we were opening ourselves to the world of other possibilities and shaking
up the status quo of our own mind sets. Once the
165
descriptions were obtained, we as a group interpreted with the phenomenological method of reflecting, intuiting, analyzing, and synthesizing. We
interviewed 15 patients over a period of 8 months,
on their day of admission and every 4 weeks thereafter until discharge.
A brief example of the outcome of this study was
that we found from our interviews that there were
many anxiety-producing experiences on the first day
in the day hospital, but very few anxiety-reducing experiences that offered the patient comfort and support. The two patients who left the study at this time
found no anxiety-reducing experiences at all. Subsequently recommendations were made that were hypothesized to reduce the anxiety of the patient on
the first day. This is an example of how through this
method hypotheses are generated that can then be
tested in the scientific method.
The concept of research as praxis is also illustrated in this research project. On an individual basis
the nurses related that they experienced an increased awareness of the need to be open to the patients expressions of themselves. The nurses also
expressed that they now felt that they had an awareness of a comfortable method that would help them
with this openness, as well as a method for analyzing
the experience to gain a better understanding of the
phenomenon.
After reviewing the interviews of a patient who
had had a particularly difficult course of treatment,
one of the nurses who was on her treatment team remarked, We werent listening to what she was
telling uswe just didnt hear the pain. Another
nurse had a similar insight into a patients experiences. She noted with some surprise that her initial
impression that a patient she was working with
was hostile and withholding had given way to the
realization that this patientas a result of the negative symptoms of schizophreniawas quite empty
and was really giving us all that she had to give. In future interactions with this patient the nurse was empathic and supportive rather than judgmental and
angry.
Developing a Community of Nurses

Another group experience in which Humanistic
Nursing Theory was utilized was the formation of a
community of nurses who were mutually struggling
with changes in their nursing roles. You will recall
that the inner mandate of Humanistic Nursing
Theory is to share with, thereby allowing each to become more. You will also recall that when we spoke
of call, it was indicated that the call, in Humanistic
Nursing Theory terms, can be from an individual, a
166
family, a community, or humanity itself. In this instance I became aware of my own experiences as a
nursing care coordinator as I struggled with the
changes that were happening around me and how
these changes were impacting on me.
The nursing shortage, the increased salaries, even
government agencies were calling for nurses to be
proactive in the current health-care crises. In the report of the Secretary of Health and Human Services
Commission on Nursing (December, 1988) we were
told that the perspective and expertise of nurses are
a necessary adjunct to that of other health care professionals in the policy-making, and regulatory, and
standard setting process (p. 31). The challenge being posed to nurses is to help create the changes in
the health-care system today. The ability to initiate
and cause change is a definition of power (Miller,
1982, p. 2). To be asked to act and to be perceived in
a powerful way was a shift for us as nurses, who have
historically been reactive rather than proactive. In reflecting and analyzing my own experience of this
challenge, I identified some anxiety about this call
from the community at large. Recalling my past experience when I was anxious about trying the phenomenological method of inquiry, I identified that going
through the process with a group of nurses who
were experiencing the same newness was helpful. I
called to the community of nurses where I work, and
we joined together to struggle with this challenge.
For while the importance of organized nursing
power cannot be overemphasized, it is the individual
nurse in her day-to-day practice who can actualize or
undermine the power of the profession.
In settings such as hospitals the time pressure,
the unending tasks, the emotional strain, and the
conflicts do not allow nurses to relate, reflect, and
support each other in their struggle toward a center
that is nursing. This isolation and alienation does not
allow for the development of either a personal or
professional voice. Within our community of nurses
it became clear that developing individual voices was
clearly our first task. Talking and listening to each
other about our nursing worlds allowed us to become more articulate and clear about function and
value as nurses. The theme of developing an articulate voice has pervaded and continues to pervade
this group. There is an ever-increasing awareness of
both manner and language as we interact with each
other and those outside the group. The resolve for an
articulate voice is even more firm as members of the
group experience and share the empowering effect
it can have on both ones personal and professional
life. It has been said that [t]hose that express themselves unfold in health, beauty, and human potential.
your thoughts
They become unblocked channels through which

creativity can flow (Hills & Stone, 1976, p. 71).
Group members offered alternative approaches
to various situations that were utilized and subsequently brought back to the group. In this way each
member shared in the experience. That experience
therefore became available to all members as they individually formulated their own knowledge base and
expanded their angular view. As Dr. Paterson and Dr.
Zderad proposed, [E]ach person might be viewed as
a community of the beings with whom she has meaningfully related (1978, p. 45), and as a potential resource for expanding herself as a knowing place.
Through openness and sharing we were able to
differentiate our strengths. Once the members could
truly appreciate the unique competence of each
other they were able to reflect that appreciation
back. Through this reflection members began to internalize and then project a competent image of
themselves. They learned that this positive mirroring
did not have to come from outsiders. They can reflect
back to each other the image of competence and
power. They as a community of nurses can empower
each other. This reciprocity is a self-enhancing process, for the degree to which I can create relationships which facilitate the growth of others as separate
persons is a measure of the growth I have achieved in
myself (Rogers, 1976, p. 79). And so by sharing in
our community of nurses we can empower each
other through mutual confirmation as we help each
other move toward a center that is nursing. This is an
example of Martin Bubers basic human need (previously described but worth repeating), to be confirmed by others of their kind: [S]ecretly and bashfully [they] watch for a Yes which allows [them] to
be (1965, p. 71). We as nurses strive to do this with
our patients. We as nurses must also strive to do this

for each other and the profession of nursing.
The Call of Humanity

Today I perceive another call. This call is resounded
in and exemplified by the following description of
examining a pregnant woman: Instead of having to
approach the woman, to rest your head near her
belly, to smell her skin, to feel her breathing, you
could now read the information [on her and her fetus] from across the room, from down the hall
(Rothman, 1987, p. 28).
The call I hear is for nursing. It is the call from humanity to maintain the humanness in the health-care
system, which is becoming increasingly sophisticated
in technology, increasingly concerned with cost containment, and increasingly less aware of and concerned with the patient as a human being. The
context of Humanistic Nursing Theory is humans. The
basic question it asks of nursing practice is: Is this particular intersubjective-transactional nursing event humanizing or dehumanizing? Nurses as clinicians,
teachers, researchers, and administrators can use the
concepts and process of Humanistic Nursing Theory
to gain a better understanding of the calls we are
hearing. Through this understanding we are given direction for expanding ourselves as knowing places
so that we can fulfill our reason for being which, according to Humanistic Nursing Theory, is nurturing
the well-being and more-being of persons in need.
References
Barnum, B. J. S. (1990) .Nursing theory:Analysis, application, evaluation. Glenview, IL: Scott, Foresman Co.
167
Benner, P. (1984). From novice to expert. Menlo Park,

CA: Addison-Wesley.
Buber, M. (1965). The knowledge of man. New York:
Harper & Row.
Heidegger, M. (1977). The question concerning technology. New York: Harper & Row.
Hills, C., & Stone, R. B. (1976). Conduct your own
awareness sessions: 100 ways to enhance selfconcept in the classroom. Englewood Cliffs, NJ:
Prentice-Hall.
Husserl, L. (1970). The idea of phenomenology. The
Hague, Netherlands: Martinus Nijhoff.
Miller, J. B. (1982). Toward a new psychology of
woman. Boston: Beacon Press.
May, R. (1995). The courage to create. New York: Norton.
Parse, R. (1981). Man-living-health:A theory of nursing. New York: Wiley.
Paterson, J. G. (1977). Living until death, my perspective. Paper presented at the Syracuse Veterans Administration Hospital, New York.
168
Paterson, J. G., & Zderad, L. T. (1976). Humanistic

nursing. New York: Wiley.
nursing. New York: National League for Nursing.
Rogers, C. R. (1976). Perceiving, behaving, and
becoming: 100 ways to enhance self-concept in
the classroom. Englewood Cliffs, NJ: PrenticeHall.
Rothman, B. (1987). The tentative pregnancy: Prenatal
diagnosis and the future of motherhood. New
York: Penguin.
U.S. Public Health Services. (1988, December). Secretarys commission on nursing, final report. Washington, DC: Department of Health & Human Services.
Watson, J. (1988). Nursing: Human science and human care. New York: National League for Nursing.
Zderad, L. T. (1978). From here-and-now theory:
Reflections on how. In Theory development:
What? Why? How? New York: National League for
Nursing.
Section III
Nursing Theory in Nursing
Practice, Education, Research,
and Administration
Chapter 13
Dorothea E. Orem
The Self-Care Deficit
Nursing Theory
Views of Human Beings Specific to Nursing
References
Dorothea E. Orem
Part 1

Dorothea E. Orem is described as a pioneer in the development of distinctive nursing knowledge (Fawcett, 1995, p. 278). Orem contends that the term
care describes nursing in a most general way, but
does not describe nursing in a way that distinguishes
it from other forms of care (Orem, 1985). She argues
that nursing is distinguished from other human services and other forms of care by the way in which it
focuses on human beings. In the 1950s she had the
foresight to recognize the need to identify the proper
focus of nursing and to clarify the domain and
boundaries of nursing as a field of practice in order
to enhance nursings disciplinary evolution. She began her work by seekIt is nursings special focus ing an answer to the
question of what conon human beings that disditions exist in people
tinguishes or differentiates when judgements are
made about their need
it from other human
for nursing care. She
services. concluded that the human condition associated with the need for nursing is the existence of a
health-related limitation in the ability of persons to
provide for self the amount and quality of care required (Orem, 1985). This insight provided Orem
with an answer to the question, What is nursings
phenomenon of concern? She identified nursings
special concern as individuals needs for self-care and
their capabilities for meeting these needs.
172
Nursing-Specific Views
The powers and properties of human beings specific
to nursing are named in the Nursing Development
Conference Groups general concept of nursing systems presented in Table 131. They are further developed in Orems 1995 work and earlier expressions of
Self-Care Deficit Nursing Theory with its constituent
theories of self-care, self-care deficit, and nursing system. Without question it is individual human beings,
through the activation of their powers for resultseeking and result-producing endeavors, who generate the processes and systems of care named nursing.
Nursing science is knowing and seeking to extend
and deepen knowing of both the structure of the
processes of nursing and of the internal structure,
constitution, and nature of the powers and properties of individuals who require nursing and individuals who produce it. Harr (1970) identifies a theory
as a statement-picture complex that supplies an account of the constitution and behavior of those entities whose interactions with each other are responsible for the manifested patterns of behaviors. The
Nursing Development Conference Groups 1971
Theory of Nursing System and the general theory of
nursing named the Self-Care Deficit Nursing Theory
express both the nature of the entities and the interactions of the entities responsible for processes, the
patterns of behavior, known as nursing. Both theoretical expressions had their beginning in understandings of their formulators about the reasons why
individuals need and can be helped through nursing.
Such understanding marks the beginning of nursing
science.
It is posited that in valid general theories of nursing the named nursing-specific conceptualizations
Section III Nursing Theory in Nursing Practice, Education, Research, and Administration
are the human points of reference that reveal the human properties and powers, the entities investigated
in nursing science. For example, in Self-Care Deficit
Nursing Theory individuals throughout their life cycles are viewed as having a continuing demand for
engagement in self-care, in care of self; the constituent action components of the demand together
are named the therapeutic self-care demand. The
Theory of Self-Care (Orem, 1995) offers a theoretical
explanation of this continuing action demand. Individuals also are viewed as having the human power
(named self-care agency) to develop and exercise capabilities necessary for them to know and meet the
components of their therapeutic self-care demands.
Nursing is required when individuals developed and
operational powers and capabilities to know and
meet their own therapeutic self-care demands, in
whole or in part, in time-place frames of reference
(that is, their self-care agency), are not adequate
because of health state or health-care-related conditions.
The idea central to these nursing-specific views of
individuals is that mature human beings have learned
and continue to learn to meet some or all components of their own therapeutic self-care demands and
the therapeutic self-care demands of their dependents. Engagement of mature and maturing human
beings in self-care and dependent-care can be known
by others by observing their actions in time-place
frames of reference and securing subjective information about what is done and what is not done for self
and dependents including the rationales for what is
done or what is not done. Both kinds of care are
time-specific entities produced by individuals.
It is known that therapeutic self-care demands

and self-care agency vary qualitatively and quantitatively in time and over time for individuals. For this
reason they are identified in Self-Care Deficit Nursing
Theory as patient variables dealt with by nurses and
persons in need of nursing care within the processes
through which nursing is produced. As the values of
each vary, the relationship between them varies.
When, for health and health-care-associated reasons,
self-care agency of individuals is unequal in its development or operability for meeting their existent and
changing therapeutic self-care demand, a self-care
deficit exists (Orem, 1995). The real or potential existence of such a health-related deficit relationship
between the care demand and power of agency is
the reason why individuals require nursing care.
Self-Care Deficit Nursing Theory offers the explanation that both internal and external conditions
arising from or associated with health states of individuals can bring about action limitation of individuals to engage in care of self, for example, lack of
knowledge or developed skills, or lack of energy
(Orem, 1995). The presence and nature of such action limitations can set up action deficit relationships
between individuals developed and operational
powers of self-care agency and the kinds and frequencies of deliberate actions to be performed to
know and meet individuals therapeutic self-care demands in time and place frames of reference.
The critical power that is operative in nursing is
the power of nurses to design and produce nursing
care for others. This human power with its constituent capabilities and disposition is named nursing agency.The centrality of nursing agency as exer-
Chapter 13 Dorothea E. Orem The Self-Care Deficit Nursing Theory
173
cised by nurses in the production of nursing care is

made clear in the Nursing Development Conference
Groups concept of nursing system (see Table 131).
The identification and development of the power of
nurses to design and produce nursing care for others
are essential elements in any valid general theory of
nursing. The investigation of this power and the capabilities and conditions for its exercise are critical
components of nursing science.
Nurses must be knowledgeable about and skilled
in investigating and calculating individuals therapeutic self-care demands, in determining the degrees of
development and operability of self-care agency, and
in estimating persons potential for regulation of the
exercise or development of their powers of self-care
agency. Nurses capabilities extend to appropriately
helping individuals with health-associated self-care
deficits to know and meet with appropriate assistance the components of their therapeutic self-care
demands and to regulate the exercise and development of their powers of self-care agency. These outcomes of nursing are contributory to the life, health,
and well-being of individuals under the care of
nurses. Outcomes, of course, are related to the reasons why individuals require nursing care.
Self-Care Deficit Nursing Theory as it has been developed builds from expressed insights about the
powers and properties of persons who need nursing
care and those who produce it, to the nature and constitution of those properties, to the details of the
structure of the processes of providing nursing care
for individuals, and to the processes for providing
nursing care in multiperson situations, including family and community (Orem, 1995). These are developments of the professional-technological features of
nursing. In the initial and later stages of development
of this general theory of nursing developers formally
recognized that nursing is a triad of interrelated action systemsa professional-technical system, the
existence of which is dependent on the existence of
an interpersonal system, and a societal system that
establishes and legitimates the contractual relationship of nurses and persons who require nursing care.
Nursing students should be helped to understand
and recognize in concrete nursing practice situations
the tripartite features of nursing systems and the relationships between and among them. Theoretical
nursing science differentiates content that is specifically interpersonal from professional-technological
content and specifies content that establishes the
linkages between interpersonal and professionaltechnological features of nursing as well as content
that establishes the validity or lack of validity of a societal-contractual system.
174
Societal systems usually begin or are established

by specifying the contracting parties and their legitimate relationships. Initial relationships may or may
not endure or be legitimate throughout nursing practice situations. There may be or should be changes in
both nurses and persons contracting for the care.
The societal-contractual system legitimizes the interpersonal relationships of nurses and persons seeking
nursing and their next of kin or their legitimate
guardians. The interpersonal system is constituted
from series and sequences of interaction and communication among legitimate parties necessary for
the design and production of nursing in time-place
frames of reference. The professional-technological
nursing system is the system of action productive of
nursing. It is dependent upon the initial and continuing production of an effective interpersonal system.
Comprehensive general theories of nursing address what nurses do, why they do what they do,
who does what, and how they do what they do. A
valid general theory of nursing thus sets forth nursings professional-technological features specific to
the production of nursing. A general theory of nursing that addresses nursings professional-technological features provides points of articulation with interpersonal features of nursing and sets the standards
for safe, effective interpersonal systems. These features also point to the legitimacy of, or need for
change in, societal-contractual systems. For the initial expression of the tripartite nature of nursing systems within the frame of Self-Care Deficit Nursing
Theory, see the Nursing Development Conference
Groups (1979) development of a Triad of Systems.
Broader Views
Nursing-specific views of individuals fit within one
or more broader views of human beings. Consider,
for example, the conceptual element self-care agency
in Self-Care Deficit Nursing Theory.
Agency within this conceptual element is understood as the human power to deliberate about, make
decisions about, and deliberately engage in resultproducing actions or refrain from doing so. The selfcare portion of the conceptual element specifies that
agency in this context is specific to deliberating
about, making decisions about, and producing the
kind of care named self-care. Thus the concept and
the term self-care agency stand for a specialized
form of agency that demands the development of
specialized knowledge and action capabilities by humans. However, the power of self-care agency is necessarily attributed to human beings viewed as persons, for it is individuals as persons who investigate,
reason, decide, and act, exercising their human pow-
ers of agency. Thus the view of human beings as selfcare agents fits within the view of human beings as
persons. The general term attached to persons who
act deliberately to produce a foreseen result is the
term agent of action.Within the frame of reference
of Self-Care Deficit Nursing Theory, persons who deliberate about and engage in self-care are referred to
as self-care agents and their power to do so is
named self-care agency.The power of persons who
are nurses to produce nursing is named nursing
agency.
The idea is that the specialized powers and characteristic properties of human beings specified in
the conceptual elements of general nursing models
and theories are necessarily understood within the
context of broader views of human beings. Orem
(1995) and the Nursing Development Conference
Group (1979) suggest five broad views of human beings that are necessary for developing understanding
of the conceptual constructs of Self-Care Deficit
Nursing Theory and for understanding the interpersonal and societal aspects of nursing systems. The
five views are summarized as follows:
1. The view of person. Individual human beings are
viewed as embodied persons with inherent rights
that become sustained public rights who live in
coexistence with other persons. A mature human
being is at once a self and a person with a distinctive I and me: . . . with private, publicly
viable rights and able to possess changes and
pluralities without endangering his [or her]
constancy or unity (Weiss, 1980, p. 128).
2. The view of agent. Individual human beings are
viewed as persons who can bring about conditions that do not presently exist in humans or in
their environmental situations by deliberately acting using valid means or technologies to bring
about foreseen and desired results.
3. The view of user of symbols. Individual human
beings are viewed as persons who use symbols to
stand for things and attach meaning to them, to
formulate and express ideas, and to communicate
ideas and information to others through language
and other means of communication.
4. The view of organism. Individuals are viewed as
unitary living beings who grow and develop exhibiting biological characteristics of homo sapiens during known stages of the human life cycle.
5. The view of object. Individual human beings are
viewed as having the status of object subject to
physical forces whenever they are unable to act
to protect themselves against such forces. Inability of individuals to surmount physical forces
such as wind or forces of gravity can arise from

both the individual and prevailing environmental
conditions.
The person view is central to and an integrating
force for understanding and using the other four
views. All other views are subsumed by the person
view. The person view also is the view essential to
understanding nursing as a triad of action systems. It
is the view that nurses use (or should use) in all interpersonal contacts with individuals under nursing
care and with their family and friends.
The person-as-agent view is the essential operational view in understanding nursing. If there is nursing, nursing agency is developed and operational.
If there is self-care on the part of individuals, selfcare agency is developed and operational. The agent
view incorporates not only discrete deliberate actions to achieve foreseen results and the structure of
processes to do so but also the powers and capabilities of persons who are the agents or actors. The internal structure, the constitution, and the nature of
the powers of nursing agency and self-care agency
are content elements of nursing science. The structure of the processes of designing and producing
nursing and self-care is also nursing science content.
The view of person as user of symbols is essential
in understanding the nature of interpersonal systems
of interaction and communication between nurses
and persons who seek and receive nursing. The age
and developmental state, culture, and experiences of
persons receiving nursing care affect their use of
symbols and the meaning they attach to events internal and external to them. The ability of nurses to be
with and communicate effectively with persons receiving care and their families incorporates the use
of meaningful language and other forms of communication, knowledge of appropriate social-cultural
practices, and willingness to search out the meaning
of what persons receiving care are endeavoring to
communicate.
The user-of-symbol view is relevant to how persons who are nurses communicate with other nurses
and other health-care workers. Ideally, persons who
are nurses use the language of nursing and at the
same time understand and can use the language of
disciplines that articulate with nursing. The lack of a
nursing language has been a handicap in nurses
communications about nursing to the public as
well as to persons with whom they work in the
health field. There can be no nursing language until
the features of humankind specific to nursing are
conceptualized and named and their structure uncovered.
175
Men, women, and children are unitary beings.

They are embodied persons, and nurses must be
knowing about their biological and psychobiological
features. Viewing human beings as organisms brings
into focus the internal structure, the constitution
and nature of those human features that are the foci
of the life sciences. Knowing human beings as agents
or users of symbols has foundations in biology and
psychology. Understanding human organic functioning including its aberrations requires knowledge of
human physiology and environmental physiology as
well as pathology and other developed and developing sciences.
The object view of individual human beings is a
view taken by nurses whenever they provide nursing
for infants, young children, or adults unable to control their positions and movement in space and contend with physical forces in their environment. This
includes the lack of capabilities to ward off physical
force exerted against them by other human beings.
Taking the object view carries with it a requirement
for protective care of persons subject to such forces.
The features of protective care are understood in
terms of impending or existent environmental forces
and known incapacities of individuals to manage and
defend themselves in their environments, as well as
in the nursing-specific views of individuals that
nurses take in concrete nursing practice situations.
These five broad views of human beings not only
subsume nursing-specific views, they also aid in understanding them and in revealing their constitution
and nature. These broad views point to the sciences
and disciplines of knowledge that nurses must be
knowing in, and have some mastery of, in order to
be effective practitioners of nursing. Establishing the
linkages of nursing-specific views of human beings
to the named broader views is a task of nursing
scholars.
Throughout the processes of giving nursing care
to individuals or multiperson units, such as families,
nurses use changing combinations of the named
views of human beings in accord with presenting
conditions and circumstances. Nurses also may need
to help individuals under nursing care to take these
views about themselves. As previously stated, the
person view is the guiding force.
The five described views of individual human beings also come into play when persons who are
nurses think about and deal with themselves in nursing situations. They know that they have rights as
persons and as persons who are nurses and that they
must defend and safeguard these personal and professional rights; their powers of nursing agency must
be adequate to fulfill responsibilities to meet nursing
176
requirements of persons under their care; they must

know their deficiencies, act to overcome them, or
secure help to make up for them; they must be protective of their own biological well-being and act to
safeguard themselves from harmful environmental
forces. Nurses also have requirements for knowing
nursing and articulating fields in a dynamic way.
There is also a need for a nursing language that is enabling for thinking nursing within its domain and
boundaries and in its articulation with other disciplines and for communicating nursing to others in
nursing practice situations.
Model Building and Theory Development

The previously described nursing-specific views of
individual human beings are necessary for understanding and identifying (1) when and why individuals need and can be helped through nursing and (2)
the structure of the processes through which the
help needed is determined and produced. Nurses
continuing development of their knowing about the
person, agent, symbolist, organism, and object views
of individuals is essential continuing education for
themselves as persons who are nurses and nursing
scholars.
Such knowing is foundational to model making
and theory development in nursing. For example,
Louise Hartnett-Rauckhorst (1968) developed models to make explicit what is involved physiologically
and psychologically in voluntary, deliberate human
action, including motor behaviors. She moved from
available authoritative knowledge in the fields of
physiology, psychology, and the broad field of human behavior to develop:
1. A basic psychological model of action with three
submodels:
a. The personal frame of reference of the basic
psychologic model of action.
b. The veridical (coinciding with reality) frame of
reference of the basic psychologic model of action.
c. The sociocultural frame of reference of the basic psychologic model of action.
2. A physiologic model of action.
The Hartnett-Rauckhorst theoretical models set
forth structural features of the process of voluntary
human action (that is, deliberate action). These models develop the agent view; however, their structure
reflects the person, the user of symbols, and the
organism views of individual human beings (Nursing
Development Conference Group, 1979).
The study of these and other general theoretical
models of deliberate action stimulated some mem-
bers of the Nursing Development Conference Group

to investigate and formalize the conceptual structure
of self-care agency, conceptualizing it as the developed power to engage in a specific kind of deliberate
action. The goal of these efforts was the construction
of models to identify types of relevant information
and to aid in the development of techniques for collection and analysis of data about self-care agency. By
1979, the following theoretical models were developed:
1. A model of self-care operations, estimative, decision making, and productive operations and their
results.
2. A model of power components operationally involved with and enabling for performance of selfcare operations.
3. A model of human capabilities and dispositions
foundational for:
a. the development and operability of the power
components.
b. the performance of the self-care operations in
time and place frames of reference.
(Refer to Orem, 1995, for descriptions of these
models and highlights of their development.) The
three theoretical models descriptive and explanatory
of self-care agency when considered together in their
articulations constitute the elements for process
models of the operation of self-care agency, a process
with a specified structure. The first model, the selfcare operations model, is modeled on deliberate action. The power component model names specific
enabling capabilities necessary for performing each
of the named operations. Capabilities are powers
that can be developed or lost without a substantial
change in the possessor of the power. The foundational capabilities and dispositions model expresses
physiologically or psychologically described capabilities and dispositions that permit for or facilitate or
hinder persons performance of self-care operations
or the development or adequacy of the power components.
The nursing-specific view that each and every individual human being has a therapeutic self-care demand to be met continuously over time was conceptually developed through the construction of
theoretical models using the broad views of human
beings. Models of categories of constituent care requisites within the demand (universal, developmental, and health deviation types) were developed as
well as a model to show the constituent content elements of a therapeutic self-care demand and their derivation (Orem, 1995). A process model of the structural elements of an action system to meet a specific
self-care requisite particularized for an individual was

developed as an example of what actions must be
performed to meet each of the self-care requisites of
individuals.
These models express the content elements of
the conceptual entity therapeutic self-care demand.
The models also express the derivation of the content elements, the relationships among them, and
the regulatory results sought. The therapeutic selfcare demand models represent what is to be known
and met by individuals through their exercise of selfcare agency or met for them when required by reason of self-care agency limitations.
These examples of models demonstrate that nursing theorists and scholars involved in development
of Self-Care Deficit Nursing Theory used both nursing-specific and more general views of individual human beings in the processes of model building. The
examples also demonstrate that in model development theorists used knowledge from more than one
science or discipline of knowledge. The subjects of
the models, namely, nursing systems, deliberate action, self-care agency, and therapeutic self-care demand, also differed from the sources and content elements of the respective models.
The models are offered as a means toward understanding the reality of the named entities in concrete
nursing practice situations. Despite the diversity of
these models, they are all directed toward knowing
the structure of the processes that are operational or
become operational in the production of nursing systems, systems of care for individuals or for dependentcare units or multiperson units served by nurses.
For information about models and scientific
growth involving growth of knowledge in individual
scientists the reader is referred to Wallace (1983) and
Harr (1970). Blacks Models and Metaphors (1962)
was the source first used by the writer.
Conclusions
The use of specific views of human beings by nurses
or persons in other disciplines does not negate their
acceptance of the unity, the oneness of each individual man, woman, or child. In human sciences, specific views of human beings identify the domain and
boundaries of the science within the broad frames of
humanity and society. In nursing, for example, the
views of human beings expressed in Self-Care Deficit
Nursing Theory identified the proper object of nursing and were enabling for the development and
structuring of nursing knowledge.
Science, including models and theories, is about
existent entities. A valid comprehensive theory of
nursing has as its reality base individuals who need
177
and receive nursing care and those who produce it,

as well as the events of its production. Nursing does
exist in human societies. Nursing is something produced by human beings for other human beings
when known conditions and relationships prevail. It
is posited that the life experiences of nursing theorists, their observations and judgments about the
world of nurses, can and do result in insights about
nursing that can lead to descriptions and explanations of the human health-care service, nursing.
Nurses and nursing students who are confronted
with tasks of reviewing, studying, mastering, or taking positions about extant general models or theories
of nursing should look for and identify the view(s) of
human beings being expressed or implicit in them.
The adequacy of the theories should be explored.
Models and theories that purport to be general models of nursing can be adequate or deficient in their
scope as related to expressing why people need and
can be helped through nursing or in describing and
explaining the structure of nursing processes.
In any practice field a general model or theory incorporates not only the what and the why, but also
the who and the how. The adequacy of a general theory comes into question when there is omission of
any one of the named elements. The validity and
specificity of theories referred to as nursing theories
are in question when there is no reference to the human condition that gives rise to needs for nursing on
the part of individuals, to the presence and the powers of persons qualified as nurses, to the structure of
processes of production of nursing, and to the results sought.
What comes first, the view of humankind or the
view of nursing in the cognitional processes of theo-
178
rists, is a moot question. The writers position is that

a theorists life experiences in and accumulated
knowledge of nursing practice situations support the
recognition and naming of nursing-specific views of
human beings. Nursing-specific views of individual
human beings are differentiated from those general
views that are relevant to all the health services or
even to human existence. Such general views include the view of human beings as energy fields, or
as living health, as culture-oriented, or as caring beings. Such general views, however helpful in understanding humankind or in identifying approaches to
data collection, do not and cannot support viable
nursing science, theoretical and practical.
References
Black, M. (1962). Models and metaphors. Ithaca, NY:
Cornell University Press.
Harr, R. (1970). The principles of scientific thinking.
Chicago: University of Chicago Press.
Hartnett-Rauckhorst, L. (1968). Development of a theoretical model for the identification of nursing requirements in a selected aspect of self-care. Unpublished masters thesis, Catholic University of
America, Washington, DC.
Nursing Development Conference Group. (1979). Concept formalization in nursing: Process and product
(2nd ed., D. E. Orem, Ed.). Boston: Little, Brown.
Orem, D. E. (1995). Nursing: Concepts of practice. St.
Louis: Mosby-Year Book.
Wallace, W. A. (1983). From a realist point of view: Essays on the philosophy of science. Washington, DC:
University Press of America.
Weiss, P. (1980). You, I, and the others. Carbondale, IL:
Southern Illinois University Press.
Chapter 13
Part 2
Self-Care Deficit Nursing Theory:

Directions for Advancing Nursing
Science and Professional Practice
Summary
References
Marjorie A. Isenberg
Orems General Theory of Nursing

According to Orem (1985), it is the special focus on
human beings that distinguishes or differentiates
nursing from other human services. From this point
of view, the role of nursing in society is to enable individuals to develop and exercise their self-care abilities to the extent that they can provide for themselves the amount and quality of care required.
According to the theory, individuals whose requirements for self-care exceed their capabilities for engaging in self-care are said to be experiencing a selfcare deficit. Moreover, it is the presence of an
existing or potential self-care deficit that identifies
those persons in need of nursing. Thus, Orems SelfCare Deficit Nursing Theory explains when and why
nursing is required. Clearly, the work of this theorist
differentiates nursing as a discipline and provides a
basis for structuring nursing knowledge and nursing
practice.
Orem (1995) describes the Self-Care Deficit Nursing Theory as a general theory of nursing. General
theories of nursing are those that are applicable
across all practice situations in which persons are in
need of nursing care. As such, the Self-Care Deficit
Nursing Theory describes and explains the key concepts common to all nursing practice situations
(Orem, 1995, p. 167). The theory consists of four
concepts about persons under the care of nurses,
two nurse-related concepts, and three interrelated
theories: the Theory of Nursing Systems, the Theory
of Self-Care Deficit, and the Theory of Self-Care. Concepts in the general theory include: self-care, selfcare agency, therapeutic self-care demand, self-care
deficit, nursing agency, and nursing systems. The
theory describes and explains the relationship between the capabilities of individuals to engage in
self-care (self-care agency) and their requirements
for self-care (therapeutic self-care demand). The
term deficit refers to a particular relationship between self-care agency and self-care demand that is
said to exist when capabilities for engaging in selfcare are less than the demand for self-care.
Self-care is defined by Orem (1995, p. 104) as the
practice of activities that individuals initiate and perform on their own behalf in maintaining life, health,
and well-being. Meeting the self-care requisites (requirements) is identified as the purpose of self-care.
Self-care requisites are expressed by Orem (1995, p.
191) as actions to be performed by individuals that
are regulatory of human functioning and development. As one would expect in a general theory of
nursing, the concepts of the Self-Care Deficit Nursing Theory are developed comprehensively. The sub-
180
stantive structure of the self-care requisites provides

a good example of the scope of the theory. In the initial description of the requisites, only two categories
were identified: universal and health deviation
(Orem, 1971). Since the initial description of the
self-care requisites, Orem has expanded the categories to include developmental as well as universal
and health-deviation self-care requisites (1995, p.
192).
Meeting of the universal self-care requisites contributes to maintenance of human structure and
function, which, in turn, fosters positive health
and well-being (Orem,
1995, p. 192). Meeting Self-care is the practice of
of the developmental
self-care requisites pro- activities that individuals
motes human develop- initiate and perform on
ment and prevents or
overcomes conditions their own behalf in mainand situations encoun- taining life, health, and
tered throughout the
well-being.
life cycle that can adversely affect human
development (Orem, 1995, p. 197). Health-deviation
self-care requisites relate to the health states of individuals. According to the theory, health deviation
self-care requisites exist for persons who are ill or injured, have specific forms of pathology, have a predisposition to specific diseases, or are under medical
diagnosis and treatment (Orem, 1995, p. 201). Meeting of the health-deviation self-care requisites contributes to the goals of health maintenance, health
restoration, and the prevention of disease. As can be
seen from this description, the comprehensive development of the three types of self-care requisites enhances the usefulness of the Self-Care Deficit Nursing
Theory as a guide to nursing practice situations involving individuals across the life span who are experiencing health or illness, and nurse-client situations
aimed at health promotion, health restoration, or
health maintenance.
According to this theory, nurses use their specialized capabilities to create a helping system in situations where persons are deemed to have an existent
or potential self-care deficit. Three variations in nursing systems are described: wholly compensatory,
partly compensatory, and supportive-educative nursing systems (Orem, 1995, p. 309). Decisions about
what type of nursing system is appropriate in a given
nursing practice situation rests with the answer to
the question Who can and should perform the selfcare operations that require movement in space and
controlled manipulations? (Orem, 1995, p. 306).
When the answer to the question is the nurse, a
wholly compensatory
system of helping is apized capabilities to create propriate. When it is
concluded that the paa helping system in situa- tient can and should
tions where persons have perform all self-care actions, the nurse assumes
an existent or potential a supportive-educative
self-care deficit. role and designs a nursing system accordingly.
In each of the three nursing practice situations the
goal of nursing is to empower the person to meet
their self-care requirements by doing for (wholly
compensatory system), doing with (partly compensatory system), or developing agency (supportive-educative system). Clearly, these three variations in the
types of nursing systems to be employed in practice
situations enhances the breadth or scope of the SelfCare Deficit Nursing Theory.
Nurses use their special-
The Development of Nursing Science

This chapter focuses on the extent to which Orems
theory is offering direction to nurse scholars and scientists in advancing nursing science and professional
practice. Dorothy Johnson (1959), in her treatise on
the development of nursing theory, viewed this attribute of a theory as its value for the profession, its
social utility. The social utility of a theory is assessed
by the extent to which it provides clear direction for
nursing practice and research.
It is important to note that Dorothea Orems theory is offering clear direction to nurses in the advancement of nursing science in the new millennium. Recall that when she began her theoretical
work in the 1950s, Orems goal was to identify the
domain and boundaries of nursing as a field of
knowledge. She recognized the need to clarify the issue of what is it that nurses study in order for the discipline to evolve. Orem set forth the Self-Care Deficit
Nursing Theory as the foundation for the development of nursing science. Moreover, men, women,
and children who have existent or potential self-care
deficits are identified as the focus of inquiry of nurse
scientists (Orem, 1995, p. 167).
Orem describes nursing as a practical science that
is comprised of both theoretical and practical knowledge, a point of view that is grounded in modern realism (1995, p. 167). Parallels can be seen between
Orems description of nursing as a practical science
and Donaldson and Crowleys discussion of nursing
as a professional discipline. Recall that Donaldson
and Crowley (1978) stated that the aim of professional disciplines is to know and to use knowledge to
achieve the practical goal of the discipline. Both per-
spectives address the need for nurses to develop

both theoretical and practical knowledge.
A model comprised of five stages for development
of nursing science has been identified by Orem
(1995, p. 178). Each stage is intended to yield different kinds of knowledge about persons with existent
or potential health-related self-care deficits. Stage 1
and Stage 2 of this developmental schema for science
focus on the advancement of the theoretical component of nursing science. The theory is the result
of Stage 1. Stage 2 is described as the study of concurrent variations between the concepts proposed
within the Self-Care Deficit Nursing Theory (Orem
1995, p. 179) for the purpose of verifying and further explicating the propositions. Clearly, the propositions of the Self-Care Deficit Nursing Theory provide direction to nursing researchers who aim to
focus their inquiry in theory-based research.
Numerous examples of research illustrating scientific inquiry at the Stage 2 level of development can
be found in the nursing literature. The aspect of the
Self-Care Deficit Nursing Theory that has generated
the most research of this type is the relationship
posited between basic conditioning factors and selfcare agency. The basic conditioning factors were
identified initially by the Nursing Development Conference Group (1979) and were formalized later in a
proposition linking them to self-care agency. The second proposition listed in the Self-Care Deficit Theory
states that individuals abilities to engage in self-care
(self-care agency) are conditioned by age, developmental state, life experiences, sociocultural orientation, health, and available resources (Orem, 1995, p.
175). This proposition offers direction to nurses with
an interest in engaging in theory-based research.
Basic conditioning factors are defined as [c]onditions or events in a time-place matrix that affect the
value of persons abilities to care for themselves
(Orem, 1995). It is important to note that the influence of the basic conditioning factors on self-care
agency is not assumed to be operative at all times.
Nor are all the basic conditioning factors assumed to
be operative at all times. Because the influence of
these factors occurs within a time-place matrix, research is necessary to identify those nursing practice
situations in which the factors are operative and to
explain the nature of their influence on self-care
agency. Based upon research findings, relationships
between the basic conditioning factors and the substantive structure of self-care agency can then be
made explicit. Programs of research designed in this
way can verify the existence of linkages between
these concepts and can explain the nature of the
linkages. Scholarly work of this type is vital to the
Chapter 13 Marjorie A. Isenberg Self-Care Deficit Nursing Theory
181
advancement of the theoretical knowledge of nursing science.

Over the past decade, nurse researchers have
studied the influence of basic conditioning factors,
singularly and in combination, on individuals selfcare abilities. Foremost among the basic conditioning factors studied is health state. Several studies designed to determine the nature of the influence of
variations in health state on self-care abilities are reported in the research literature. Research suggests
that this relationship is particularly salient in practice
situations with persons experiencing chronic health
problems. The work of selected investigators is presented here to exemplify this line of inquiry. The influence of change in health state on the self-care abilities of persons with coronary artery disease has
been studied with both American and Dutch adult
patient populations (Isenberg et al., 1987, 1991).
Across these studies, changes in health state were
found to be critical determinants of the quality of the
self-care abilities of this patient population. As the
health state of patients improved as manifested by
absence of chest pain, so did their capabilities for
self-care. Conversely, self-care capabilities tended to
decline as patients experienced recurrence of chest
pain and declining health. The findings revealed a
positive relationship between health state and selfcare agency in patients with cardiac disease.
In addition to the study of variation in health state
due to pathophysiology, the conditioning influence
of health state on self-care agency has also been explored in situations in which the variation in health
state is due to psychopathology. West (1993) investigated the influence of clinical variations in the level
of depression, conceptualized as a health-state factor,
on the self-care abilities of young American women.
West (1993) reported that of the basic conditioning

factors studied, the level of depression (health state)
was the dominant predictor of the quality of the selfcare abilities of her sample. In a study with Dutch
psychiatric patients, Brouns (1991) also reported
that variations in mental health state significantly influenced patients self-care capabilities. In both studies a positive relationship between health state and
self-care agency was revealed. Higher levels of mental health were correlated with higher self-care
agency scores. These findings verified the conditioning influence of health state on the self-care agency
of patients experience variations in physical and
mental health. Moreover, the research findings clarified the nature of the influence of health state on
self-care agency.
The conditioning influence of other basic factors
on the self-care abilities of clinical and nonclinical
populations has been the focus of inquiry of several
nurse scholars. For example, Brugge (1981) studied
the influence of family as a social support system on
the self-care agency of adults with diabetes mellitus.
Vannoy (1989) explored the influence of basic conditioning factors on the self-care agency of persons enrolled in a weight-loss program. Schott-Baer (1989)
studied the influence of family variables and caregiver variables on the self-care abilities of the spouses
of patients with a diagnosis of cancer. Baker (1991)
explored the predictive effect of basic conditioning
factors on the self-care agency and self-care in adolescents with cystic fibrosis. McQuiston (1993) investigated the influence of basic conditioning factors on
the self-care capabilities of unmarried women at risk
for sexually transmitted disease. Horsburgh (1994)
conceptualized personality as a basic conditioning
factor and tested the model with a healthy popula-
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182
tion and a comparative clinical population with

chronic renal disease. Two personality factorsneuroticism and extroversionwere reported to have a
conditioning effect on self-care agency (Horsburgh,
1994). OConnor (1995) studied the influence of basic conditioning factors on the self-care abilities of a
healthy and clinical adult population enrolled in a
nurse-managed primary care clinic. In this study
health state, adult developmental status, and age
were found to be the strongest predictors of self-care
agency (OConnor, 1995). Baiardi (1997) explored
the influence of health state and caregiving factors
on the self-care agency of the caregivers of cognitively impaired elders. Health status of the caregiver
and the degree of burden associated with caregiving
were shown to influence the self-care abilities of the
caregivers (Baiardi, 1997).
Opportunities to test elements of the Self-Care
Deficit Nursing Theory have been greatly enhanced
by the measurement work with self-care concepts
that has transpired over the past 20 years. It is important to note that the theory-testing studies cited
above were made possible by the development and
psychometric testing of instruments to measure the
theoretical concepts. Instruments are currently available to measure the self-care agency of adolescent
populations (Denyes, 1982), adult populations (Evers
et al., 1993; Geden & Taylor, 1991; Hanson & Bickel,
1985), and elderly populations (Biggs, 1990). The
availability of valid and reliable measures of self-care
agency has been vital to the advancement of the theoretical component self-care nursing science.
In addition to the theory verification line of research, the Self-Care Deficit Nursing Theory is being
used to guide programs of research to identify the
self-care requisites and self-care behaviors of specific
clinical populations. Intervention studies designed
to enhance self-care performance are also under way.
The work of Marylin J. Dodd exemplifies this line of
inquiry. Since completing her dissertation in 1980,
Dodd has launched a program of research focused on
the self-care of cancer patients who were receiving
chemotherapy or radiation therapy. Her early descriptive studies clarified the health-deviation selfcare requisites of this population and documented
the therapeutic self-care demand (Dodd 1982, 1984).
More recent work described specific self-care behaviors initiated by patients receiving these therapies
and led to the identification of a patient profile of
self-care that can be used in practice to target specific patient groups who are in most need of nursing
interventions (Dodd, 1997). Dodds intervention
studies demonstrated that with targeted information,
patients can learn more about their treatment and
can perform more effective self-care behaviors (Dodd,

1997). Her work has advanced to the point of conducting randomized control trials to test a self-care
intervention called PRO-SELF to decrease chemotherapy-related morbidity (Dodd, 1997). Through
her 20-year program of descriptive, predictive, and
intervention studies based on self-care theory,
Dodds research has demonstrated how to enhance
patients knowledge of their treatment and how to increase effective self-care activities. Dodd clearly qualifies as a pioneer in self-care theory-based research.
Investigators have used Orems theory to identify
the self-care requisites and self-care capabilities of patients across a broad range of health deviations.
Based on the theory, Utz and Ramos (1993) have conducted a sequence of studies to explore and describe
the self-care needs of people with symptomatic mitral valve prolapse. The self-care capabilities and the
self-care needs (requisites) of persons with rheumatoid arthritis have also been described. The most frequently reported universal self-care requisites for
these clients were the maintenance of a balance between activity and rest, the promotion of normalcy,
and the prevention of hazards (Ailinger & Dear,
1997). Duration of illness (health state) and educational level were found to be related to self-care
agency (Ailinger & Dear, 1993). Aish (1993) tested
the effect of an Orem-based nursing intervention on
the nutritional self-care of myocardial infarction patients. A supportive-educative nursing system was reported to be effective in promoting healthy low-fat
eating behavior (Aish, 1993). Metcalfe (1996) studied the therapeutic self-care demand, self-care
agency, and the self-care actions of individuals with
chronic obstructive lung disease. Health state was
found to offer significant explanation of variations in
the self-care actions of this population. Based on the
universal, developmental, and health deviation selfcare requisites, Riley (1996) developed a tool to measure the performance and frequency of the self-care
actions of patients with chronic obstructive lung disease. This tool has the potential to be useful as an
outcome measure in future intervention studies designed to enhance the self-care abilities of this population.
Moore (1995) has used Self-Care Deficit Nursing
Theory as the basis for her program of research with
children. She has developed the Child and Adolescent Self-Care Practice Questionnaire, which can be
used to assess the self-care performance of children
and adolescents. In a study of children with cancer,
Mosher and Moore (1998) reported a significant relationship between self-concept and self-care. Children with higher self-concept scores were found to
183
perform more self-care activities than children with

low self-concept scores (Mosher & Moore, 1998).
The Cross-Cultural and International

Scope of Nursing Research
In contrast to these studies focused on clinical populations experiencing health-deviation self-care requisites, Hartwegs research centers on health promotion. Hartweg (1990) conceptualized health
promotion self-care within Orems Self-Care Deficit
Nursing Theory and went on to explore through a descriptive study the self-care actions performed by
healthy middle-aged women to promote well-being.
The women studied were able to identify over 8000
diverse self-care actions, the majority of which were
related to the universal self-care requisites (Hartweg,
1993). The interview guide used with this American
population has recently been validated with healthy,
middle-aged Mexican-American women in a comparative study (Hartweg & Berbiglia, 1996). Whetstone
(1987) and Whetstone and Hansson (1989) also
conducted cross-cultural comparative studies using
self-care concepts. They compared the meanings of
self-care among Americans, German, and Swedish
populations.
In addition to the cross-cultural comparative research, the Self-Care Deficit Nursing Theory is being
applied in studies with specific cultural groups. In an
ethnographic study based on concepts within
Orems theory, Villarruel (1995) explored the cultural meanings, expressions, self-care, and dependent care actions related to pain with a MexicanAmerican population and commented on the use of
the theory with this population. Dashiff (1992) applied Orems theory in her description of the selfcare capabilities of young African-American women
prior to menarche.
Nurse scientists beyond our national borders are
currently using Self-Care Deficit Nursing Theory as a
basis for their research. Professor Georges Evers at
the Catholic University of Leuven in Belgium has developed an extensive program of research based on
the theory. His program includes descriptive and
explanatory studies of the self-care requisites and
self-care capabilities of diverse clinical populations,
the development and psychometric testing of instruments to measure self-care concepts, and the testing
of interventions to enhance self-care performance
(Evers, 1998).
Orems theory is also being applied by Jaarsma
and colleagues as a basis for an ongoing program of
research with cardiac patients in the Netherlands.
Using a questionnaire derived from the self-care req-
184
uisites described in the Self-Care Deficit Nursing

Theory, Jaarsma et al. (1995) identified problems frequently encountered by cardiac patients in the early
recovery phase from coronary artery bypass surgery
or myocardial infarction. Factors influencing the selfcare agency of Dutch patients with coronary artery
disease are also being studied (Lukkarinen, 1997).
Hanucharurnkul (1989) used Orems theory as a
basis for her work with Thai patients who were receiving chemotherapy for the treatment of cancer.
She developed and tested a model to predict the selfcare behaviors of cancer patients. Similar to the early
work of Ream (1984), she conducted a descriptive
study of the self-care behaviors used by a population of British patients to cope with chemotherapyinduced fatigue.
The utility of Self-Care Deficit Nursing Theory beyond our national borders can be explained in part
by the fact that Orems intention was to develop a
general theory of nursing that would be useful in describing and explaining universal nursing knowledge. The applicability of the theory beyond Western
civilizations may be further explained by the inclusion of culture as a primary influence on peoples
care beliefs and practices. According to the theory,
self-care is described as learned behavior, and the
activities of self-care are learned according to the beliefs and practices that characterize the cultural way
of life of the group to which the individual belongs
(Orem, 1985). The individual first learns about cultural standards within the family. Thus, the self-care
practices that individuals employ should be understood and examined by nurses within the cultural
context of social groups and within the healthcare systems of societal groups. Clearly, the theory
provides a means to study the types of self-care
needs identified by specific cultural groups and the
acceptable cultural self-care practices to meet the
needs (Meleis, Isenberg, Koerner, Lacey, & Stern,
1995).
The Self-Care Deficit Nursing Theory is grounded
in the premise that individuals have the potential to
develop their intellectual and practical skills and the
motivation essential for self-care (Orem, 1995). The
goal of nursing within this perspective is to empower persons to meet their self-care needs by helping them to develop and exercise their self-care capabilities (agency). The theory offers direction in the
study of factors that condition the development, operability, and adequacy of individuals self-care capabilities and the quality of self-care performed. The inclusion of sociocultural orientation as one of the
conditioning factors enhances the generality of the
theory and in turn its global utility.
The book Nursing: Concepts of Practice has been

translated into Dutch, French, German, Italian, and
Spanish. Records cited in a CINAHL index search of
the nursing literature included publications describing the application of Self-Care Deficit Nursing
Theory in nursing situations in Australia, Belgium,
Denmark, Finland, GerThe use of Orems theory many, the Netherlands,
Norway, Portugal, Swebeyond national borders den, Switzerland, the
can be explained by the United Kingdom, Hong
Kong, Taiwan, Thailand,
fact that her intention was Turkey, Canada, Mexto develop a general theory ico, the United States,
and Puerto Rico. Culthat would be useful in de- tural groups are being
scribing universal nursing studied independently,
such as the work of
knowledge.
Villarruel (1995) and
Hartweg and Berbiglia
(1996) with Mexican-American populations or in
comparison with other groups (Van Achterberg et
al., 1991) to discover culturally specific self-care
abilities needs and practices. Both types of research
are currently under way on national and global
levels.
Over the past 15 years, the author has been privileged to be a part of an international network of
nurse scholars and scientists focused on the development of disciplinary knowledge derived from SelfCare Deficit Nursing Theory. Our collaborative work
began in 1983 when the author was invited as a consultant to the faculty of health sciences at the University of Maastricht in the Netherlands to assist faculty
and students in developing programs of nursing theory-based research. Initially, our work focused primarily on the teaching of nursing science seminars
for nurses throughout the Netherlands. In 1986, we
extended the seminars to include nurses from all
parts of Europe. Over the subsequent 5 years, approximately 200 nurses from 12 European countries
participated in the seminars. The participants studied the Self-Care Deficit Nursing Theory, research
methodology, and the interrelatedness of theory and
research. Each participant developed a self-care theory-based research project that could be implemented in his or her home settings.
Our first collaborative research project involved
the development of an instrument to measure
Orems theoretical concept of self-care agency. The
English and Dutch versions of the Appraisal of SelfCare Agency (ASA) Scale were the products of this
endeavor. The team that participated in the development and psychometric testing of the ASA Scale in-
cluded Professor Hans Philipsen, Professor Georges

Evers, Ger Brouns, Harrie Smeets, and the author.
Soon, nurse scientists from other countries (Canada,
Denmark, Finland, Norway, Sweden, Switzerland,
Thailand, and Mexico) joined the team with a desire
to translate the ASA Scale into their native language
and to validate the instrument within their culture.
To date the ASA Scale has been translated and validated for research use with populations in the following countries: Belgium, Denmark, Finland, Canada
(French-speaking), Germany, Norway, Sweden, Switzerland (German-speaking), Japan, Korea, Thailand,
Turkey, and Mexico.
This collaborative project provided the team with
the opportunity to identify universal nursing knowledge and, by means of transnational comparisons,
identify culture-specific knowledge. The current
shared programs of research focus on: (1) influences
of aging on the self-care abilities of Americans
(Jirovec & Kasno, 1990), Canadians (Ward-Griffin &
Bramwell, 1990), Danes (Lorensen, Holter, Evers,
Isenberg, & Van Achterberg, 1993), Dutch (Evers,
Isenberg, Philipsen, Senten, & Brouns, 1993), Finns
(Katainen, Merlainen, & Isenberg, 1993), Norwegians (Van Achterberg et al., 1991), and Swedes
(Soderhamn, Evers, & Hamrin, 1996); and (2) influence of chronic health problems such as coronary
artery disease on the self-care abilities of Americans
(Isenberg, 1987, 1993), Canadians (Aish & Isenberg,
1996), and Dutch clients (Isenberg, 1993; Isenberg,
Evers, & Brouns, 1987; Senten, Evers, Isenberg, &
Philipsen, 1991). Using the Mexican version of the
ASA Scale to measure self-care agency, Professor Esther Gallegos at the University of Nuevo Leon in
Monterrey, Mexico, recently completed a study of
the influence of social, family, and individual conditioning factors on the self-care abilities and practices
of Mexican women. The results of her study indicated that health state was the predominant predictor of womens self-care agency and self-care performance (Gallegos, 1997). The level of poverty
experienced by the Mexican women also had a significant influence on their self-care performance.
One of the challenges of international collaborative research deals with establishing sources for funding to carry out the scientific work. The research
work cited above was funded in part by a variety of
agencies: the Netherlands Heart Foundation, the
Swiss National Fund, Fulbright Scholarship, Finnish
Academy of Science, and the Kellogg Foundation.
Our collaborative work was further enhanced by the
generous support that each of us received from our
respective institutions: Wayne State University, United
States; University of Maastricht, the Netherlands;
185
Catholic University of Leuven, Belgium; University of

Oslo, Norway; University of Nuevo Leon, Mexico; St.
Gallen Hospital, Switzerland; and University of Kuopio, Finland.
To this network of nurse scientists, international
collaboration has provided an opportunity and a
means to pursue a shared vision and address a shared
challenge. By means of shared ideas, resources, research designs, and instruments, we are advancing
nursing science derived from Self-Care Deficit Nursing Theory. To date, specific propositions of the theory have been tested in nine countries. Through this
theory testing program of research, data are being accrued that will provide answers to the question To
what extent is Self-Care Deficit Nursing Theory relevant to the global community? The findings of the
transnational comparative studies are identifying universal elements of the theory and suggest that the
translated versions of the ASA Scale are cross-nationally valid.
Our experience supports the idea that the testing
of nursing theories in diverse countries by means of
collaborative international research programs is an
effective strategy for nurse scientists to face the challenge of developing globally relevant nursing science. The idea to organize a forum for self-care scientists and scholars originated with this group. In
1991, the International Orem Society for Nursing Science and Scholarship was founded. The mission of
the society is to advance nursing science and scholarship through the use of Dorothea E. Orems nursing
conceptualizations in nursing education, practice,
and research. The society publishes a quarterly
newsletter and cosponsors a Biennial International
Self-Care Conference with the University of Columbia, Missouri.
The Uses of Orems Theory in

Nursing Practice: An Overview
I chose to focus this chapter on the ways in which
the Self-Care Deficit Nursing Theory is guiding nursing research. This choice was made in full awareness
that the utility of the theory to nursing practice is
well-documented in the literature. However, it
would be remiss not to comment on the extensive
applications of the theory to nursing practice. Since
the pioneering efforts of Crews (1972) and Backscheider (1974) in the use of the theory in the structuring and organization of nursing care to patients in
nurse-managed clinics, nurse scholars have been proclaiming the usefulness of the theory as a guide to
practice. The theory has been used to guide practice
across a wide range of nursing situations in all types
of care settings, ranging from neonatal intensive care
units (Tolentino, 1990) to nursing home facilities
(Anna et al., 1978). The relevance of the theory to
the care of patients in intensive care units has also
been examined. Jacobs (1990) concluded that although most patients require wholly compensatory
systems of care, patient situations do exist in which
partly compensatory or supportive-educative systems of care are more appropriate. Orem-based nursing practice has been extensively described in the
care of patients of various ages with all kinds of
health-deviation self-care requisites and developmental requisites. For example, the theory has been applied to the long-term care of ambulatory adolescent
transplant recipients. Nursing services based on
Orems theory were found to enhance the quality of
life of this adolescent population significantly (Norris, 1991). Haas (1990) also reported on the usefulness of Self-Care Deficit Nursing Theory as a basis for
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186
nursing practice aimed at meeting the care demands

of children with long-term chronic health problems.
Clearly, the extent of the documentation of this work
far exceeds the scope of this chapter. Selected citations appear in the bibliography.
Summary
I began this chapter by describing Dorothea E.
Orems quest for understanding of the proper focus
of nursing. She contended that identification of nursings focus would enhance the productivity of nurse
scholars and scientists. She set forth the premise that
the Self-Care Deficit Nursing Theory was the foundation for developing nursing science, and then described her views of nursing science. The abundance
of Orem-based research documented in the literature
today speaks of the validity of her convictions and
the utility of the theory in guiding the research and
scholarship of nurses worldwide. Clearly, the SelfCare Deficit Nursing Theory is playing, and is expected to continue to play, a pivotal role in the advancement of nursing science and professional
practice.
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191
Chapter 14
Part 1
Martha E. Rogers
Science of Unitary Human Beings
The Science of Unitary Human Beings: Overview
Theories Identified by Rogers
Examples of Proposed Theories Being Developed by
Other Rogerian Scholars
Rogerian Science-based Practice and Research
References
Bibliography
Violet M. Malinski

Martha E. Rogers, one of nursings foremost scientists, was a staunch advocate for nursing as a basic science. She believed that the art of practice could be
developed only as the science of nursing evolved. A
common refrain throughout her career was the need
to differentiate skills, techniques, and ways of using
knowledge from the body of knowledge that guides
practice to promote health and well-being for humankind. The practice of nursing is not nursing.
Rather, it is the use of nursing knowledge for human
betterment (Rogers, 1994a, p. 34). Rogers identified
the unitary human being and the environment as the
central concern of nursing, rather than health and illness. She repeatedly emphasized the need for nursing
science to encompass beings in space as well as on
Earth. Who was this visionary who introduced a new
worldview to nursing?
Martha Elizabeth Rogers was born in Dallas,
Texas, on May 12, 1914, a birthday she shared with
Florence Nightingale. Her parents soon returned
home to Knoxville, Tennessee, where Martha and
her three siblings grew up, surrounded by a closeknit extended family of grandparents, aunts, uncles,
and cousins. She loved to read, and became a frequent visitor to the public library before age 6 (Hektor, 1989/1994). Rogers found ways to share what
she learned with others at an early age. Jane Rogers
Coleman, her youngest sister, recalled plays Martha
composed for her sisters and brother to act out for
different audiences, particularly one called Nutrition and Health (Malinski, 1994).
Rogers spent two years at the University of
Tennessee in Knoxville before entering the nursing
program at Knoxville General Hospital. Next, she attended George Peabody College in Nashville, Tennessee, where she earned her bachelor of science
degree in public health nursing, choosing that field
as her professional focus.
Rogers spent the next 13 years in rural public
health nursing in Michigan, Connecticut, and Arizona, where she established the first Visiting
Nurse Service in Phoenix, serving as its executive
director (Hektor, 1989/1994). Recognizing the need
for advanced education, she took a break during
this period and returned to academia, earning her
masters degree in nursing from Teachers College,
Columbia University, in the program developed by
another nurse theorist, Hildegard Peplau. In 1951
she returned to academia, this time earning a masters of public health and doctor of science degree
from Johns Hopkins University in Baltimore, Maryland.
194
In 1954 Rogers was appointed head of the Division of Nursing at New York University (NYU), beginning the second phase of her career overseeing
baccalaureate, masters, and doctoral programs in
nursing and developing the nursing science she
knew was integral to the knowledge base nurses
needed. She articulated the need for a valid baccalaureate education that would serve as the base
for graduate and doctoral studies in nursing. Such a
program, she believed, required 5 years of study in
theoretical content in nursing as well as liberal
arts and the biological, physical, and social sciences.
Under her leadership, NYU established such a program. At the doctoral level, Rogers opposed the
federally funded nurse-scientist doctoral programs
that prepared nurses in other disciplines rather
than in the science of nursing. During the 1960s she
successfully shifted the focus of doctoral research
from nurses and their functions to human beings in
mutual process with the environment. 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 a journal that was far ahead of its
time, Nursing Science, which offered content on
theory development and the emerging science of
nursing plus research and issues in education and
practice.
Rogers recognized the need to combine both professional and political activism. Throughout her career she participated in regional, state, national, and
international organizations, both nursing and nonnursing. She helped draft the revised Nurse Practice
Act in New York State, lobbied for its passage, and
participated in the nurses march on the state capitol in 1970 to urge its passage, which occurred in
1972.
Along with a number of nursing colleagues,
Rogers established the Society for Advancement in
Nursing in 1974. Among other issues, this group supported differentiation in education and practice for
professional and technical careers in nursing. They
drafted legislation to amend the Education Law in
New York State proposing licensure as an Independent Nurse (IN) for those who had a minimum of a
baccalaureate degree and introduced a new exam
and licensure as a Registered Nurse (RN) for those
with either a diploma or an associate degree in nursing who passed the traditional boards (Governing
Council of the Society for Advancement in Nursing,
1977/1994). Differentiation of practice according to
educational preparation remains a contentious issue
today.
Rogers is best remembered for the paradigm she

introduced to nursing, the Science of Unitary Human
Beings, which displays her visionary, future-oriented
perspective. Her theoretical ideas appeared in embryonic form in her two earlier books and were
fleshed out in the 1970 book, then revised and refined in a number of articles and book chapters written between 1980 and 1994. She helped create the
Society of Rogerian Scholars, Inc., chartered in New
York in 1988, as one avenue for furthering the development of this nursing science.
In her personal life Rogers was devoted to her extended family, who remember her as a treasured sister, aunt, and cousin who gave unstintingly of her
time and affection. Every summer Rogers returned
by car to her home in Phoenix, each time with assorted family members. They traveled the scenic
routes so Martha could introduce different nieces,
nephews, and cousins
The unique focus of to sites like the Grand
Canyon, Yellowstone,
nursing is the irreducible
and Lake Louise. She
human being and its gifted her nieces and
environment, both identi- nephews with books of
all genres and with trips
fied as energy fields. to Europe following
high school graduation.
In the words of one niece, the Reverend Nancy J.
Wilhite, Aunt Martha was the Auntie Mame of all her
nieces and nephews! (Malinski, 1994, p. 7).
Rogers died in 1994, leaving a rich legacy in her
writings on nursing science, the space age, research,
education, and professional/political issues in nursing. Readers interested in further information on her
life and reprints of her seminal works will find them
in Martha E. Rogers: Her Life and Her Work, edited
by Malinski and Barrett (1994).
THE SCIENCE OF UNITARY

HUMAN BEINGS: OVERVIEW
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 (1994a) identified the unique focus of
nursing as the irreducible human being and its environment, both identified as energy fields (p. 33).
Human encompasses both Homo sapiens and
Homo spatialis, the evolutionary transcendence of
humankind as we voyage into space, and environment encompasses outer space. This perspective ne-
cessitates a new worldview, out of which emerges

the Science of Unitary Human Beings, a pandimensional view of people and their world (Rogers,
1992/1994, p. 257).
Rogers Worldview
Rogers described the new worldview underpinning
her conceptual system to students and colleagues
beginning in 1968. It has been available in print
with some revisions in language since 1986 (Madrid
& Winstead-Fry, 1986; Malinski, 1986; Rogers, 1990a,
1990b, 1992, 1994a, 1994b). Rogers (1992) described the evolution from older to newer worldviews in such shifting perspectives as cell theory to
field theory, entropic to negentropic universe, three
dimensional to pandimensional, person-environment
as dichotomous 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 evolutionary emergent, and
In a universe of open
closed to open systems. She pointed out systems, energy fields are
that in a universe of
continuously open, infinite,
open systems, energy
fields are continuously and integral with each
open, infinite, and in- other.
tegral with each other.
Change that is predictable, brought about by a linear, causal chain of
events, gives way to change that is diverse, creative,
innovative, and unpredictable. In addition to her
own worldview as an example of this paradigm
change, Rogers (1992) identified other examples,
such as synthesis and holism, represented in the
works of people like Buckminster Fuller, James Lovelock, David Bohm, Fritjof Capra, and Rupert Sheldrake.
Rogers was aware that the world looks very different from the vantage point of the 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 people are not always fully aware that
these shifts have occurred or are in pro- The four fundamental poscess. She urged that
tulates of Rogerian nursing
nurses be visionary,
looking forward and science are energy fields,
not backward, not alopenness, pattern, and
lowing themselves to
become stuck in the pandimensionality.
present, in the details
Chapter 14 Martha E. Rogers Science of Unitary Human Beings
195
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, although traditional modalities of practice and methods of research
serve a purpose, they are inadequate for the newer
worldview, which urges nurses to use the knowledge
base of Rogerian nursing science creatively in order
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 postulates: energy fields, openness, pattern, and pandimensionality, formerly called both four-dimensionality and multidimensionality. In their irreducible unity
they form reality as experienced in this worldview.
Rogers (1990a, 1994a, 1994b) defined the energy
field as the fundamental unit of the living and the
non-living, noting that the energy field is infinite and
dynamic, meaning that it is continuously moving
and flowing (1990a, p. 7). She identified two energy
fields of concern to nurses, which are distinct but
not separate: the human field, or unitary human being; and the environmental field. The human field
can be conceptualized as one person or a group,
family, or community. The human and environmental
fields are irreducible; they cannot be broken down
into component parts or subsystems. Parts have no
meaning in unitary science. For example, the unitary
human is not described as a bio-psycho-sociocultural
or body-mind-spirit entity. Rogers interpreted such
designations as representative of current uses of
holistic, meaning a summation of parts to arrive at
the whole, where a nurse would assess the domains,
subsystems, or components identified, then synthesize the accumulated data to arrive at a picture of the
total person. Instead, Rogers maintained that each
field, human and environmetal, is identified by pattern, defined as the distinguishing characteristic of
an energy field perceived as a single wave (Rogers,
1990a, p. 7). Pattern manifestations and characteristics are specific to the whole.
Because human and environmental fields are integral with each other, they cannot be separated. They
are always in mutual process. A concept like adaptation, a change in one preceding change in another,
loses meaning in this nursing science. Change occurs simultaneously for human and environment.
The fields are pandimensional, defined as a nonlinear domain without spatial or temporal attributes
(Rogers, 1992, p. 28). Pandimensional reality tran-
196
scends traditional notions of space and time, which

can be understood as perceived boundaries only. Examples of pandimensionality include phenomena
commonly labeled paranormal that are, in Rogerian
nursing science, manifestations of the changing diversity of field patterning and examples of pandimensional awareness.
It is possible for people who are not in the same
room or in contact via phone with family members
to know suddenly that the latter are in trouble and
need help. It is not unusual to think of a friend, who
may live in another town, state, or country, decide to
call that person, and go to the phone only to have it
ring and hear that very friend on the other end.
The postulate of openness resonates throughout
the above 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 repeatedly emphasized that person and environment
are energy fieldsbut they do not have energy fields,
such as auras, surrounding them. In an open universe, there are multiple potentials and possibilities.
Nothing is predetermined or foreordained. Causality
breaks down, paving the way for a creative, unpredictable future. People experience their world in
multiple ways, evidenced by the diverse 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 characteristics of a
particular person are not characteristics of field patterning. Pattern manifestations reflect the humanenvironmental field mutual process as a unitary, irreducible whole. Person and environment cannot be
examined or understood as separate entities. Pattern
manifestations reveal the relative diversity, lower frequency, and higher frequency patterning of this 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 experienced as slower, faster,
and timelessness; pragmatic, imaginative, and visionary; and longer sleeping, longer waking, and beyond
waking. She explained seems continuous as a wave
frequency so rapid that the observer perceives it as a
single, unbroken event (Rogers, 1990a, p. 10). This
view of the ongoing process of change is captured in
Rogers Principles of Homeodynamics.
your thoughts
Principles of Homeodynamics
Like adaptation, homeostasismaintaining balance
or equilibriumis an outdated concept in the worldview represented in Rogerian nursing science.
Rogers chose homeodynamics to convey the dynamic, ever-changing nature of life and the world.
Her three principles of homeodynamicsresonancy,
helicy, and integralitydescribe the nature of
change in the human-environmental field process.
Resonancy specifies the continuous change from
lower to higher frequency wave patterns in human
and environmental fields (Rogers, 1990a, p. 9). Resonancy presents the way change occurs. Although
Rogers stated that this process is nonlinear, she was
unable to move away from the language of from
lower to higher in the principle itself that seems to
indicate a linear progression. Rogers (1990b, p. 10)
elaborated: [I]ndividuals experience lesser diversity
and greater diversity . . . time as slower, faster, or unmoving. Individuals are sometimes pragmatic, sometimes imaginative, and sometimes visionary. Individuals experience periods of longer sleeping, longer
waking, and periods of beyond waking.
Resonancy, then, specifies change flowing in
lower and higher frequencies that continually fluctuate, rather than flowing from lower to higher frequencies. Both lower and higher frequency awareness 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 theory. When the rhythmicities of lowerhigher frequencies work together, they yield innovative, diverse patterns.
Helicy is the continuous innovative, unpredictable, increasing diversity of human and environmental field patterns (Rogers, 1990a, p. 8). This principle describes the nature of change. Integrality is
continuous mutual human field and environmental
field process (Rogers, 1990a, p. 8). It specifies the
context of change as the integral human-environmental field process where person and environment are
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 (1990a, p. 9) believed that they serve as
guides both to the practice of nursing and to research in the science of nursing.
THEORIES IDENTIFIED BY ROGERS

Rogers clearly stated her belief that multiple theories
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. Nursing research uses it to illuminate the nature of the human-environmental field change process and its many unpredictable potentials.
The theory of accelerating evolution suggests that
the only norm is accelerating change. Higher frequency field patterns that manifest growing diversity
open the door to wider ranges of experiences and
behaviors, calling into question the very idea of
norms as guidelines. Human and environmental
197
field rhythms are speeding up. We experience faster

environmental motion now than ever before, in cars
and high-speed trains
Rogers clearly stated her and planes, for example. It is common for
belief that multiple theopeople to experience
ries can be derived from time as rapidly speeding by. People are livthe Science of Unitary Huing longer. Rather than
man Beings. viewing aging as a
process of decline or
a running down, as in an entropic worldview, this
theory views aging as a creative process whereby
field patterns show increasing diversity in such
manifestations as sleeping, waking, and dreaming.
Rogers hypothesized that hyperactive children provide a good example of speeded-up rhythms relative
to other children. They would be expected to show
indications of faster rhythms, increased motion, and
other behaviors indicative of this shift. She expected
that relative diversity would manifest in different patterns for individuals within any age cohort, concluding that chronological age is not a valid indicator of
change in this system: [I]n fact, as evolutionary diversity continues to accelerate, the range and variety
of differences between individuals also increase; the
more diverse field patterns evolve more rapidly than
the less diverse ones (Rogers, 1992, p. 30).
The theory of the emergence of paranormal phenomena suggests that experiences commonly labeled paranormal are actually manifestations of the
changing diversity and innovation of field patterning.
They are pandimensional forms of awareness, examples of pandimensional reality that manifest visionary, beyond waking potentials. Meditation, for example, transcends traditionally 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 experiences during
therapeutic touch, such as a visualization sharing
common features that evolves spontaneously for
both, a shared experience arising within the mutual
process both are experiencing, with neither able to
lay claim to it as a personal, private experience. Precognition, dj vu, and clairvoyance become normal
rather than paranormal experiences.
McEvoy (1990) hypothesized that the process of
dying exemplifies four-dimensional awareness and
thus encompasses paranormal events such as out-ofbody and apparitional experiences. She cited Margeneaus discussion in Science, Creativity, and Psi,
identifying paranormal experiences as ability to perceive within a four-dimensional world: It is our
human lot to look at the four-dimensional world
through a slit-like opening. . . . Whenever the slit
opens, and for some people the slit only opens at the
time of death, you see more than a segmented threedimensional slice of the four-dimensional universe
(cited in McEvoy, 1990, p. 211). Death itself is a transition, not an end, a manifestation of increasing diversity as energy fields transform.
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 diversity, including
the rhythms of motion, time experience, and sleeping-waking, encouraging others to suggest further
examples.
your thoughts
198
Barretts Theory of Power as Knowing

Participation in Change
Change is ongoing in Rogerian nursing science.
Rogers maintained that one cannot stop or start the
change process; it simply is. However, one is capable
of knowing participation in that change. Barrett
(1986, 1990) took that assumption and looked at
how people can change the nature of their participation in change. She developed both a theory of and a
tool to measure power as knowing participation in
change. Barrett (1990, p. 108) defined power as the
capacity to participate knowingly in the nature of
change characterizing the continuous patterning of
the human and environmental fields as manifested by
awareness, choices, freedom to act intentionally, and
involvement in creating change. She continued,
Power is being aware of what one is choosing to do,
feeling free to do it, and doing it intentionally. Depending on the nature of the awareness, the choices
one makes, and the freedom to act intentionally, the
range of situations in which one is involved in creating change varies (Barrett, 1986, p. 174). Rather
than good or bad power, more power or less power,
power is a lower and higher frequency phenomenon. Higher frequency power or knowing participation in change may be descriptive of the accelerating
change theorized by Rogers.
The power tool is one of the most widely used in
Rogerian sciencebased research to explore power
and variables such as leadership, human field motion, creativity, purpose in life, well-being, chronic
pain, reminiscence, empathy, feminism, and spirituality. Caroselli and Barrett (1998) and Barrett and
Caroselli (1998) have critically reviewed the research
literature and discussed methodological issues raised
and insights gained from this body of work.
EXAMPLES OF PROPOSED
THEORIES BEING DEVELOPED
BY OTHER ROGERIAN SCHOLARS
Theory of Perceived Dissonance
Bultemeier (1997) explored health concerns labeled
as abnormal or illness processes, offering a theoretical perspective for pattern appraisal of these field
manifestations. The inherent rhythmicity of fields
can evolve into rhythms that vary and may manifest
as discordant . . . perceived as nonharmonic and as
uncomfortable or unsettling to the person; thus the
person views himself/herself as out of harmony
or ill (Bultemeier, 1997, p. 158). She linked her
theory with Barretts and the steps of the health patterning process to show how nurses can use clients
perceptions and feelings to highlight areas of harmony and dissonance in pattern appraisal, then identify possible patterning activities such as meditation,
therapeutic touch, light and color, affirmations, and
humor.
The Theory of Sentience Evolution

Parker (1989) proposed this theory of sleeping, waking, and beyond waking, building on the concept of
sentience (the capability to think, feel, and perceive)
introduced by Rogers in her 1970 book. Although
Rogers dropped this concept in later writings, the
sleeping-waking-beyond waking manifestations of
change are well established. Parker proposed that beyond waking is sentience experienced as a higher
frequency phenomenon and that sentience evolution is thinking, feeling, and perceiving in the sleeping, waking, and beyond waking states (p. 5). Reiterating that this is a nonlinear process, Parker
suggested that changes in sleeping-waking-beyond
waking patterning occur continuously and change in
association with different life events and circumstances. Drawing on Barretts Power Theory, she proposed that this process involves and can be enhanced by knowing participation in change. She
used the example of sleep management to illustrate
the implications of this theory for practice. Nurses
would work with clients to describe sleep pattern
changes, dreams, out-of-body experiences, and other
manifestions of beyond waking experiences. Journaling, imagery, sleep hygiene, dietary changes, and the
alleviation of anxiety, stress, and depression become
alternatives to sedatives and hypnotics.
Theory of Healthiness
Leddy (Leddy & Fawcett, 1997) proposed that
greater perceived ease and expansiveness of humanenvironmental mutual process (participation) is associated with less perceived change, which, in turn, is
associated with greater perceived energy contributing to healthiness (p. 76). She defined healthiness as
characterized by purpose, the perception of being
energized by meaningful and significant goals, connections, perception of having rewarding mutual
process with others, and power to achieve goals (p.
77). She developed power along the dimensions of
challenge-curiosity, confidence-assurance, capacity,
choice-creativity, and capability. Leddy and Fawcett
present the conceptual and methodological problems associated with the proposed derivation of this
theory from Rogerian nursing science.
199
Enfolding Health-as-Wholenessand-Harmony
Carboni (1995a) synthesized concepts and principles from Rogerian nursing science and the holonomic (meaning whole) theory of physicist David
Bohm to derive a Rogerian practice theory whereby
nurse and client have the potential to participate
knowingly in evolutionary change for the betterment
of humankind. Carboni encapsulates this process as
the evolutionary movement of fragmentation and
disharmony to wholeness and harmony (p. 77),
which becomes the focus of knowing participation
in patterning for Rogerian nursing practice. Identifying the mutual human/environmental field pattern
involves changing configurations of lower frequency
and lesser complexification, such as a fragmenting
human fieldenvironmental field relationship, and
higher frequency and greater complexification such
as a healing human fieldenvironmental field relationship (p. 76). Awareness can manifest as unitary
knowing or fragmented knowing, action as unitary
or fragmented action. The field pattern of place can
reflect a healing place or a fragmented place. The nature of health and illness can reflect a pattern of
health-within-illness or disease. The purpose of nursing practice is coparticipation in the evolutionary
change of patterns of disease and fragmenting place
to new syntheses of patterns of health-within-illness
and healing place, perhaps involving such experiences as peace, sacredness, and belonging (p. 78).
ROGERIAN SCIENCE-BASED
PRACTICE AND RESEARCH
Practice
Rogers identified noninvasive modalities as the basis
for nursing practice now and in the future. She said
that nurses must use nursing knowledge in noninvasive ways in a diRogers stated that nurses rect effort to promote
well-being (Rogers,
must use knowledge in
1994a, p. 34). This fononinvasive ways in a cus gives nurses a cendirect effort to promote tral role in health care
rather than medical
well-being. care. She also noted
that health services
should be community-based, not hospital-based.
Hospitals are properly used to provide satellite services in specific instances of illness and trauma; they
do not provide health services. In a 1990 panel discussion among Rogers and five other theorists, she
200
maintained that [o]ur primary concern . . . is to focus on people wherever they are and to help them
get better, whatever that means. . . . Our job is better
health, and people do better making their own
choices. The best prognosis is for the individual who
is non-compliant (Randell, 1992, p. 181). In yet another panel discussion in 1991, she explained that
greater diversity necessitates services that are far
more individualized than we have ever provided
(Takahashi, 1992, p. 89), and went on to reiterate her
lack of support for nursing diagnosis.
Rogers consistently identified the need for individualized, community-based health services incorporating noninvasive modalities. She offered examples from those currently in use, such as therapeutic
touch, meditation, imagery, humor, and laughter,
while stating her belief that new ones will emerge
out of the evolution toward spacekind (Rogers,
1994b). The principles of homeodynamics provide a
way to understand the process of human-environmental change and, therefore, can serve as guidelines for developing nursing practice.
Multiple examples of practice based on Rogerian
nursing science exist in the literature. For example,
Morwessel (1994) and Tudor, Keegan-Jones, & Bens
(1994) presented the way they and their colleagues
implement Rogerian sciencebased nursing at the
Childrens Hospital Medical Center in Cincinnati,
Ohio. Heggie, Garon, Kodiath, and Kelly (1994) and
Woodward and Heggie (1997) discussed its use to
guide nursing practice at the San Diego Veterans Affairs Medical Center. Andersen and Smereck (1989,
1992) developed the Personalized Nursing LIGHT
Model for use with hard-to-reach clients, including
those actively involved in substance abuse and at risk
for AIDS/HIV.
Barrett (1988, 1990) developed a blueprint for
Rogerian-based practice designed to assist clients
with knowing participation in change, calling it
health patterning.The first phase, pattern manifestion knowing, involves the continuous process of
identifying manifestations of the human and environmental fields that relate to current health events
(Barrett, 1988, p. 50; Barrett, 1998). The second,
voluntary mutual patterning, is the process whereby
the nurse with the client patterns the environmental
field to promote harmony related to health events
(Barrett, 1988, p. 50; Barrett, 1998). The nurse assists clients to knowingly participate in their own
well-being. One health-patterning modality Barrett
(1992) specifically developed to assist in this process
is a particular form of imageryinnovative imagery
where the content reflects this power theory and
thus the Science of Unitary Human Beings.
your thoughts
Cowling (1990, 1997) has offered a template of

unitary pattern appreciation to guide both practice
and research. Pattern information derived from a persons experiences, perceptions, and expressions is
used to compose a pattern appreciation profile. This
is a coparticipatory process involving nurse and
client. The client provides information in various
forms that may involve speaking, journaling, music,
art, poetry, photographs, and audio and/or visual recordings. The nurse records the process in journal
forms such as reflective notes, theoretical and/or
methodological notes, and peer review notes. The
synthesized pattern profile is verified by the client
and used by the nurse to suggest and reflect on
possibilities for facilitating change, with the client
appraising and reflecting on how these potential
strategies fit or do not fit with personal experiences.
Cowling describes pattern appreciation as a transformative process, both in offering clients a context for
new awareness and in helping them access the infinite potentials for change inherent in pandimensionality. He also describes how his pattern appreciation
fits with Barretts pattern appraisal and deliberative
mutual patterning (Cowling, 1990).
Research
Rogers maintained that both qualitative and quantitative methods were appropriate for Rogerian science
based research, with the nature of the question and
the phenomena under investigation guiding the selection. However, she cautioned that neither is totally adequate for the new worldview and encouraged the development of new methods.
Pattern manifestations have provided a common
research focus, highlighting the need for tools by
which they can be measured. The earliest such tool,
developed by Ference (1986) in her 1979 dissertation, is the Human Field Motion Tool, a semantic differential scale rating two concepts, my motor is running and my field expansion.
Barrett (1986, 1990) developed the next tool in
her 1983 dissertation. The Power as Knowing Participation in Change Tool (PKPCT) uses the semantic differential technique to rate the four concepts of her
power theoryawareness, choices, freedom Rogers noted that qualito act intentionally, and
involvement in creat- tative and quantitative
ing changes.
research methods were
Paletta (1990) developed the Temporal appropriate for Rogerian
Experience Scales us- nursing science, depending metaphors to capture the experiences ing on the nature of the
of time dragging, time question and the phenomracing, and timelessena under investigation.
ness. Johnston (1994;
Watson et al., 1997)
developed the Human Field Image Metaphor Scale to
measure awareness of the infinite wholeness of the
human field. Gueldner (cited in Watson et al., 1997)
developed the Index of Field Energy, composed of
18 pairs of line drawings judged to represent low and
high frequency descriptions of a concept. Respondents indicate how they feel now along a 7-point
scale. Hastings-Tolsmas (Watson et al., 1997) Diversity of Human Field Pattern Scale explores diverse
pattern changes and personal preferences for participation in change. Watsons (Watson et al., 1997)
Assessment of Dream Experience Scale explores
dreaming as a beyond-waking experience. Leddy
(1995) developed the Person-Environment Parti-
201
cipation Scale and the Leddy Healthiness Scale

(1996).
Carboni (1992) developed an interview guide designed to reflect the mutuality of the nurse-client
relationship as well as the unitary nature of the
human-environment patterning process. The Mutual
Exploration of the Healing Human FieldEnvironmental Field Relationship asks for narrative descriptions of this relationship, including thoughts and
feelings as well as any spiritual qualities that surfaced
for the participants. Each is asked to express the relationship metaphorically, artistically, and through
evocative words such as flowing, peace, partnership, harmonize, or healing. Together, nurse and
client explore their perceptions of the relationship.
Two examples of new research methods developed in Rogerian nursing science come from
Butcher and Carboni. Butcher (1994, 1998) created
the Unitary Field Pattern Portrait research method, a
new qualitative research method that assists in illuminating well-being from a unitary perspective. Carboni (1995b) developed a qualitative Rogerian process of inquiry to explore the enfolding-unfolding
change of human-environmental field patterning.
Currently researchers are using Rogerian tools
such as those described in multiple investigations,
while other tools are in various stages of development. Innovative potentials for promoting the wellbeing of people and their environment emerge daily
as nurses apply the knowledge gained through Rogerian nursing science. Rogers challenge has been eagerly taken up by a community of committed scholars.
The Science of Unitary Human Beings reflects
Rogers optimism and hope for the future. She envisioned humankind poised on the threshold of a fantastic and unimagined future (Rogers, 1992, p. 33),
looking toward space while simultaneously engaging
in a transformative Rogerian revolution in health care
on Earth. One manifestation will surely be the establishment of autonomous Rogerian nursing centers
here on Earth and ultimately in space.
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Chapter 14
Part 2
Nursing Science
in the New Millennium:
Practice and Research
within Rogers Science
of Unitary Human Beings
Rogerian Practice Models
Research within the Science of Unitary Human Beings
Summary
References
Howard K. Butcher
Nursing practice and research guided by nursing theory distinguishes nursing care from other healthcare disciplines. Because nursing theory is the scientific core of the nursing discipline, nursing theory
needs to: (1) be integrated into all aspects of nursing
education; (2) serve as the conceptual guide for
nursing practice; and 3) function as the conceptual
orientation of nursing research. Rogers (1970, 1980,
1988, 1992) Science of Unitary Human Beings is a
major conceptual system unique to nursing that offers nurses a radically new way of viewing persons
and their universe concordant with the most contemporary emerging scientific theories describing a
worldview of wholeness (Bohm, 1980; Briggs &
Peat, 1984; Capra, 1982; Lovelock, 1979; Sheldrake,
1988; Woodhouse, 1996). New worldviews require
new ways of thinking, sciencing, languaging, and
practicing. Rogers nursing science postulates a pandimensional universe of mutually processing human
and environmental energy fields manifesting as continuously innovative, increasingly diverse, creative,
and unpredictable unitary field patterns.
A hallmark of a maturing scientific practice discipline is the development of specific practice and research methods evolving from the disciplines extant
conceptual systems. Over the past decade, practice
and research methods have been derived from specific nursing concepNew worldviews require tual systems. Rogers
(1992) asserted that
new ways of thinking, practice and research
sciencing, languaging, and methods must be consistent with the Scipracticing. ence of Unitary Human Beings in order to
study irreducible human beings in mutual process
with a pandimensional universe. Therefore, Rogerian
practice and research methods must be congruent
with Rogers postulates and principles if they are to
be consistent with Rogerian science. The purpose of
this chapter is to present recent innovations in the development of practice and research methods derived
from Rogers postulates and principles.
ROGERIAN PRACTICE MODELS

Nursing exists as a human service. 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 practicethe art
of nursingis the application of substantive scientific knowledge developed through research. Since
the 1960s, the nursing process has been the dominant nursing practice method. The nursing process is
206
an appropriate practice methodology for many nursing theories, including Roys Adaptation Model,
Kings Theory of Goal Attainment, and Orems
Theory of Self-Care Deficit. However, there has been
some confusion in the nursing literature concerning
the use of the nursing
process within Rogers Nursing exists as a human
Nursing Science.
service; practice methods
In early writings,
Rogers (1970) did make have been derived from
reference to nursing
Rogers postulates and
process and nursing
diagnosis. But in later principles.
years she asserted that
nursing diagnoses were not consistent with her scientific system. Rogers (quoted in Smith, 1988, p. 83)
stated:
[N]ursing diagnosis is a static term that is quite
inappropriate for a dynamic system . . . it
[nursing diagnosis] is an outdated part of an
old worldview, and I think by the turn of the
century, there is going to be new ways of organizing knowledge.
Furthermore, nursing diagnoses are particularistic
and reductionistic labels describing cause and effect
(i.e., related to) relationships inconsistent 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 pandimensional view of reality. In addition,
the term intervention is not consistent with Rogerian science. Intervention means to come, appear,
or lie between two things (American Heritage Dictionary, 1992, p. 944). The principle of integrality describes the human and environmental field as integral and in mutual process. Energy fields are open,
infinite, dynamic, and constantly changing. The human and environmental fields are inseparable, so one
cannot come between. The nurse and the client are
already inseparable and interconnected. Outcomes
are also inconsistent with Rogers principle of helicy:
that 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 (Butcher, 1997).
Given the inconsistency of the traditional nursing
process with Rogers postulates and principles, the
Science of Unitary Human Beings requires the development of new and innovative practice methods derived from and consistent with the conceptual system. Over the last decade, a number of practice
methods have been derived from Rogers postulates

and principles.
Barretts Rogerian Practice

Methodology for Health Patterning
Barretts two-phase Rogerian practice methodology
for health patterning is the accepted alternative to
the nursing process for Rogerian practice and is currently the most widely used Rogerian practice
model. Barretts (1988) practice model was derived
from the Science of Unitary Human Beings and consisted of two phases: pattern manifestation appraisal
and deliberative mutual patterning. Barrett (1998)
expanded and updated the methodology by refining
each of the phases, now more appropriately referred
to as processes. Each of the processes have also
been renamed for greater clarity and precision. Pattern manifestation knowing is the continuous process of apprehending the human and environmental
field (Barrett, 1998). Appraisal means to estimate an
amount or to judge the value of something, negating
the egalitarian position of the nurse, whereas knowing means to recognize the nature, achieve an understanding, or become familiar or acquainted with
something. Voluntary mutual patterning is the continuous process whereby the nurse assists clients in
freely choosingwith awarenessways to participate in their well-being (Barrett, 1998). The change
to the term voluntary emphasizes freedom, spontaneity, and choice of action. The nurse does not invest in changing the client in a particular direction,
but rather facilitates and mutually explores with the
client options and choices, and provides information
and resources so the client can make informed decisions regarding his or her health and well-being.
Thus, clients feel free to choose with awareness how
they want to participate in their own change process.
The two processes are continuous and nonlinear,
and therefore not necessarily sequential. Patterning
is continuous and occurs simultaneously with knowing. Control and predictability are not consistent with
Rogers postulate of pandimensionality and principles
of integrality and helicy. Rather, acausality allows for
freedom of choice, and means outcomes are unpredictable. The goal of voluntary mutual patterning is
the actualization of potentialities for well-being
through knowing participation in change.
Cowlings Pattern
Appreciation Practice Method
Cowling (1990) expanded Barretts original practice
methodology by proposing a template comprising
ten constituents for the development of Rogerian
practice models consistent with the postulates and

principles of Rogerian science. Cowling (1993b,
1997) refined the template and proposed that pattern appreciation was a method for unitary knowing
in both Rogerian nursing research and practice.
Cowling preferred the term appreciation rather
than assessment or appraisal because appraisal is
associated with evaluation. Appreciation has broader
meaning, which includes being full aware or sensitive to or realizing; being thankful or grateful for; and
enjoying or understanding critically or emotionally
(Cowling, 1997, p. 130). Pattern appreciation is approached with gratefulness, enjoyment, and understanding and reaches for the essence of pattern. Pattern appreciation has a potential for deeper
understanding.
The first constituent for unitary pattern appreciation identifies the human energy field emerging from
the human/environment mutual process as the basic
referent. Pattern manifestations emerging from the
human/environment mutual process are the focus
of nursing care. Next, the persons experiences, perceptions, and expressions are unitary manifestations
of pattern and provide a focus for pattern appreciation. Third, pattern appreciation requires an inclusive perspective of what counts as pattern information (energetic manifestations) (Cowling, 1993b,
p. 202). Thus, any information gathered from and
about the client, family, or community, including
sensory information, feelings, thoughts, values, introspective insights, intuitive apprehensions, lab values, and physiological measures, are viewed as energetic manifestations emerging from the human/
environmental mutual field process.
The fourth constituent is that the nurse uses
pandimensional modes of awareness when appreciating pattern information. In other words, intuition,
tacit knowing, and other forms of awareness beyond
the five senses are ways of apprehending manifestations of pattern. Fifth, all pattern information has
meaning only when conceptualized and interpreted
within a unitary context. Synopsis and synthesis are
requisites to unitary knowing. Synopsis is a process
of deliberately viewing together all aspects of a human experience (Cowling, 1997). Interpreting pattern information within a unitary perspective means
that all phenomena and events are related nonlinearly. Also, phenomena and events are not discrete or
separate but rather coevolve together in mutual process. Furthermore, all pattern information is a reflection of the human/environment mutual field process.
The human and environmental fields are inseparable.
Thus, any information from the client is also a reflection of his or her environment. Physiological and
Chapter 14 Howard K. Butcher Nursing Science in the New Millennium
207
your thoughts
other reductionistic measures have new meaning

when interpreted within a unitary context. For example, a blood pressure interpreted within a unitary
context means the blood pressure is a manifestation
of pattern emerging from the entire human/environmental field mutual process rather than simply a
physiological measure. Thus, any expression from
the client is unitary and not particular by reflecting
the unitary field from which it emanates (Cowling,
1993b).
The sixth constituent in Cowlings practice
method describes the format for documenting and
presenting pattern information. Rather than stating
nursing diagnoses and reporting assessment data in
a format that is particularistic and reductionistic by
dividing the data into categories or parts, the nurse
constructs a pattern profile. Usually the pattern profile is in the form of a narrative summarizing the
clients experiences, perceptions, and expression inferred from the pattern appreciation process. The
pattern profile tells the story of the clients situation
and should be expressed in as many of the clients
own words as possible. Relevant particularistic data
such as physiological data interpreted within a unitary context may be included in the pattern profile.
Cowling (1990, 1993b) also identified additional
forms of pattern profiles, including single words or
phrases; and listing pattern information, diagrams,
pictures, photographs, or metaphors that are meaningful in conveying the themes and essence of the
pattern information.
Seventh, the primary source for verifying pattern
appreciation and profile is the client. Verifying can
occur by sharing the pattern profile with the client
for revision and confirmation. During verification,
the nurse also discusses options, mutually identifies
208
goals, and plans mutual patterning strategies. Sharing the pattern profile with the client enhances participation in the planning of care and facilitates the
clients knowing participation in the change process
(Cowling, 1997).
The eighth constituent identifies knowing participation in change as the foundation for health patterning. Knowing participation in change is being aware
of what one is choosing to do, feeling free to do it,
doing it intentionally, and being actively involved in
the change process. The purpose of health patterning is to assist clients in knowing participation in
change (Barrett, 1988). Ninth, pattern appreciation
incorporates the concepts and principles of unitary
science, and approaches for health patterning are determined by the client. Last, knowledge derived
from pattern appreciation reflects the unique patterning of the client (Cowling, 1997).
Toward a Synthesis
of Rogerian Practice Models
Butcher (1993, 1997), and Martin, Forchuk, Santopinto, and Butcher (1992) synthesized Cowlings
Rogerian practice model with Barretts practice
methodology to develop an inclusive and comprehensive Rogerian practice model. The more detailed
model presented below incorporates both Barretts
and Cowlings recent refinements and clarifications.
In addition, in an ethical analysis of Rogers life and
science, Butcher (1999) identified a constellation of
values intrinsic to the Science of Unitary Human Beings and asserted that Rogerian practice also includes
making the following cherished values of Rogerian
ethics intentional in the mutual patterning process:
reverence, human betterment, generosity, commit-
ment, diversity, responsibility, compassion, wisdom,

justice-creating, openness, courage, optimism, humor, unity, transformation, and celebration.
The focus of nursing care guided by Rogers nursing science is on recognizing manifestations of patterning through pattern manifestation knowing
and appreciation, and facilitating the clients ability
to participate knowingly in change, harmonizing
person/environment integrality, and promoting healing potentialities and well-being using noninvasive
modalities through voluntary mutual patterning.
Pattern Manifestation Knowing

and Appreciation
Pattern manifestation knowing and appreciation is
the process of identifying manifestations of patterning emerging from the human/environmental field
mutual process and involves focusing on the clients
experiences, perceptions, and expressions. Knowing refers to apprehending pattern manifestations
(Barrett, 1988), whereas appreciation seeks for a
perception of the full force of pattern (Cowling,
1997). Appreciation requires sensitivity, recognition
of the excellence of the meaning of energy field patterning, and is approached with gratefulness, enjoyment, and understanding. Appreciation is reaching
for the essence of pattern and has the potential to
deepen understanding in the service to the clients
process of knowing participation in change and
transformation (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
co-equal participants.
Pattern is the distinguish- Clients may be persons,
families, and/or coming feature of the human/ munities. Intentionality
environmental field. The is expressed by approaching nursing situfocus of nursing is on recations with the intent
ognizing manifestations of to facilitate human betterment guided by a scipatterning through knowentific base for practice
ing and appreciation. and a commitment to
enhance the clients potentionalities for well-being. It is also important to
create an atmosphere of openness and freedom so
clients can freely participate in the process of knowing participation in change. Approaching the nursing
situation with an appreciation of the uniqueness of
each person, unconditional love, compassion, and
empathy can help create an atmosphere of openness

and healing patterning.
Pattern manifestation knowing and appreciation
involves focusing on the experiences, perceptions,
and expressions of a health situation, 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 dialogue is guided toward focusing on
uncovering the clients 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 expressing (Cowling,
1993a). Experience involves the rawness of living
through sensing and being aware as a source of
knowledge and includes any item or ingredient the
client senses (Cowling, 1997). The clients own observations and description of his or her health situation includes his or her experiences. Perceiving is
the apprehending of experience or the ability to reflect while experiencing (Cowling, 1993a, p. 202).
Perception is making sense of the experience
through awareness, apprehension, observation, and
interpreting. Asking clients about their concerns,
fears, 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 pattern. Body language, communication patterns, gait, behaviors, lab values, and vital
signs are examples of energetic manifestations of human/environmental field patterning.
Throughout pattern manifestation knowing and
appreciating, the nurse is open to and uses multiple
forms of knowing, including pandimensional modes
of awareness (intuition, meditative insights, tacit
knowing). Since all information about the client/environment/health situation is relevant, various health
assessment tools such as the comprehensive holistic
assessment tool developed by Dossey, Keegan,
Guzzetta, and Kolkmeirer (1995) 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 manifestations
of pattern emerging from a pandimensional human/environment mutual process. All information is
interconnected, inseparable from environmental
context, unfolds rhythmically and acausally, and reflects the whole. Data are not divided or understood
by dividing information into physical, psychological,
209
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.
More importantly, a unitary perspective in nursing practice leads to an appreciation of new kinds of
information that may not be considered within other
conceptual approaches to nursing practice. For example, pattern information concerning time perception, sense of rhythm or movement, sense of connectedness with the environment, ideas of ones
own personal myth, and sense of integrity are relevant indicators of human/environment/health potentialities (Madrid & Winstead-Fry, 1986). A persons
hopes and dreams, communication patterns, sleeprest rhythms, comfort-discomfort, waking-beyond
waking experiences, and degree of knowing participation in change provide important information regarding each clients thoughts and feelings concerning a health situation.
The nurse can also use a number of tools derived
from Rogers postulates and principles to enhance
the collecting and understanding of relevant information specific to Rogerian science. Barrett (1989) developed the Power as Knowing Participation in
Change Tool (PKPCT) as a way of knowing the
clients energy field pattern in relation to his or her
capacity to knowingly participate in the continuous
patterning of human and environmental fields as
manifested in frequencies of awareness, choicemaking ability, sense of freedom to act intentionally,
and degree of involvement in creating change. A
score on each of the four scales is an indicator of human/environmental field patterning in relation to the
clients sense of how he or she is participating in his
or her own change process. The Hastings-Tolsma
Diversity of Human Field Pattern Scale (HastingsTolsma, 1992) may be used as a means of knowing
and appreciating clients perceptions of the diversity
of their energy field patterns, and Johnsons Human
Image Metaphor Scale (Johnson, 1994) can be used
as a way of knowing and appreciating the clients
perceptions of the wholeness of their energy fields.
Watsons Assessment of Dream Experience Scale
(Watson, 1993) can be used to know and appreciate
each clients dream experiences and Ferences Human Field Motion Tool (Ference, 1979) is an indicator of the wave frequency pattern of the energy field.
Paletta (1990) developed a tool consistent with
Rogerian science that measures the subjective awareness of temporal experience. Leddys (1995) PersonEnvironment Participation Scale may be used to
know and appreciate expansiveness and ease of a
persons participation in the human/environment/
210
health process. Disturbances are energy field patterning and may manifest as a low score in either
power, human field motion, diversity of pattern, or
human field image.
When initial pattern manifestation knowing and
appreciation is complete, the nurse synthesizes all
the pattern information into a meaningful pattern
profile. Usually the pattern profile will be in the
form of a narrative that describes the essence of the
properties, features, and
qualities of the human/ Middle-range Rogerian
environment/health situation. The pattern pro- practice theories are
file reflects the essence useful for pattern maniof the clients experifestation knowing and
ences, perceptions, and
expressions, and, in ad- appreciation, and voluntary
dition to a narrative
mutual patterning
form, the pattern profile may also include di- processes.
agrams, poems, listings,
phrases, and/or metaphors. Interpretations of any
measurement 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 patterning is to facilitate
each clients ability to participate knowingly in
change, harmonize person/environment integrality,
and promote healing potentialities, lifestyle changes,
and well-being in the clients desired direction of
change or 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. The
process is voluntary and intentional in that the nurse
approaches each nursing situation with the intention of promoting well-being and human betterment.
Intentionality is an active process of desiring action
and is the volitional propagation of energy. Action is
a process of movement or transformation of energy
(Butcher, 1998a). 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 pattern profile with
the client is a means of validating 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
your thoughts
pattern recognition and also may enhance the

clients knowing participation in his or her own
change process. An increased awareness of ones
own pattern may offer new insight and increase
ones desire to participate in the change process. In
addition, the nurse and client can continue to mutually explore goals, options, choices, and voluntary
mutual patterning strategies as a means to facilitate
the clients actualization of his or her human/environmental field potentials.
A wide variety of mutual patterning strategies
may be used in Rogerian practice, including many
interventions identified in the Nursing Intervention
Classification (McCloskey & Bulechek, 1996). However, interventions are reconceptualized within a
unitary perspective as voluntary mutual patterning
strategies. Furthermore, Rogers (1988, 1992, 1994)
placed great emphasis on modalities that are traditionally viewed as holistic and noninvasive. In particular, therapeutic touch, guided imagery, and the use
of humor, sound, dialogue, affirmations, music, 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. 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
literature (Barrett, 1990; Madrid, 1997; Madrid &
Barrett, 1994) and in the holistic nursing practice literature (Dossey, 1997; Dossey, Keegan, Guzzetta, &
Kolkmeirer, 1995; Guzzetta, 1998). Evaluation is
continuous and is integral both to pattern manifesta-
tion knowing and appreciation and to voluntary mutual patterning. The nurse is continuously evaluating
changes in patterning emerging from the human/
environmental field mutual process. Regardless of
which combination of voluntary patterning strategies is used, the intention is for clients to actualize
their potentials related to human well-being and betterment.
Selected Mid-range
Rogerian Practice Theories
In addition to the processes of the practice model, a
number of mid-range Rogerian practice theories have
been developed that are useful in informing the pattern manifestation knowing and appreciation and
voluntary mutual patterning processes. Nursing science is advanced when mid-range theory development evolves from nursings conceptual models.
Each of the selected mid-range Rogerian practice
theories is briefly described below.
Theory of Power as Knowing

Participation in Change
Barretts (1989) Theory of Power as Knowing Participation in Change was derived directly from Rogers
postulates and principles and interweaves awareness, choices, freedom to act intentionally, and involvement in creating changes. Power is a natural
continuous theme in the flow of life experiences and
dynamically describes how human beings participate
with the environment to actualize their potential.
Barrett (1983) pointed out that most theories of
power are causal and define power as the ability to
influence, prevent, or cause change with dominance, force, and hierarchy. Power, within a Roger-
211
ian perspective, is being aware of what one is choosing to do, feeling free to do it, doing it intentionally,
and being actively involved in the change process. A
persons ability to participate knowingly in change
varies in given situations. Thus, the intensity, frequency, and form that power manifests vary. Power
is neither inherently good nor evil; however, the
form in which power manifests may be viewed as either constructive or destructive depending on ones
value perspective (Barrett, 1989). Barrett (1989) stated
that her theory does not value different forms of
power, but instead recognizes differences in power
manifestations. The Power as Knowing Participation
in Change Tool (PKPCT), mentioned earlier, is a measure of ones relative frequency of power. Barrett
(1989) suggests that the Power Theory and PKPCT
may be useful in a wide variety of nursing situations.
Barretts Power Theory is useful with clients who are
experiencing hopelessness, suicidal ideation, hypertension and obesity, drug and alcohol dependence,
grief and loss, self-esteem issues, adolescent turmoil,
career conflicts, marital discord, cultural relocation
trauma, or the desire to make a lifestyle change. In
fact, all health/illness experiences involve issues concerning knowing participation in change.
During pattern manifestation knowing and appreciation, the nurse invites the client to complete the
PKPCT as a means to identify the clients power pattern. To prevent biased responses, the nurse should
refrain from using the word power. The power
score is determined on each of the four subscales
(manifestations of power): awareness, choices, freedom to act intentionally, and involvement in creating
changes. The scores are documented as part of the
clients pattern profile and shared with the client
during voluntary mutual patterning. Scores are considered as a tentative and relative measure of the
ever-changing nature of ones field pattern in relation
to power. At this time the nurse can explain the
meaning of the scores and the power theory and
continues until the client understands each of the
four manifestations of power. Misinterpretations are
clarified, judgements are suspended, and understanding is validated. Power is viewed acausally. Instead of focusing on issues of control, the nurse
helps the client identify the changes and the direction of change the client desires to make. Exploring
aspects of the situation potentially increases the
clients awareness. Using open-ended questions, the
nurse and the client mutually explore choices and
options and identify barriers preventing change,
strategies, and resources to overcome barriers; the
nurse facilitates the clients active involvement in
creating the changes. For example, asking the ques-
212
tions What do you want?What choices are open to

you now? How free do you feel to do what you
want to do? and How will you involve yourself in
creating the changes you want? can enhance the
clients awareness, choice-making, freedom to act intentionally, and his or her involvement in creating
change (Barrett, 1998).
A wide range of voluntary mutual patterning strategies may be used to enhance knowing participation
in change, including meaningful dialogue, dance/
movement/motion, sound, light, color, music, rest/
activity, imagery, humor, nutrition, therapeutic
touch, bibliotherapy, journaling, drawing, and nutrition (Barrett, 1998). The PKPCT can be used at intervals to evaluate the clients relative changes in
power.
Theory of Perceived Dissonance

Bultemeier (1997) derived a mid-range theory from
Rogers postulates and principles that is also useful in
a wide variety of nursing practice situations. The Theory of Perceived Dissonance proposes that experiences labeled as illness or as abnormal processes
are manifestations of human/environmental field patterning characterized by nonharmonic, uncomfortable, unsettling, discordant rhythmicities perceived
as dissonance (Bultemeier, 1997). Pain, anxiety, fear,
anger, and depression are just a few human experiences relevant to nursing practice that may be conceptualized as dissonance. During pattern manifestation knowing and appreciation, the nurse identifies
human and environmental field patterns of dissonance and harmony. Barretts Theory of Power and
Bultemeiers Theory of Perceived Dissonance can be
used together in a client situation. During voluntary
mutual patterning, the nurse and client mutually design and participate together in patterning activities
to strengthen the coherence, harmony, and integrity
of the human/environmental field.
Theory of Kaleidoscoping in Lifes Turbulence

Butchers (1993) mid-range practice theory of Kaleidoscoping in Lifes Turbulence was derived from
Rogers Science of Unitary Human Beings, chaos theory (Briggs & Peat, 1989; Peat, 1991), and Csikszentmihalyis (1990) Theory of Flow. It focuses on facilitating well-being and harmony amid turbulent life
events. Turbulence is a dissonant commotion in the
human/environmental 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 crisis. The
turbulent life event may be an illness, the uncertainty
of a medical diagnosis, marital discord, or loss of a

loved one. Turbulent life events are often chaotic in
nature, unpredictable, and always transformative.
Kaleidoscoping is a way of engaging in mutual
process with clients who are in the midst of experiencing a turbulent life event by mutually flowing with
turbulent manifestations of patterning (Butcher,
1993). Flow is an intense harmonious involvement in
the human/environment mutual field process. The
term kaleidoscoping was used because it evolves directly from Rogers writings and conveys the unpredictable continuous flow of patterns, sometimes turbulent, that one experiences when looking through
a kaleidoscope. Rogers (1970, p. 62) explained that
the organization of the living system is maintained
amidst kaleidoscopic alterations in the patterning of
system.
The Theory of Kaleidoscoping with Turbulent Life
Events is used in conjunction with the pattern manifestation knowing and appreciation and voluntary
mutual patterning processes. In addition to engaging
in the processes already described in pattern manifestation knowing and appreciation, the nurse identifies manifestations of patterning and mutually explores the meaning of the turbulent situation with
the client. A pattern profile describing the essence of
the clients experiences, perceptions, and expressions related to the turbulent life event is constructed and shared with the client.
In the theory of kaleidoscoping, voluntary mutual
patterning also incorporates the processes of transforming turbulent events by cultivating purpose,
forging resolve, and recovering harmony (Butcher,
1993). Cultivating purpose involves assisting clients
in identifying goals and developing an action system.
The action system is comprised of patterning strategies designed to promote harmony amid adversity
and facilitate the actualization of the potential for
well-being.
In moments of turbulence, clients may want to increase their awareness of the complexity of the situation. Creative suspension is a technique that may be
used to facilitate comprehension of the situations
complexity (Peat, 1991). Guided imagery is a useful
strategy for facilitating creative suspension because it
potentially enhances the clients ability to enter a
timeless suspension directed toward visualizing the
whole situation and facilitating the creation of new
strategies and solutions. Forging resolve is assisting
the clients in becoming involved and immersed in
their action system. Since chaotic and turbulent systems are infinitely sensitive, actions are gentle or
subtle in nature and distributed over the entire system involved in the change process. Entering chaotic
systems with a big splash or trying to force a
change in a particular direction will likely lead to increased turbulence (Butcher, 1993).
Forging resolve involves incorporating flow experiences into the change process. Flow experiences promote harmonious human/environmental field patterns. There are a wide range of flow experiences that
can be incorporated into the daily activities: art, music, exercise, reading, gardening, meditation, dancing, sports, sailing, swimming, carpentry, sewing,
yoga, or any activity that is a source of enjoyment,
concentration, and deep involvement. The incorporating of flow experiences into daily patterns potentiates
the recovering of harmony. Recovering harmony is
achieving a sense of courage, balance, calm, and resilience amid turbulent and threatening live events.
your thoughts
213
The art of kaleidoscoping with turbulence is a mutual

creative expression of beauty and grace and is a way of
enhancing perseverance through difficult times.
Enfolding Health-as-Wholeness-and-Harmony
Carboni (1995a) defined Rogerian nursing practice
as the nurse and the client knowingly participating
in evolutionary patterning of the human and environmental fields for the purpose of enfolding health-aswholeness-and-harmony. Carboni derived the Enfolding Health-as-Wholeness-and-Harmony practice theory
from a synthesis of Bohms (1980) theory of the implicate-explicate order with Rogers postulates and
principles. According to Carboni, the three guiding
principles of Rogerian nursing practice are: (1) knowingly participating, (2) evolutionary patterning of human and environmental fields, and (3) enfolding
health-as-wholeness-and-harmony (Carboni, 1995a).
Carboni defined each of the major concepts.
Knowingly participating is enfolding the subtle
configurations of patterning of healing humanenvironmental field relationship and unitary knowing within a pandimensional field of nonlinearity and
acausality (Carboni, 1995a, p. 76). Evolutionary
patterning of the human and environmental fields
is enfolding the subtle configurations of patterning
of unitary action while co-participating in the nonlinear and acausal transforming of the gross configurations of patterning of dis-ease and fragmenting
place to a new synthesis of subtle configurations of
patterning of health-within-illness healing place
(Carboni, 1995a, pp. 7677). Enfolding health-aswholeness-and-harmony is enfolding the dynamic
matrix of subtle configurations of patterning of the
healing human fieldenvironmental field relationship, unitary knowing, unitary action, health-withinillness and healing place within increasingly complex
and diverse pandimensional human fieldenvironmental field mutual process of higher wave frequency patterns of wholeness-and-harmony-in-process (Carboni, 1995a, p. 77).
Carboni goes on to define each of the subconcepts, including unitary knowing and unitary action.
Carbonis model has wide application in nursing
practice. Any illness or dis-ease is understood as experiences, perceptions, and expressions reflecting
an unfolding of disharmony or fragmenting of the
integrity of human and environmental fields. Within
this enfolding of subtle configurations of patterning,
the nurse and the client participate together in patterning fragmented field patterns to a new synthesis
and harmony in humanenvironmental field patterns.
A wide variety of noninvasive voluntary mutual patterning strategies may be used to create a sense of
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unity, harmony, peace, sacredness, belonging, and

home.
Personalized Nursing LIGHT Practice Model

The final mid-range Rogerian practice theory discussed in this overview is the successful Personalized Nursing LIGHT Practice Model (Anderson &
Smereck, 1989, 1992, 1994). For more than 10 years
the model has been used by the Personalized Nursing Corporation, an independent, nurse-owned,
nurse-managed company providing outreach nursing
care to high-risk and active drug users in Detroit,
Michigan. The goal of the LIGHT model is to assist
clients in improving their sense of well-being. With a
higher sense of well-being, clients are less likely to
continue to engage in high-risk drug-related behaviors. Drug-addicted behaviors are postulated to be a
painful means to experience an awareness of integrality. During the pattern manifestation knowing
and appreciation process, clients are asked to name a
painful experience, encouraged to be in the moment in a safe place with the experience/feeling,
asked to identify the choices they usually make during the painful experience, and then asked to identify pattern manifestations associated with their
usual choices. Well-being (global and current), life
pattern manifestations, and talents are also assessed
using a heuristic teaching tool.
The acronym LIGHT guides the voluntary mutual
patterning process. Nurses Llove the client, Iintend to help, Ggive care gently, Hhelp the client
improve well-being, and Tteach the healing process of the LIGHT model. Clients make progress toward well-being as they learn to Llove themselves,
Iidentify concerns, Ggive themselves goals, H
have confidence and help themselves, and Ttake
positive action. In a three-year pre- and postcontrol
treatment group study involving 744 participants,
clients who received nursing care with the LIGHT
model improved their sense of well-being associated
with a decrease in high-drug behaviors (Anderson &
Hockman, 1997).
Nursing practice is the application of nursing theory. Together, the mid-range practice theories briefly
described offer a rich tapestry of theoretical guides
for unitary practice in any nursing situation. Practicing nursing from a unitary perspective is a creative
leap into a new worldview in concert with contemporary and progressive scientific theories of wholeness. Shifting ones perspective from an old worldview to a new one requires immersion and serious
study. Readers are encouraged to study the original
works cited for each of the mid-range theories. For
students and nurses wishing to advance Rogerian sci-
ence, each of the practice theories is an abounding

source for theory-testing research.
RESEARCH WITHIN THE SCIENCE

OF UNITARY HUMAN BEINGS
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 modalities evolve from the Science
of Unitary Human Beings, there remains a need to
test the viability and usefulness of mid-level theories
and voluntary health patterning strategies. The mass
of Rogerian research has been reviewed in a number
of publications (Caroselli & Barrett, 1998; Dykeman
& Loukissa, 1993; Fawcett, 1995; Malinski, 1986,
1994; Phillips, 1989b;
Research is the bedrock of Watson, Barrett, Hastings-Tolsma, Johnson,
nursing practice. Criteria & Gueldner, 1997).
for research methods guide, Rather than repeat the
reviews of Rogerian rethe design of investigations. search, the following
section describes current methodological trends within the Science of
Unitary Human Beings to assist researchers interested in Rogerian science in making methodological
decisions.
Methodological Issues
Although there is some debate among Rogerian
scholars and researchers concerning the choice of
an appropriate methodology in Rogerian research,
Rogers (1994) maintained that both quantitative and
qualitative methods may be useful for advancing
Rogerian science. Similarly, Barrett (1996), Barrett

and Caroselli (1998), Barrett, Cowling, Carboni, and
Butcher (1997), Cowling (1986), and Rawnsley
(1994) have all advocated for the appropriateness of
multiple methods in Rogerian research. Conversely,
Butcher (cited in Barrett et al., 1997); Butcher
(1994), and Carboni (1995b) have argued that the
ontological and epistemological assumptions of
causality, reductionism, particularism, control, prediction, and linearity of quantitative methodologies
are inconsistent with Rogers unitary ontology and
participatory epistemology. For the purpose of this
chapter, an inclusive view of methodologies is advocated. However, the researcher needs to present an
argument as to how the design of the study and interpretations of results are congruent with Rogers
postulates and principles. Furthermore, nurses interested in engaging in Rogerian research are encouraged to use, test, and refine the research methods
and tools that have been developed consistent with
the ontology and epistemology of the Science of Unitary Human Beings. Most importantly, since the development of unique research methods is a route toward disciplinary definition, there continues to be a
great need to develop new research methods and
tools consistent with Rogerian science (Barrett et al.,
1997; Butcher, 1994; Carboni, 1992; Phillips, 1988;
Rogers, 1994).
Criteria for Rogerian Inquiry

The criteria for developing Rogerian research methods presented in this chapter 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 may be a useful guide in design-
your thoughts
215
ing research investigations guided by the Science of

Unitary Human Beings.
1. A Priori Nursing Science: All research flows
from a theoretical perspective. Every step of the
inquiry, including the type of questions asked,
the conceptualization of phenomena of concern, choice of research design, selection of participants, selection of instruments, and interpretation of findings is guided by the Science of
Unitary Human Beings. The researcher explicitly
identifies the Science of Unitary Human Beings
as the conceptual orientation of the study. Nursing research must be grounded in a theoretical
perspective unique to nursing in order for the
research to contribute to the advance of nursing
science.
2. Creation: The Rogerian research endeavor is a
creative and imaginative process for discovering
new insights and knowledge concerning unitary
human beings in mutual process with their environment.
3. Irreducible Human-Environmental Energy
Fields Are the Focus of Rogerian Inquiry: Energy fields are postulated to constitute the fundamental unit of the living and nonliving. Both
human beings and the environment are understood as dynamic energy fields that cannot be reduced to parts.
4. Pattern Manifestations Are Indicators of
Change: Pattern is the distinguishing characteristic of an energy field and gives identity to the
field. Pattern manifestations are the source of information emerging from the human/environmental mutual field process and are the only
valid reflections of the energy field. The phenomenon of concern in Rogerian inquiry is conceptualized and understood as manifestations of
human/environmental energy mutual process.
5. Pandimensional Awareness: Rogerian inquiry
recognizes the pandimensional nature of reality.
All forms of awareness are relevant in a pandimensional universe. Thus, intuition, both tacit
and mystical, and all forms of sensory knowing
are relevant ways of apprehending manifestations of patterning.
6. Human Instrument Is Used for Pattern Knowing and Appreciation: The researchers use
themselves as the primary pattern-apprehending
instrument. The human instrument is the only
instrument sensitive to, and which has the ability to interpret and understand, pandimensional
potentialities in human/environmental field patterning. Pattern manifestation knowing and ap-
216
7.
8.
9.
10.
preciation is the process of apprehending information or manifestations of patterning emerging

from the human/environmental field mutual process. The process of pattern knowing and appreciation is the same in the research endeavor as
described earlier in the Rogerian practice
methodology.
Both Quantitative and Qualitative Methods
Are Appropriate: Quantitative methods may be
used when the design, concepts, measurement
tools, and results are conceptualized and interpreted in a way consistent with Rogers nursing
science. It is important to note, that because of
the incongruency between ontology and epistemology of Rogerian science with assumptions in
quantitative designs, Carboni (1995b) argues
that the researcher must select qualitative methods exclusively over quantitative methods. Barrett and Caroselli (1998), however, recognize
the inconsistencies of quantitative methods with
Rogerian science, and argue that the research
question drives the choice of method; hence,
both qualitative and quantitative methods are
not only useful but necessary (p. 21). The ontological and epistemological congruence is reflected in the nature of questions asked and
their theoretical conceptualization (Barrett,
1996). However, qualitative designs, particularity those that have been derived from the postulates and principles of the Science of Unitary
Human Beings, are preferred because the ontology and epistemology of qualitative designs are
more congruent with Rogers notions of unpredictability, irreducibility, acausality, integrality,
continuous process, and pattern (Barrett et al.,
1997; Butcher, 1994).
Natural Setting: Rogerian inquiry is pursued in
the natural settings where the phenomenon of
inquiry occurs naturally, because the human
field is inseparable and in mutual process with
the environmental field. Any manipulation of
variables is inconsistent with mutual process,
unpredictability, and irreducibility.
The Researcher and the Researcher-Into Are Integral: The principle of integrality implies that
the researcher is inseparable and in mutual process with the environment and the participants
in the study. Each evolves during the research
process. The researchers values are also inseparable from the inquiry. Objectivity and bracketing are not possible when the human and environmental field are integral to one another.
Purposive Sampling: The researcher uses purposive sampling to select participants who mani-
11.
12.
13.
14.
fest the phenomenon of interest. Recognition of

the integrality of all that is tells us that information about the whole is available in individuals,
groups, and settings; therefore, representative
samples are not required to capture manifestations of patterning reflective of the whole.
Emergent Design: The Rogerian researcher is
aware of dynamic unpredictability and continuous change, and is open to the idea that patterns
in the inquiry process may change in the course
of the study that may not have been envisioned
in advance. Rather than adhere to preordained
rigid patterns of inquiry, the research design
may change and evolve during the inquiry. It is
essential that the researcher document and report any design changes.
Pattern Synthesis: Rogerian science emphasizes
synthesis rather than analysis. Analysis is the separation of the whole into its constituent parts.
The separation of parts is not consistent with
Rogers notion of integrality and irreducible
wholes. Patterns are manifestations of the whole
emerging from the human/environmental mutual field process. Synthesis allows for creating
and viewing a coherent whole. Therefore, data
are not analyzed within Rogerian inquiry, but
synthesized. Data processing techniques that
put emphasis on information or pattern synthesis are preferred over techniques that place emphasis on data analysis.
Shared Description and Shared Understanding: Mutual process is enhanced by including
participants in the process of inquiry where possible. For example, sharing of results with participants in the study enhances shared awareness, understanding, and knowing participation
in change. Furthermore, participants are the
best judges of the authenticity and validity of
their own experiences, perceptions, and expressions. Participatory action designs and focus
groups conceptualized within Rogerian science
may be ways to enhance mutual exploration,
discovery, and knowing participation in
change.
Evolutionary Interpretation: The researcher interprets all the findings within the perspective
of the Science of Unitary Human Beings. Thus,
the findings are understood and presented
within the context of Rogers postulates of energy fields, pandimensionality, openness, pattern, and the principles of integrality, resonancy,
and helicy. Evolutionary interpretation provides
meaning to the findings within a Rogerian science perspective. Interpreting the findings
within a Rogerian perspective advances Rogerian science, practice, and research.
Potential Rogerian Research Designs

Cowling (1986) was among the first to suggest a
number of research designs that may be appropriate
for Rogerian research, including philosophical, historical, and phenomenological ones. There is strong
support for the appropriateness of phenomenological methods in Rogerian science. For example,
Rogers, quoted in Malinski (1986), stated: [A]nother
resource in terms of research we havent used much
yet [is] phenomenology. . . . Description and phenomenology both provide further ways of trying to
look at things (p. 14). According to Reeder (1986),
phenomenological methods better reflect the Rogerian paradigm because they are not limited to sensory
experience, but include multiple modes of awareness inherent in a pandimensional universe. Reeder
(1986) provided a convincing argument demonstrating the congruence between Husserlian phenomenology and the Rogerian Science of Unitary Human
Beings, stating:
[G]iven the congruency between Husserlian
phenomenology and the Rogerian conceptual
system, a sound, convincing rationale is established for the use of this philosophy of science
as an alternative for basic theoretical studies in
Rogerian nursing science . . . Nursing research
in general requires a broader range of human
experience than sensory experience (whether
intuitive or perceptive) in the development
and testing of conceptual systems for gaining
better access to multifaceted phenomena. . . .
Husserlian phenomenology as a rigorous science provides just such an experience. (p. 62)
Phillips (1989b, p. 52) asserted that phenomenological research leads to knowledge about the whole
by uncovering meaning of the human/environmental
mutual field process. In phenomenological research,
there is no need to deal with such polarities as
subjective-objective, since the living experience
emerges from the interconnectedness of the two,
where reality is experienced as a whole.
Experimental and quasi-experimental designs 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 notions of unpredictability, integrality, and nonlinearity. Emerging
217
your thoughts
interpretive evaluation methods, such as Guba and

Lincolns (1989) Fourth Generation Evaluation, offer
an alternative means for testing for differences in
the change process within and/or between groups
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 Unitary 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) statistical analysis may also be a
means to uncover knowledge about the pattern of
change rather than just knowledge of parts of a
change process (Phillips, 1990). Barrett (1996) suggests that canonical correlation may be useful in examining relationships and patterns across domains
and may also be useful for testing theories pertaining to the nature and direction of change. Another
potentially promising area yet to be explored is participatory action and cooperative inquiry (Reason,
1994) because of their congruence with Rogers notions of knowing participation in change, continuous
mutual process, and integrality. Cowling (1998) proposed that a case-orientated approach is useful in
Rogerian research, because case inquiry allows the
researcher 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
218
most relevant. The focus of inquiry flows from the

postulates, principles, and concepts relevant to the
conceptual system. Noninvasive voluntary patterning modalities such as guided imagery, therapeutic
touch, humor, sound, dialogue, affirmations, music,
massage, journaling, exercise, nutrition, reminiscence, aroma, light, color, artwork, meditation, storytelling, literature, poetry, movement, and dance
provide a rich source for Rogerian sciencebased research. Creativity, mystical experiences, transcendence, sleeping-beyond-waking experiences, time
experience, and paranormal experiences as they relate to human health and well-being are of interest in
this science. New concepts that describe unitary
phenomena may be developed through research.
Dispiritedness (Butcher, 1996), human field image
(Johnson, 1994), and power (Barrett, 1983) are just a
few examples of concepts developed through research within Rogers nursing science. Feelings and
experiences are a manifestation of human/environmental field patterning and are a manifestation of
the whole (Rogers, 1970); thus, feelings and experiences relevant to health and well-being are an unlimited source for potential Rogerian research. Discrete
particularistic biophysical phenomena are usu- Measurement tools have
ally not an appropriate
focus for inquiry be- been developed within
cause Rogerian science Rogerian science and
focuses on irreducible
provide potential for future
wholes. Diseases or
medical diagnoses are research.
not the focus of Rogerian inquiry. Disease conditions are conceptualized as
labels and as manifestations of patterning emerging
acausally from the human/environmental mutual

process. However, the researcher needs to ensure
that concepts and measurement tools used in the inquiry are defined and conceptualized within a unitary perspective. Several measurement tools have already been developed within Rogerian science, and
they provide an abundant potential for future research within this conceptual system.
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 conceptsmy motor is running and my field expansionare rated
using a semantic differential technique (Ference,
1979). Examples of indicators of higher human field
motion include feeling imaginative, visionary, transcendent, strong, sharp, bright, and active. Indicators
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 over 26 major research studies (Caroselli & Barrett, 1998) and is a
measure of ones capacity to participate knowingly
in change as manifested by awareness, choices, freedom to act intentionally, and involvement in creating
changes using semantic differential scales. Statistically significant correlations have been found between power as measured by the PKPCT and the
following: human field motion, life satisfaction, spirituality, purpose in life, empathy, transformational
leadership style, feminism, imagination, and socioeconomic status. Inverse relations with power have
been found with anxiety, chronic pain, personal distress, and hopelessness (Caroselli & Barrett, 1998).
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 (HFMIS) used 25 metaphors that capture
feelings of potentiality and integrality rated on a Likert-type scale. For example, 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 ones potential (Johnston, 1994; Watson et al., 1997). Future research may focus on developing an understanding 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.
Diversity is inherent in the evolution of the human/environmental mutual field process. The evolu-
tion 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 (DHFPS) measures the process of diversifying human field pattern and may also be a useful tool
to test theoretical propositions derived from the
postulates and principles of Rogerian science to examine the extent of selected patterning modalities
designed to foster harmony and well-being (HastingsTolsma, 1992; Watson et al., 1997). Other measurement tools developed within and unitary science
perspective that may be used in a wide variety of research studies and in combination with other Rogerian measurements include Assessment of Dream Experience, which measures the diversity of dream
experience as a beyond-waking manifestation using a
20-item Likert scale (Watson, 1993; Watson et al.,
1997); Temporal Experience Scale (TES), which
measures the subjective experience of temporal
awareness (Paletta, 1990); and Leddys (1995)
Person-Environment Participation Scale, which
measures expansiveness and ease of participation
in the continuous human/environmental mutual
field process using semantic differential scales. Another noteworthy tool is the Mutual Exploration of
the Healing Human FieldEnvironmental Field Relationship Creative Measurement Instrument developed by Carboni (1992). It is a creative qualitative measure designed to capture the changing
configurations of energy field pattern of the healing human/ environmental field relationship. As a
means to reach a better understanding of the healing
human/environmental field relationship, the participant and the researcher explore together experiences and expressions related to changing configurations of healing. In part of the instrument, the
meaning of such terms as flowing, energy, connectedness, oneness, process, whole, harmony, movement, constant change, no boundaries, and resonating is explored.
New tools to measure unitary constructs need to
be developed. In addition, the tools described need
further testing for validity and reliability in a variety
of nursing situations and populations. Although the
quantitative measures provide a rich source for future research, Rogerian researchers are encouraged
to use methods developed specific to the Science of
Unitary Human Beings. Three methods have been developed: Rogerian Process of Inquiry, the Unitary
Field Pattern Portrait Research Method, and Unitary
Case Inquiry. Each method was derived from Rogers
unitary ontology and participatory epistemology and
is congruent with the criteria for Rogerian inquiry
presented earlier in this chapter.
219
Rogerian Process of Inquiry

Carboni (1995b) developed the Rogerian Process of
Inquiry from her characteristics of Rogerian inquiry.
The purpose of the method is to investigate the dynamic enfolding-unfolding of the human fieldenvironmental field energy 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 phenomenologists 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 summation
of the researchers purpose, aims, and visionary insights. Visionary insights emerge from the studys
purpose and researchers understanding of Rogerian
science. The researcher recognizes the integrality of
the researcher-participant and natural setting. The inquiry takes place in a setting where nursing is practiced. The focus of inquiry is on pattern manifestations that are significant to the science of nursing
and the emergence of evolutionary change. Dynamic
purposive sampling is used to select participants.
Participants in the study are viewed as integral to the
research process and are included in open discussions and the sharing of ideas. Next, the researcher
focuses on becoming familiar with the participants
and the setting of the inquiry. Shared descriptions of
energy field perspectives are identified through observations and discussions with participants and
processed through mutual exploration and discovery. Enfoldment of evolutionary change provides a
unitary means of accessing potentialities for change.
The researcher uses the Mutual Exploration of the
Healing Human FieldEnvironmental Field Relationship Creative Measurement Instrument (Carboni,
1992) as a way to identify, understand, 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 manifested
in diverse multiple configurations of patterning.
Conversations can be taped, and video recordings
and any documents and artifacts that may help illuminate configurations of patterning emerging from the
human and environmental field mutual process related to the focus of the inquiry may be used. Also,
field notes and a reflexive journal are used to record
data. All the data are synthesized using inductive and
deductive data synthesis. Through the mutual shar-
220
ing and synthesis of data, unitary constructs are identified. The constructs are interpreted within the perspective of unitary science, and a new unitary theory
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 Report. The new unitary theory advances the evolution of Rogers nursing science and
may be used to guide unitary nursing practice. Carbonis research method affords a way of creatively
measuring manifestations of field patterning emerging during coparticipation of the researcher and participants process of change.
The Unitary Field Pattern

Portrait Research Method
The Unitary Field Pattern Portrait (UFPP) research
method (Butcher, 1994, 1996, 1998b) was developed at the same time Carboni was developing the
Unitary Process of Inquiry and was derived directly
from the criteria of Rogerian inquiry. The purpose of
the UFPP research method is to create a unitary understanding of the dynamic kaleidoscopic 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
betterment and well-being. There are eight processes
in the method: initial engagement, a priori nursing
science, immersion, manifestation knowing and appreciation, unitary field pattern profile construction,
mutual field pattern portrait construction, unitary
field pattern portrait construction, and theoretical
unitary field pattern portrait construction. Each process is briefly described (see Figure 1).
1. Initial engagement is a passionate search for a research question of central interest to understanding unitary phenomena associated with human
betterment and well-being.
2. A priori nursing science identifies the Science of
Unitary Human Beings as the researchers perspective. As in all research, the perspective of the
researcher guides all processes of the research
method, including the interpretation of findings.
3. Immersion involves becoming steeped in the research topic. The researcher may immerse himself
or herself in poetry, art, literature, music, dialogue with self and other, research literature, or
any activity that enhances the integrality of the researcher and the research topic.
4. Pattern manifestation knowing and appreciation,
formally referred to as pattern appraisal, includes
Figure 141 The Unitary Field

Pattern Portrait Research
Method.
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 indepth dialoguing. The activities described earlier
in the pattern manifestation knowing and appreciation 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 associated with the phenomenon of
concern. The researcher also maintains an informal conversational style while focusing on revealing the rhythm, flow, and configurations 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

observational, methodological, and theoretical
field notes, and a reflexive journal. Any artifacts
the participant wishes to share that illuminate the
meaning of the phenomenon may also be included. Artifacts may include pictures, drawings,
poetry, music, logs, diaries, letters, notes, and
journals.
5. Pattern profile construction is the process of creating a pattern profile for each participant using
creative pattern synthesis. All the information collected for each participant is synthesized into a
narrative statement revealing the essence of the
participants description of the phenomenon of
concern. The field pattern profile is in the language of the participant, and is then shared with
the participant for verification and revision.
6. Mutual unitary field pattern profile construction
is the process of mutually sharing an emerging
221
joint or shared profile with each successive participant at the end of each participants pattern manifestation knowing and appreciation process. For
example, at the end of the interview of the fourth
participant, a joint construction of the phenomenon 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 verification of the fourth participants
pattern profile, the profile is folded into the
emerging mutual unitary field pattern profile. Pattern manifestation knowing and appreciation continues until there are no new pattern manifestations to add to the mutual unitary field pattern
profile.
7. Unitary field pattern portrait construction is the
process of identifying emerging unitary themes
from each participants field pattern profile, sorting the unitary themes into common categories,
creating the resonating unitary themes of
human/environmental pattern manifestations
through immersion and crystallization, and synthesizing the resonating themes into a descriptive
portrait of the phenomenon. The unitary field pattern portrait is expressed in the form of a vivid,
rich, thick, and accurate 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. Finally, the unitary field pattern portrait is interpreted from the perspective of the Science of Unitary Human Beings, creating a theoretical unitary
field pattern portrait of the phenomenon. The
purpose of theoretical unitary field pattern por-
trait construction is to explicate the theoretical

structure of the phenomenon from the perspective of Rogers nursing science. The theoretical
unitary field pattern portrait is expressed in the
language of Rogerian science, thereby lifting the
unitary field pattern portrait from the level of description to the level of unitary science. Scientific
rigor is maintained throughout processes by using
the criteria of trustworthiness and authenticity.
The findings of the study are conveyed in a Unitary Field Pattern Report.
Unitary Case Inquiry

Cowlings Unitary Case Inquiry is very similar to his
pattern appreciation practice method (Cowling,
1993b, 1997, 1998): The approach of pattern appreciation serves both science and practice simultaneously in a scientist/practitioner model (Cowling,
1997, p. 136). Unitary Case Inquiry is a case-orientated approach guided by the assumptions of Rogerian science. Case-oriented approaches attend to the
whole and strive for essence. Essence is pattern
(Cowling, 1998). The case-oriented approach fits
well with Rogerian science because features in cases
can be treated as ensembles rather than as disaggregated variables. An example of a research question
within Unitary Case Inquiry may be What is the patter of a person experiencing pain?The approach to
Unitary Case Inquiry (Cowling, 1997, 1998) includes
the following steps.
1. The researcher seeks engagement with a participant who is willing to mutually explore the
essence of the phenomenon of interest. Researcher and participant are equal coparticipants in the process of inquiry.
your thoughts
222
2. Specific intentions of the researcher are made

explicit through a mutually derived and negotiated informed consent process.
3. The participant cocreates the form and structure for engagement. Interviewing, observing,
and creative expressions or any combination of
these may be means for mutually exploring and
comprehending essence.
4. Journaling, audiotaping, photographs, drawing,
music, and poetry may be used to document the
participants experience, perceptions, and expressions of the phenomenon of concern.
5. The researcher also maintains a journal that may
include methodological notes, peer review
notes, and general reflections.
6. A pattern appreciation profile is created through
a process of synopsis. Features are synthesized
into an ensemble that reflects the essence and
wholeness of the phenomenon of concern.
7. The pattern appreciation profile of the participant is verified by the participant.
8. A conceptual/theoretical synthesis is developed
based on the pattern information collected by
interpreting the profile from the perspective of
Rogers postulates and principles.
9. A peer review system may be used to assist the
researcher in ensuring logical consistency of the
process.
10. To ensure scientific credibility, audit procedures
are developed. Both the peer reviewer and the
auditor should be an expert on Rogers conceptual system and the method.
The methods and measurement tools derived from
the postulates and principles of Rogerian science are
means to answer vital questions related to the wellbeing and human betterment of unitary human beings. The challenge for students, researchers, and
practitioners interested in Rogerian research is to use
the methods that have been developed. Furthermore, new methods need to be created and tested.
Research conducted consistent with the postulates
and principles of Rogerian science advances the evolution of nursing knowledge central to the health
and well-being of all.
Summary
Nursings continued survival rests on its ability to
make a difference in promoting the health and wellbeing of people. Making a difference refers to nursings contribution to the clients desired health goals,
and offering care is distinguishable from the ser-
vices of other disciplines. If a discipline has nothing

unique and valuable to offer, or offers the same services as another discipline, then that disciplines survival will be in jeopardy.
Every disciplines uniqueness evolves from its
philosophical and theoretical perspective. All disciplines are identified and exist because of their
uniqueness. The Science of Unitary Human Beings
offers nursing a distinguishable and new way of
conceptualizing health events concerning human
well-being congruent with the most contemporary
scientific theories. As with all major theories embedded in a new worldview, new terminology is needed
to create clarity and precision of understanding and
meaning. Rogers nursing science leads to a new understanding of the experiences, perceptions, and expressions of health events and leads to innovative
ways of practicing nursing. There is an ever-growing
body of literature demonstrating the application of
Rogerian science to practice and research. This chapter included a description of the Rogerian practice
model and a set of criteria for Rogerian inquiry. In
addition, five mid-level practice theories and three
research methods derived from the postulates and
principles of Rogerian science were presented.
Rogers 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 inseparable from their environment. People
seeking health care want to be more involved in the
decision-making process. Mutuality between the
nurse and client is inherent to Rogerian In the new millennium,
practice. For 30 years,
Rogers advocated that Rogerian science will have
nurses should become more relevance as outthe experts and prodated reductionistic modviders of noninvasive
modalities that pro- els are replaced by those
mote health. Now, the
depicting the emerging
growth of alternative
medicine and nonin- worldview of wholeness.
vasive practices is outpacing the growth of traditional medicine. If nursing
continues to be dominated by biomedical frameworks indistinguishable from medical care, nursing
will lose an opportunity to become expert in holistic
health-care modalities.
In this new millennium, the Science of Unitary
Human Beings will have more relevance as outdated
reductionistic models are replaced by models depicting the emerging worldview of wholeness. The Science of Unitary Human Beings has even more rele-
223
vance as nursing moves into more autonomous

health-care settings such as communities, homes,
and nurse-owned and nurse-run wellness centers.
The space age future that Rogers envisioned has arrived. The international space station is under construction. Space-bound human civilizations will follow. Autonomous nurse health patterning centers
will be established in space communities. In this
new millennium, nurse entrepreneurial opportunities abound for nurses who dare to be creative. Nursings future is replete with infinite possibilities.
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and time experience in older women. Unpublished
225
doctoral dissertation, New York University, New

York.
Watson, J., Barrett, E. A. M., Hastings-Tolsma, M., Johnston, L., & Gueldner, S. (1997). Measurement in
Rogerian Science: A review of selected instruments.
226
In Madrid, M. (Ed.), Patterns of Rogerian knowing

Woodhouse, M. B. (1996). Paradigm wars:Worldviews
for a new age. Berkeley, CA: Frog, Ltd.
Chapter 15
The Human Becoming
School of Thought
The Human Becoming School of Thought
Human Becoming Research Methodologies
Human Becoming Practice Methodology
Human Becoming Global Presence
Summary
References
Bibliography
Part 1

Rosemarie Rizzo Parse is professor and Niehoff chair
at Loyola University in Chicago. She is founder and
editor of Nursing Science Quarterly; president of
Discovery International, Inc., which sponsors international nursing theory conferences; and founder of
the Institute of Human Becoming, where she teaches
the ontological, epistemological, and methodological aspects of the human becoming school of
thought. Her most recent work is Hope: An International Human Becoming Perspective (1999). Previous works include Nursing Fundamentals (1974);
Man-Living-Health: A Theory of Nursing (1981);
Nursing Science: Major Paradigms, Theories, and
Critiques (1987); Illuminations:The Human Becoming Theory in Practice and Research (1995); and
The Human Becoming School of Thought (1998).
Her theory is a guide for practice in health-care settings in the United States, Canada, Finland, and Sweden; her research methodology is used as a method
of inquiry by nurse scholars in Australia, Canada,
Denmark, Finland, Greece, Italy, Japan, South Korea,
Sweden, the United Kingdom, and the United States.
Dr. Parse is a graduate of Duquesne University in
Pittsburgh and received her masters and doctorate
from the University of Pittsburgh. She was on the faculty of the University of Pittsburgh, was dean of the
Nursing School at Duquesne University, and from
1983 to 1993 was professor and coordinator of the
Center for Nursing Research at Hunter College of the
City University of New York. She has been a visiting
professor at a number of universities in the United
States and around the world. She has consulted with
numerous doctoral programs in nursing and with
health-care settings that are using her theory as a
guide to practice and research.
THE HUMAN BECOMING

SCHOOL OF THOUGHT
by Rosemarie Rizzo Parse
As the twenty-first century dawns, nurse leaders in
research, administration, education, and practice are
focusing attention on expanding the knowledge base
of nursing through enhancement of the disciplines
frameworks and theories. Nursing is a discipline and
a profession. The goal of the discipline is to expand
knowledge about human experiences through creative conceptualization and research. This knowledge is the scientific guide to living the art of nursing. The discipline-specific knowledge is given birth
and fostered in academic settings where research
228
and education move the knowledge to new realms of

understanding. The goal of the profession is to provide service to humankind through living the Knowledge of the disciart of the science. Members of the nursing pro- pline is the scientific guide
fession are responsible to living the art of nursing.
for regulation of standards of practice and
education based on disciplinary knowledge that reflects safe health service to society in all settings.
The Discipline of Nursing

The discipline of nursing encompasses at least two
paradigmatic perspectives related to the humanuniverse-health process. One view is of the human as
body-mind-spirit (totality paradigm) and the other is
of the human as unitary (simultaneity paradigm)
(Parse, 1987). The body-mind-spirit perspective
is particulatefocusing on the bio-psycho-socialspiritual parts of the whole human as the human interacts with and adapts to the environment. Health is
considered a state of biological, psychological, social, and spiritual well-being. This ontology leads to
research and practice on phenomena related to preventing disease and maintaining and promoting
health according to societal norms. In contrast, the
unitary perspective is a view of the human as irreducible in mutual process with the universe. Health
is considered a process of changing value priorities.
It is not a static state but, rather, ever-changing as the
human chooses ways of living. This ontology leads to
research and practice on patterns (Rogers, 1992),
lived experiences, and quality of life (Parse, 1981,
1992, 1997a, 1998a). Because the ontologies of
these paradigmatic perspectives lead to different research and practice modalities, they lead to different
professional services to humankind.
The Profession of Nursing

The profession of nursing consists of people educated according to nationally regulated, defined, and
monitored standards. The standards and regulations
are to preserve the safety of health care for members
of society. The nursing regulations and standards are
specified predominantly in medical scientific terms.
This is according to tradition and largely related to
nursings early subservience to medicine. Recently
the nurse leaders in health-care systems and in regulating organizations have been developing standards
(Mitchell, 1998) and regulations (Damgaard & Bunkers, 1998) consistent with discipline-specific knowledge as articulated in the theories and frameworks of
nursing. This is a very significant development that
will fortify the identity of nursing as a discipline with

its own body of knowledgeone that specifies the
service that society can expect from members of the
profession. With the rapidly changing health policies
and the general dissatisfaction of consumers with
health-care delivery, clearly stated expectations for
services from each paradigm are a welcome change.
Just as in other disciplines, the nursing education
and practice standards must be broad enough to encompass the possibility of practice within each paradigm. The totality paradigm frameworks and theories
are more closely aligned with the medical model tradition. Nurses living the beliefs of this paradigm are concerned with participation of persons in health-care decisions but have specific regimes and goals to bring
about change for the people they serve. Nurses living
the beliefs of the simultaneity paradigm hold peoples
perspectives of their health situations and their desires to be primary. Nurses focus on knowing participation (Rogers, 1992) and bearing witness, as persons
in their presence choose ways of changing health patterns (Parse, 1981, 1987, 1992, 1995, 1997a, 1998a).
Human Becoming, a school of thought named
such because it encompasses an ontology, epistemology, and methodologies, emanates from the simultaneity paradigm (Parse, 1997c). It is this school of
thought that is explained and discussed in this chapter.
A Metaperspective of Parses
Human Becoming School of Thought
Parses (1981) original work was named Man-LivingHealth: 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 principles changed. With
the 1998 publication of The Human Becoming
School of Thought, Parse expanded the original
work to include descriptions of three research
methodologies and a unique practice methodology,
thus classifying the science of Human BecomHuman becoming is a basic
ing as a school of
human science that has thought (Parse, 1997c).
original
work
cocreated human The
(Parse, 1981) included
experiences as its central the ontology and episfocus. temology with general
specifications for the
research and practice
methodologies. In the years following the 1981 publication, the research and practice methodologies
were refined, tested, presented, and published in a

variety of venues. As a school of thought, the philosophical ideas provide nurses and other health professionals with guides for their research and practice.
Human Becoming is a basic human science that
has cocreated human experiences as its central focus. The ontologythat is, the assumptions and
principlessets forth beliefs that are clearly different from other nursing frameworks and theories. Discipline-specific knowledge is articulated in unique
language specifying a position on the phenomenon
of concern for each discipline. The Human Becoming
language is unique to nursing. The three Human Becoming 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 human-universe emergence. The fundamental idea
that humans are unitary beings, as specified in the
ontology, precludes any use of terms such as physiological,biological,psychological, or spiritual, because these terms describe the human in a particular
way.
Philosophical Assumptions
The assumptions of the human becoming school of
thought are written at the philosophical level of discourse (Parse, 1998a). There are nine fundamental
assumptions: four about the human and five about
becoming (Parse, 1998a). Also, three assumptions
about human becoming were synthesized from these
nine assumptions (Parse, 1998a). The assumptions
arose from a synthesis of ideas from Rogers Science
of Unitary Human Beings (Rogers, 1992) and existential phenomenological thought (Parse, 1981, 1992,
1994a, 1995, 1997a, 1998a). In the assumptions, the
author sets forth the view that unitary humans, in
mutual process with the universe, are cocreating a
unique becoming. The mutual process is the all-atonceness of living freely chosen meanings arising
with multidimensional experiences. The chosen
meanings are the value priorities cocreated in transcending with the possibles in unitary emergence
(see Parse 1998a, pp. 1930).
Principles of Human Becoming

The principles and the assumptions of the human becoming school of thought make up the ontology. The
principles are referred to as the theory. A theory is a
set of congruent concepts written at the same level
of discourse and connected in a unique way to describe the central phenomenon of a discipline. The
principles of human becoming, which describe the
central phenomenon of nursing (the human-universehealth process), arise from the three major themes of
Chapter 15 Rosemarie Rizzo Parse The Human Becoming School of Thought
229
your thoughts
the assumptions: meaning, rhythmicity, and transcendence. Each principle describes a theme with
three concepts. Each of the concepts explicates fundamental paradoxes of human becoming (see Parse,
1998a, p. 58). The paradoxes are dimensions of the
same rhythm lived all-at-once. Paradoxes are not opposites or problems to be solved but, rather, ways
humans live their chosen meanings. This way of
viewing paradox is unique to the human becoming
school of thought (Mitchell, 1993; Parse, 1981,
1994b).
With the first principle (see Parse, 1981, 1998a),
the author explicates the idea that humans construct
personal realities with unique choosings from multidimensional realms of the universe. Reality, the
meaning given to the situation, is the individual humans ever-changing seamless symphony of becoming (Parse, 1996). The seamless symphony is the
unique story of the human as mystery emerging with
the explicittacit knowings of imaging. The human
lives priorities of valuing in confirmingnot confirming cherished beliefs, while languaging with speakingbeing silent and movingbeing still.
The second principle (see Parse, 1981, 1998a) is
a description of the rhythmical patterns of relating
human with universe. The paradoxical rhythm is
revealingconcealing is disclosingnot disclosing
all-at-once (Parse, 1998a, p. 43). Not all is explicitly
known or can be told in the unfolding mystery of human becoming. Enablinglimiting is living the opportunities-restrictions present in all choosings all-atonce (Parse, 1998a, p. 44). There are opportunities
and restrictions no matter what the choice. Connectingseparating is being with and apart from others, ideas, objects and situations all-at-once (Parse,
1998a, p. 45). It is coming together and moving
230
apart, and there is closeness in the separation and

distance in the closeness.
With the third principle (see Parse, 1981, 1998a),
the author explicates the idea that humans are everchanging; that is, moving beyond with the possibilities, which are their intended hopes and dreams. A
changing diversity unfolds as humans push and resist
with powering in creating new ways of living the
conformitynonconformity and certaintyuncertainty
of originating, while shedding light on the familiarunfamiliar of transforming. Powering is the pushingresisting process of affirmingnot affirming being in light of nonbeing (Parse, 1998a, p. 47). The
beingnonbeing rhythm is all-at-once living the everchanging now moment as it melts with the not-yet.
Humans, in originating, seek to conformnot conform; that is, to be like others and unique all-at-once,
while living the ambiguity of the certaintyuncertainty embedded in all change. The changing diversity arises with transforming the familiarunfamiliar
as others, ideas, objects, and situations are viewed in
a different light.
The three principles are referred to as the human
becoming theory. The concepts, with the paradoxes,
describe the human-universe-health process. This ontological base gives rise to the epistemology and
methodologies of human becoming. Epistemology
refers to the focus of inquiry. Consistent with the human becoming school of thought, the focus of inquiry is on humanly lived experiences.
HUMAN BECOMING
RESEARCH METHODOLOGIES
Sciencing Human Becoming is the process of coming
to know; it is an ongoing inquiry to discover and un-
derstand the meaning of lived experiences. The Human Becoming research tradition has three methods;
two are basic research methods and the other is an
applied research method (Parse, 1998a, pp. 5968).
The 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) and the Human Becoming Hermeneutic
Method (Cody, 1995c; Parse, 1995, 1998a). The purpose of these two methods is to advance the science
of Human Becoming by studying lived experiences
from participants descriptions (Parse Method) and
written texts and art forms (Human Becoming
Hermeneutic Method). The phenomena for study
with the Parse Method are universal lived experiences such as joysorrow, hope, grieving, and
courage, among others. Written texts from any literary source or any art form may be the subject of research with the Human Becoming Hermeneutic
Method. The processes of both methods call for a
unique dialogue, researcher with participant or researcher with text or art form. The researcher in the
Parse Method is truly present as the participant
moves through an unstructured discussion about the
lived experience under study. The researcher in the
Human Becoming Hermeneutic Method is truly present to the emerging possibilities in the horizon of
meaning arising in dialogue with texts or art forms.
True presence is an intense attentiveness to unfolding essences and emergent meanings. The researchers intent with these research methods is to discover
essences (Parse Method) and emergent meanings
(Human Becoming Hermeneutic Method). The contributions of the findings from studies using these
two methods is new knowledge and understanding
of humanly lived experiences (Parse, 1998a, p. 62).
Many studies have been conducted and some have
been published in which nurse scholars used the
Parse Method (for example, Allchin-Petardi, 1996;
Baumann, 1996; Beauchamp, 1990; Blanchard,
1996; Bunkers, 1998;
The goal of the nurse living Cody, 1991, 1995a,
1995b; Daly, 1995;
the human becoming be- Gouty, 1996; Jonasliefs is true presence in Simpson, 1998; Kelley,
1991; Kruse, 1996; Lui,
bearing witness and being 1993; Milton, 1998;
with others in their chang- Mitchell, 1990a, 1995b;
Mitchell & Heidt, 1994;
ing health patterns. Northrup, 1995; Parse,
1990, 1994a, 1997b,
1999; Pilkington, 1993, 1997; Smith, 1990a, 1990b;
Thornburg, 1993; Wang, 1997, among others). Only
one study has been published in which the author
Chapter 15
used the Human Becoming Hermeneutic Method

(Cody, 1995c).
The applied research method is the descriptive
qualitative preproject-process-postproject method. It
is used when a researcher wishes to evaluate the
changes, satisfactions, and effectiveness of health
care when human becoming guides practice. A number of studies have been published in which the authors used this method (Jonas, 1995a; Mitchell,
1995; Northrup & Cody, 1998; Santopinto & Smith,
1995). Details of the processes of these three methods can be found in Parses 1998 work, The Human
Becoming School of Thought.
HUMAN BECOMING
PRACTICE METHODOLOGY
The goal of the discipline from the human becoming
perspective is quality of life. The goal of the nurse living the human becoming beliefs is true presence in
bearing witness and being with others in their changing health patterns. True presence is lived through
the human becoming dimensions and processes: illuminating meaning, synchronizing rhythms, and mobilizing transcendence (Parse, 1987, 1992, 1994a,
1995, 1997a, 1998a). The nurse with individuals or
groups is truly present 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 human
becoming. It is sometimes misinterpreted as simply
asking persons what they want and respecting their
desires. This alone is not true presence. True presence is an intentional reflective love, an interpersonal art grounded in a strong knowledge base
(Parse, 1998a, p. 71). The knowledge base underpinning true presence is specified in the assumptions
and principles of human becoming (see Parse, 1981,
1992, 1995, 1997a, 1998a). True presence is a freeflowing attentiveness that arises from the belief that
the human in mutual process with the universe is
unitary, freely chooses in situation, structures personal meaning, lives paradoxical rhythms, and
moves beyond with changing diversity (Parse,
1998a). Parse states: To know, understand, and live
the beliefs of human becoming requires concentrated study of the ontology, epistemology, and
methodologies and a commitment to a different way
of being with people. The different way that arises
from the human becoming beliefs is true presence
(Parse, 1998b). Many papers are published explicating human becoming practice; for example, Arndt,
1995; Banonis, 1995; Butler, 1988; Butler & Snodgrass, 1991; Chapman, Mitchell, & Forchuk, 1994;
Rosemarie Rizzo Parse The Human Becoming School of Thought
231
Jonas, 1994, 1995b; Lee & Pilkington, in press; Liehr,

1989; Mattice, 1991; Mattice & Mitchell, 1990;
Mitchell, 1988, 1990b; Mitchell & Copplestone,
1990; Mitchell & Pilkington, 1990; Quiquero,
Knights, & Meo, 1991; Rasmusson, 1995; Rasmusson, Jonas, & Mitchell, 1991, among others.
True presence is a powerful human-universe connection experienced in all realms of the universe. It
is lived in face-to-face discussions, silent immersions,
and lingering presence (Parse, 1998a, pp. 7180).
Nurses may be with persons in discussions, imaginings, or remembrances through stories, films, drawings, photographs, movies, metaphors, poetry, rhythmical movements, and other expressions (Parse,
1998a, p. 72).
your thoughts
HUMAN BECOMING
GLOBAL PRESENCE
The human becoming school of thought is a guide
for research and practice in settings throughout the
world. Scholars from four continents have embraced
the belief system and live human becoming in research and practice.
In Toronto, Sunnybrook Health Science Centres
multidisciplinary standards of care arise from the
beliefs and values of the human becoming school of
thought. There are other health centers throughout
the world that have these beliefs and values as guides
to health care.
In South Dakota, a parish nursing model was built
on the principles of human becoming to guide
nursing practice at the First Presbyterian Church in
Sioux Falls (Bunkers & Putnam, 1995; Bunkers,
Michaels, & Ethridge, 1997). Also, the Board of Nursing of South Dakota has adopted a decisioning model
based on the human
True presence is inten- becoming school of
thought (Damgaard &
tional reflective love, an
Bunkers, 1998). Auinterpersonal art grounded gustana College (in
Sioux Falls) has huin a strong knowledge
man becoming as one
base. central focus of the
curricula for the baccalaureate and masters programs. It is the basis of
Augustanas Health Action Model for Partnership in
Community (Bunkers, Nelson, Leuning, Crane, &
Josephson, 1999).
A research project on the lived experience of
hope was conducted using the Parse method, with
participants from Australia, Canada, Finland, Italy,
Japan, Sweden, Taiwan, the United Kingdom, and
232
the United States. The findings from these studies

and the stories of the participants are published in
the book Hope:An International Human Becoming
Perspective (Parse, 1999).
Approximately 300 participants subscribe to
Parse-L, an E-mail listserv where Parse scholars share
ideas. There is a Parse homepage on the World Wide
Web that is updated regularly.
Each year most of the 100 or more members of
the International Consortium of Parse Scholars meet
in Niagara-on-the-Lake, Canada, for a weekend immersion in human becoming research and practice.
Members of the consortium have prepared a set of
teaching modules (Pilkington & Jonas-Simpson, 1996)
and a video recording (International Consortium of
Parse Scholars, 1996) of Parse nurses in true presence with persons in different settings. Parse scholars present lectures and symposia regularly at international forums.
The Institute of Human Becoming, founded in
1992, was created to offer interested nurses and others the opportunity to study with the author the on-
tological, epistemological, and methodological aspects of the human becoming school of thought. Toward that goal, the institute offers regular sessions
devoted to the study of the ontology and the research and practice methodologies. All of the sessions have as their goal the understanding of the
meaning of the human-universe-health process from
a human becoming perspective.
Summary
Through the efforts of Parse scholars the human becoming school of thought will continue to emerge as
a force in the twenty-first century evolution of nursing science. Knowledge gained from the basic research studies will be synthesized to explicate further the meaning of lived experiences. The findings
from applied research projects related to evaluation
of human becoming practice will be synthesized and
conclusions drawn. These syntheses will guide decisions in creating the continuing vision for sciencing
and living the art of the human becoming school of
thought.
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53.
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Parse, R. R. (1990). A time for reflection and projection. Nursing Science Quarterly, 3, 143.
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Parse, R. R. (1993). Cartoons: Glimpsing paradoxical
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Parse, R. R. (1996). Critical thinking: What is it? Nursing Science Quarterly, 9, 138.
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Parse, R. R. (1996). The human becoming theory: Challenges in practice and research. Nursing Science
Quarterly, 9, 5560.
Parse, R. R. (1996). Nursing theories: An original path.
Parse, R. R. (1996). Quality of life for persons living
with Alzheimers disease: A human becoming perspective. Nursing Science Quarterly, 9, 126133.
Parse, R. R. (1996). [Review of the book Martha E.
Rogers: Her life and her work.] Visions:The Journal
of Rogerian Science, 2, 5253.
Parse, R. R. (1997). Concept inventing: Unitary creations. Nursing Science Quarterly, 10, 6364.
Parse, R. R. (1997). The human becoming theory and
its research and practice methodologies. In Oster-
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Parse, R. R. (1997). The language of nursing knowledge: Saying what we mean. In Fawcett, J., & King,
I. M. (Eds.), The Language of theory and metatheory (pp. 7377). Sigma Theta Tau monograph.
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Parse, R. R. (1997). [Review of the book Quality of life
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Parse, R. R. (1997). Transforming research and practice
with the human becoming theory. Nursing Science
Parse, R. R. (1998). The art of criticism. Nursing Science Quarterly, 11, 43.
Parse, R. R. (1998). Moving on. Nursing Science Quarterly, 11, 135.
Parse, R. R. (1998). Will nursing exist tomorrow? A
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Parse, R. R. (1999). Expanding the vision: Tilling the
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Chapter 15
Part 2
The Human Becoming Theory in

Practice, Research, Administration,
Regulation, and Education
Fostering the Human Becoming Practice Method:
Creating a Space for Living the Art of True Presence
Research on Human Becoming
Nursing Leadership from a Human Becoming Perspective:
One Leaders Story
A Nursing Regulatory Decisioning Model
The Human Becoming Theory in Teaching-Learning
References
William K. Cody
Sandra Schmidt Bunkers
Gail J. Mitchell
This section of the chapter describes the application

of Parses Theory of Human Becoming in practice, research, administration, education, and regulation. An
overview of the application of the theory in each
arena is given in each section, followed by more detailed and specific illustrations of actual situations.
FOSTERING THE HUMAN

BECOMING PRACTICE METHOD:
CREATING A SPACE FOR LIVING
THE ART OF TRUE PRESENCE
Living the human becoming practice methodology
offers nurses infinite opportunities for unique experiences lovingly coparticipating with people as they
explore life options, steer-and-yield with the flow of
life events, choose paths, and bear the consequences
of choices. In choosing to practice from a human becoming perspective, a nurse commits to an explicit
matrix of values and beliefs about humans, health,
and nursing. What a nurse believes about humans,
health, and nursing finds expression in every dimension of her or his way of being with others.
As Rosemarie Rizzo Parse has shown earlier in the
chapter, the Theory of Human Becoming has given
rise to a school of thought. The theorys assumptions
and principles. comprise the ontology of the school
of thought, which describes the person as freely
choosing meaning in situation, continuously coexisting and interrelating multidimensionally with others
in the universe, and transcending with the possibles
in uniquely personal ways. Freely choosing meaning
is cocreating reality through ones self-expression in
living cherished values. In continuously interrelating
with others, one cocreates the rhythmic paradoxes
experienced in the bittersweet ups and downs of living. One continuously transcends with the possibles
through shifting perspectives of unfolding events
and committing to a chosen course of action while
never fully knowing the outcome.
The human becoming practice methodology
flows from these beliefs and delineates a way of authentically living these beliefs. The essence of the
methodology is structured in the written dimensions
and process first published by Parse in 1987 but augured by less formal guidance for practice offered in
1981. The dimensions and processes are stated in
Table 151.
Since Parses theory was published in 1981 (and
before that time, among Parses students and colleagues from Duquesne University, where she first
developed the theory), an increasing number of
nurses have cited Parses theory as the single most
240
important influence on their practice. Nurses of

many backgrounds and many different levels of
preparation in varied settings have found Parses perspective to be closest to their own beliefs about nursing and have therefore chosen to use the theory to
guide their practice.
As Parse pointed out in the first section of this
chapter, the theory serves as the guide to practice in
many settings in several countries and has been described in many publications (Arndt, 1995; Banonis,
1995; Butler, 1988; Butler & Snodgrass, 1991; Chapman, Mitchell, & Forchuk, 1994; Cody, 1995a; Jonas,
1994, 1995; Lee & Pilkington, 2000; Liehr; 1989;
Mattice, 1991; Mattice & Mitchell, 1990; Mitchell,
1988, 1990b; Mitchell & Copplestone, 1990;
Mitchell & Pilkington, 1990; Northrup & Cody, 1998;
Quiquero, Knights, & Meo, 1991; Rasmusson, 1995;
Rasmusson, Jonas, & Mitchell, 1991). For example,
at Sunnybrook Health Science Centre in Toronto,
Canada, the nursing leadership developed standards
of care based on the Human Becoming Theory to be
applied throughout this 1100-bed health science center. On a much smaller scale, the Center for Human
Becoming was established in 1997 in Charlotte, North
Carolina, as a milieu for the nurse-person process
within a 25-unit housing complex for people living
with HIV. In other settings, where the human becoming theory is not the overall guide to nursing
practice institutionally, individual nurses also live the
values and beliefs of the theory.
Implementing the human becoming theory as the
central guide to nursing practice is never easy for individuals or institutions. For individuals, adopting
the Human Becoming Theory often means confronting doubts about ones profession, experiencing conflict and confusion in practice, and alienating
coworkers committed to the old paradigm. Such individual nurses may gain knowledge and encouragement from available texts and other media (Fitne,
1997; International Consortium of Parse Scholars,
1996), from the regular conferences of the International Consortium of Parse Scholars and its regional
chapters, and from the annual conferences led by
Parse at Loyola University in Chicago. It is difficult,
though not impossible, to implement the theory in
practice without the support of others. Small enclaves of Parse nurses exist in a wide variety of workplaces in towns and cities around the globe.
In institutions, a dependable commitment of resources from top-level administration and the ready
availability of well-prepared education and practice
leaders are minimal essentials for implementing
Parses theory-guided practice. Guiding nursing practice in an institution by the Human Becoming Theory
TABLE 15-1
Themes
Themes, Assumptions, Principles, and Practice Dimensions of

Parses Theory
Assumptions
Principles
Practice Dimensions
Meaning
Human becoming
is freely choosing
personal meaning
in situations in the
intersubjective
process of relating
value priorities.
Structuring
meaning
multidimensionally is cocreating
reality through
the languaging of
valuing and
imaging.
Illuminating meaning is
shedding light through
uncovering the what
was, is, and will be, as
it is appearing now; it
happens in explicating
what is.
People always participate in

creating their realities through
choosing how to understand
and interpret experiences.
Expressing oneself clarifies
values and furthers understanding of experiences.
Rhythmicity
Human becoming
is cocreating
rhythmical
patterns of relating
in open
interchange with
the universe.
Cocreating rhythmical patterns of

relating is living
the paradoxical
unity of revealing
concealing,
enablinglimiting,
while connecting
separating.
Synchronizing rhythms
happens in dwelling
with the pitch, yaw, and
roll of the interhuman
cadence.
People live potentialities with

actualities all-at-once; the
apparent opposite of what is in
the fore of experience is always
also present with us. Exploring
options in the attentive, loving
presence of another is a way of
connectingseparating with
others in the universe.
Transcendence
Human becoming
is transcending
multidimensionally
with the unfolding
possibles.
Cotranscending
with the
possibles is
powering
originating in the
process of
transforming.
Mobilizing transcendence happens in

moving beyond the
meaning moment to
what is not yet.
People live with change in

chosen ways that evolve into
patterns of living that also
change over time.
Coparticipating in change
through ones choice affirms
self and cocreates with the
universe what will be. By
exploring options in the
presence of another, one moves
beyond what is to what is not
yet.
requires a profound paradigm shift within the local

nursing culture, far beyond what is often called a
paradigm shift in the rhetoric of the health-care industry. To adopt Parses theory as the guide to practice is to adopt fundamentally different definitions of
such key notions as health, family, presence, options, person, freedom, and reality. Parses Theory of
Human Becoming is not a model for nursing practice
that can be imposed on unwilling workers. The Parse
nurse lives the values and beliefs manifest and structured linguistically in the theory. Clearly, this can
only become an actuality through individual choice.
However, as shown at Sunnybrook Health Science
Centre, the Human Becoming school of thought can
serve as the guide to generate standards of practice
that reflect the values and beliefs of the theory,
which thereby brings practice within an institution
closer to that school of thought.
Fostering the art of true presence in nursing practicewhich is living the values and beliefs under-
Comments
pinning Parses practice methodology in the nurseperson processrequires the creation of a space
where nurses choices to move to a new paradigm of
nursing practice are honored, a space where persons individual meanings and choices are profoundly
valued, and where resources are dedicated to cocreating quality of life from each persons own perspective. In this section of the chapter, two detailed
examples of practice guided by the Human Becoming Theory are presented, illustrating a parish nursing model and a community action model.
Human Becoming as a Guide

for Parish Nursing
A Human Becoming parish nursing practice model
was developed at the First Presbyterian Church in
Sioux Falls, South Dakota (Bunkers & Putnam, 1995).
The central focus of this nursing theorybased health
model is quality of life for the parish community (see
Chapter 15 Cody, Bunkers, and Mitchell The Human Becoming Theory in Practice
241
your thoughts
Fig. 151). The nurse-person-community health process emphasizes lived experiences of health of individual parishioners and of the entire parish community. The eight beatitudes, being fundamental to the
belief system of the parish, are paralleled with concepts of the Human Becoming Theory to guide nursing practice in the parish. For example, true presence is paralleled with the beatitude, Blessed are
those who hunger
In practicing from a human and thirst for righteousness, for they
becoming perspective, a shall be filled, which
nurse commits to an ex- expresses the desire
for a deep, loving relaplicit matrix of values and tionship with people
beliefs about humans, and with God (Ward,
1972). True presence,
health, and nursing.
the cornerstone of human becoming nursing practice, is lived with the parish community in a
loving, reflective way, bearing witness to others living health and honoring each persons uniqueness
without judging him or her. The nurse, in true presence, respects people as knowing their own way, a
chosen personal way of being with the world. A further example of paralleling the beatitudes with the
Human Becoming Theory is the beatitude, Blessed
are the pure in heart, for they shall see God, which
describes a singleness of purpose for living an ethic
of love and care for others (Ward, 1972). This ethic
of love and care honors human freedom. The Parse
nurse understands that humans are inherently free,
and the nurse in parish nursing practice honors
this freedom. The nurse honors how others choose
to create their world and seeks to know and understand the wholeness of their lived experiences of
242
faith and health (Bunkers, 1998; Bunkers et al.,

1999, p. 92).
Living Parses Theory of Human Becoming in practicing nursing in the parish holds the possibility of
transforming community nursing practice and transforming ways of living health in a parish. Bunkers
and Putnam (1995) state, The nurse, in practicing
from the human becoming perspective 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).
Human Becoming as a Guide

for Nursing Education-Practice
The Health Action Model for Partnership in Community is a nursing education-practice model originating in the Department of Nursing at Augustana College in Sioux Falls, South Dakota, which addresses
the connections and disconnections existing in human relationship (Bunkers, Nelson, Leuning, Crane,
& Josephson, 1998; Bunkers et al., 1999, p. 92) (see
Fig. 152). This collaborative community nursing
practice model focuses on lived experiences of connection-disconnection 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 Health Action Model, based on Parses human
becoming school of thought, focuses on the primacy
of the nurses presence with others. The focus of the
nurse-person-community health process is quality of
life from the person-communitys perspective. Quality of life, the central concept of the model, is elaborated on in the conceptualizations of health as hu-
243
man becoming, community interconnectedness, and

voices of the person-community. The purpose of the
model is to respond in a new way to nursings 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). Advanced practice nurses, a steering committee, and six site communities are moving together
in seeking mutual understanding of human
The Health Action Model,
health issues while
based on Parses Human holding as important
Becoming school of the unique perspectives presented by inthought, focuses on the dividuals and groups
primacy of the nurses pres- with complex health
situations. The comence with others. munity of Sioux Falls,
South Dakota, has embraced this theory-based nursing education-practice
model by providing funding from community
sources, including Augustana College, Sioux Valley
Health System Community Fund, Sioux Falls Area
244
Foundation, Sioux Falls Public School System Head

Start Program, and the Sioux Empire United Way.
In the Health Action Model, advanced practice
nurses work with persons and groups in the Site
Communities in creating a prototype of collaboration in addressing issues concerning quality of life
(Bunkers et al., 1999, p. 94). Site communities are
agencies or places that seek to respond to the health
and social-welfare issues of those struggling with
lack of resources (see Fig. 153). Issues of quality of
life are addressed with nurses asking persons, families, and communities what their hopes for the future are and working with them to create personal
health descriptions and health action plans. Personal
health descriptions are written in the words of the
person, family, or community and include: (1) what
life is like for me now; (2) my health concerns are;
(3) whats most important to me now; (4) my hopes
for the future are; (5) my plans for the future are;
(6) how I can carry out my plans; and (7) my specific
health action plan is (Bunkers et al., 1999). When
a person or community identifies a health pattern
they want to develop further or identifies a desire to
245
your thoughts
change certain health patterns, the nurse explores

how she or he can support that process.
Objectives of the Health Action Model include:
(1) creating a nursing practice model to guide provision of health services based on Parses Human Becoming school of thought for families experiencing
economic and social marginalization and/or homelessness; (2) using the Health Action Model to address health issues of site communities; (3) providing educational experiences for nursing and other
health professional students focusing on diversity;
and (4) extending the Health Action Model beyond
the local area and sharing it as a prototype for health
care regionally, nationally, and internationally (Bunkers et al., 1999).
A steering committee, composed of nursing leaders from health systems in the community, individuals from a variety of social-welfare agencies dedicated
to serving society, and people who are experiencing
economic marginalization and homelessness, meets
quarterly to listen to the emerging health issues of
the site communities. The steering committee seeks
to create new linkages of care where none exist and
to expand sources of funding for the model. These
community leaders have strong beliefs that community interconnectedness occurs when everyone involved has a voice (Bunkers et al., 1999, p. 94).
Parses human becoming school of thought serves
as the linchpin in this model for developing new
ways of connecting person to person, agency to
agency, and community to community. Bunkers and
colleagues (1999) state:
The interconnectedness of community involves relationship that transcends separating
differences. There [is] no lack of spoken and
written words about persons experiencing the
246
separating differences of living with little or

no money and no place to call home. What is
missing in community is an intentional listening to the sound of these voices speaking and
writing about their own hopes and meanings.
To embrace separating differences involves listening and understanding others. The nurseperson-community health process involves being truly present with others with a listening
receptivity to differing values. Nurses practicing in this model understand that community
as process entails moving together in seeking
mutual understanding. . . . Moving together in
seeking mutual understanding calls for a type
of listening to one another where both nurse
and person-community engage in contributing
to expanding choices for living health. (pp.
9495)
Parse (1996, p. 4) writes that community in its most
abstract sense is the universe, the galaxy of human
connectedness. The Health Action Model for Partnership in Community seeks to cultivate this human
connectedness for the betterment of humankind.
RESEARCH ON HUMAN BECOMING

The published research that has been generated, inspired, and guided by the human becoming theory
has been of several types. Three research methods
have been developed and endorsed by Parseone
by Parse alone, and two others with her collaboration and leadership. The Parse Research Method
(Parse, 1987, 1990, 1995, 1999), a phenomenological method in the generic sense, is intended to
guide basic research on humanly lived experiences.
The Human Becoming Hermeneutic Method (Cody,
1995c) is intended to guide interpretive research

on the meanings of texts. The preproject-processpostproject evaluation method is intended to guide
applied research on the implementation of Parses
theory-based nursing practice in a given venue.
Parses Phenomenological Method

The essentials of Parses phenomenological research
methodology were first published in the book Nursing Science: Major Paradigms, Theories, and Critiques (Parse, 1987), in Parses individual chapter on
her theory. At the time, no other theorist in nursing
had ventured to delineate a particular method congruent with her theory. In 1990, Parse published a
more detailed explication of the method, along with
an illustration focusing on the lived experience of
hope (Parse, 1990). A number of studies using the
method have been published over the past 9 years
(for examples, see Bunkers, Damgaard, Hohman, &
Vander Woude, 1998; Cody, 1991; 1995b; Daly,
1995; Mitchell, 1990a; Parse, 1994, 1997; Pilkington, 1993; Smith, 1990). A previously unpublished
example, drawn from a study of the lived experience
of bearing witness to suffering, follows. This study
focused on the lived experience of bearing witness
to suffering, of families and caregivers of persons living with HIV.
Phenomena for study using Parses research
methodology are universal human health experienceshealth is defined as quality of life
Health is defined as quality from the persons perof life from the persons spective (Parse, 1998,
p. 64). Bearing witness
perspective. Phenomena
to suffering is posited
for study using Parses as such an experience.
Previous research on
research methodology
the grieving of families
are universal health living with HIV (Cody,
experiences. 1995b) suggested that
bearing witness to suffering was a common
yet profound and life-changing experience of family
members and caregivers. Suffering has often been
posited as a human universal (Daly, 1995). Bearing
witness to suffering is lived in being fully present
with others as they live the various dimensions of anguish inherent in humanly lived experience.
For this study, family members and occupational
caregivers of persons living with AIDS were invited
to describe their lived experiences of bearing witness to suffering. The participant group included 13
self-identified family members and 12 occupational
caregivers (including nurses, aides, therapists, and
others). There were 18 females and 7 males, 23

whites, one Hispanic, and one African-American. Participant ages ranged from 21 to 74. The study was approved by a university review board and all participants read and signed informed consent forms.
Confidentiality was maintained throughout the study,
and tapes were destroyed when the study was completed.
Data are recorded, in Parses research methodology, through the process of dialogical engagement.
Dialogical engagement is not an interview, but rather
is living true presence with participants as they describe their lived experience. In this study, the researcher was personally present in each dialogue.
Participants were encouraged to describe their experiences as thoroughly as possible, and the researcher
refrained from content-specific prompts while simply encouraging each participant to describe her or
his personal experience completely. Dialogues were
recorded on audiotape, and on videotape when permitted. Four participants declined to be videotaped.
Descriptions were transcribed verbatim.
your thoughts
247
TABLE 15-2
Extraction-Synthesis Process, Participant 2

Participant 2
Caregiver: Home Health Aide
Essences in Participants Language
Essences in Researchers Language
1. Witnessing the most hideous illness shes ever seen and

experiences that would crush her, the participant wants
to take the pain away but knows she cannot. She realizes
that life is fragile and appreciates the smaller things.
1. Attending to the wretchedness of another prompts a

desire to rectify torment and a prizing of the ordinary.
2. The participant wants to be there for the patient as she

would want someone to be there for her. Just sitting and
talking with a patient means a lot, as each tries to make
the other comfortable and she feels at peace while with
the patient.
2. Commitment to the other surfaces with the significance

of sharing as mutual succor yields to serenity.
3. The closeness makes it hard when the patients get

worse or die because the participant goes through it with
them. She tries to make a difference in their short time
together while admiring the peace and fortitude they
achieve.
3. Intimacy intensifies presence with one in calamity,

whereas reverence sparks a struggle to enhance the
moment.
Proposition
For Participant 2, bearing witness to suffering is attending to the wretchedness of another, which prompts the desire
to rectify torment, while reverence sparks a struggle to enhance the moment and commitment to the other surfaces
with the significance of sharing as mutual succor yields to serenity.
Data are not analyzed in the conventional sense,

in Parses method, as this word implies reductionistic
dissection of meaning that is antithetical to the unitary ontology of the theory. Extraction-synthesis is
culling the essences from the dialogue in the language of the participant and conceptualizing these
essences in the language of science to form a structure of the experience (Parse, 1998, p. 65). This occurs through long and contemplative dwelling with
the dialogues, through reading and listening, while
abiding with the meaning of the experience projected by the speaker. Essences are first drawn from
the words of participants, then synthesized in the
words of the researcher. From the essences generated
from one participants description, a proposition is
formulated. From all such propositions, core concepts are extracted and synthesized. From all core
concepts, a structure of the lived experience is synthesized. All these processes are illustrated in the presentation of findings found in Tables 152 to 155.
All of the participants in this study described in
some way the first concept, expressing a commitment sparked by veneration. For example, Participant 10, a group home worker, stated that she
248
regarded being with the residents as they were suffering as a sacred experience, and said she was in
awe that she was the one with the privilege to be
with them at that time in their lives. She also gave an
example of bearing witness in which she spoke
about a resident who, she said, was so afraid to
leave the house [that is, to die]. . . . And he said,
Could you just hold me? and so she just climbed in
bed with him and held him. This is the idea of expressing a commitment. It is not simply expressing
a commitment, but living it. Participant 13, who
cared for his partner as he died while he himself was
also HIV positive, said, My responsibility as a caregiver was total, completementally, physically, I
said, I am here for you, you know. My basic life was,
you know, sort of put to the side. We needed to concentrate on his health, because at that point, my
health was okay.
There was a discernible difference between the
descriptions of the families and the caregivers.
Whereas family members spoke in very personal details about the person who was suffering, how they
valued that person, and related very specifically to
that individuals suffering, the caregivers described a
TABLE 15-3
Extraction-Synthesis Process, Participant 25

Participant 25
Family Member, Spouse
Essences in Participants Language
Essences in Researchers Language
1. The participant could see the turmoil in Vinnie as the HIV

progressed and he was in constant pain. The participant
couldnt stand to see Vinnie like that and Vinnie hated
needing help, but he let the participant help.
1. Attentive presence with one in anguish intensifies

intimacy, easing limitations.
2. The participant fed and turned Vinnie, knowing he never

wanted it to be like that. He tried to carry out Vinnies
wishes, though when Vinnie could no longer talk, there
was no way to know. He did it because he loved Vinnie.
2. Endearment inspires persisting in hardship despite

doubts.
3. The participant slept with Vinnie every night to be close;

those were their special times. Visits with loving family
brightened him up. They joked and laughed, knowing that
nothing would really help, but holding on to any hope.
3. Prizing the cherished expands the now.
4. Vinnies suffering got so bad the participant told him to let

go. Afterward, they spent time together and said goodbyes; it was a good time. The participant thanked God it
was over but wondered if hed done all he could, and
loving relatives reassured him.
4. The ending of agony eases loss as sharing joysorrow

brings contentment and gratitude to the surface.
Proposition
For Participant 25, bearing witness to suffering is attentive presence with one in anguish, which intensifies as
intimacy eases limitations while endearment inspires persisting in hardship despite doubts and prizing the cherished
expands the now as sharing joy-sorrow surfaces contentment and gratitude.
more general veneration of the persons living with

AIDS whom they served in the context of a professional or occupational relationship.
The second core concept is attentive presence
with one in anguish.This is basically the essence of
the phenomenon of bearing witness to suffering itself. This concept was described very directly by
most of the participants. For example, Participant 2
(a home health aide) said, You can see them one day,
and theyre up and able to walk and talk. Two days
later, you may go in, and theyre bedridden. And yet,
through it all, they still want you to sit there, hold
their hand, and theyll still smile for you. Participant
25, a 35-year-old gay man, described a time near the
end of his partners life, when he was still in so
much painso we arranged to have IV morphine. . . . And they told me two weeks to two
months. And he was such an independent
person. . . . So he had a hard time with caregivers.
And the primary caregivers were his mother and myself. . . . Mom took care of Vinnie during the day, and
then I would come home in the evening, and I would

take care of him during the night. These quotes illustrate the concept of attentive presence with one in
anguish.
The third concept, expanding the now in light of
beliefs and doubts, refers to descriptions given by
participants in which they sought to make the most
of the time they had with the person living with AIDS
in light of the beliefs they held and equally in light of
doubts about what was right to do, what help or acceptance was available, or indeed what the future
held for this relationship in light of the presence of
AIDS. For example, Participant 13who, along with
his lover, was HIV positivesaid, We did a lot of
things after we were HIV positive that wed always
wanted to do. We did a lot of travelling and, you
know, other things that we just new that we needed
to get in. . . . And we did a lot of house hunting,
things like that . . . but we knew, looking at houses
as just a pipe dream, you know? Participant 25 said
about his lover that the feeling he had about the fu-
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TABLE 15-4
Extracted Core Concepts and Structure of Bearing Witness

to Suffering
Extracted Core Concepts
1. Expressing a commitment sparked by veneration
2. Attentive presence with one in anguish
3. Expanding the now in light of beliefs and doubts
4. A hard-won serenity amidst on-going joysorrow
Structure of the Lived Experience

The lived experience of bearing witness to suffering for families and caregivers of persons living with HIV is
expressing a commitment sparked by veneration through attentive presence with one in anguish, expanding the now
in light of beliefs and doubts, yielding a hard-won serenity amidst ongoing joysorrow.
ture was bad. I mean, he would cry about never seeing his nieces and nephews graduate, never seeing
them date, and all that. And kinda to ease himself, he
made me a promise that Id always be part of his family. His idea was that hed be able to see all this happen through me. These are illustrations of the concept of expanding the now in light of beliefs and
doubts.
TABLE 15-5
The fourth core concept, a hard-won serenity

amidst ongoing joysorrow, refers to the descriptions that participants gave of a kind of bittersweet
peace and contentment that came after witnessing
suffering over time. For example, Participant 2 said,
When they are able to feel comfortable enough with
me to say, I want to share this with you, its a feeling
of peace with me, and with them. Its just like, like I
Heuristic Interpretation of the Structure of Bearing Witness

to Suffering
Heuristic Interpretation
Structure
250
Structural Transposition
Conceptual Integration
1. Expressing a commitment sparked

by veneration
1. Incarnating devotion
1. Languaging
2. Attentive presence with one

in anguish
2. Communion in misery
2. Connectingseparating
3. Expanding the now in light of

beliefs and doubts
3. Amplifying possibilities
in light of certaintyuncertainty
3. Originating
4. A hard-won serenity amidst

ongoing joysorrow
4. A bittersweet calm
4. Transforming
Structural Statement
Bearing witness to suffering is

expressing a commitment sparked
by veneration through attentive
presence with one in anguish,
expanding the now in light of beliefs
and doubts yielding a hard-won
serenity amidst ongoing joysorrow.

incarnating devotion through communion
in misery, amplifying possibilities in
light of certaintyuncertainty, yielding
a bittersweet calm.
languaging the paradoxical unity
of connectingseparating in
originatingtransforming.
said, and old friend. Participant 10 said, Its a feeling

of oneness. . . . Theres no conflict, no dissension.
She said she has come to know God better through
the residents, she has no regretsbecause she knows
she did what she should in being there, and its very
comforting.
Through heuristic interpretation, the phenomenological structure is raised to the level of theory.
The processes of heuristic interpretation are structural transposition and conceptual integration. The
theoretical structure generated through this study is
seen in Table 155. Bearing witness to suffering is
languaging the paradoxical unity of connecting
separating in originatingtransforming. This theoretical structure explicBeing truly, fully present itly interrelated concepts of Parses theory
with one who is suffering
to represent an emerunfolds as an expression of gent conceptualization
of the phenomenon.
a commitment, living a
Bearing witness to sufchoice, sparked by venera- fering is languaging
tionprofound respect and expressing who one is
in living the paradoxigenuine fondness. cal unity of connecting
separatingintensely
being with and apart from the other all-at-once
while originatingtransformingchoosing a path
amid ambiguity, giving rise to a new perspective. The
interpretation arises from the phenomenologichermeneutic ontology of the Human Becoming
Theory.
The implications of this study mainly relate to enhanced understanding of the human experience. Being truly, fully present with one who is suffering un-
TABLE 15-6
Theme
folds as an expression of a commitment, living a

choice, sparked by venerationprofound respect
and genuine fondness. This sheds light on family relationships and caregiving relationships and the lived
experiences of those who choose to be present with
the suffering. In contrast, we know that there are
those who choose not to bear witness to the suffering. Clearly, the value of a loving presence cannot be
overestimated. Bearing witness to suffering is also
expanding the nowor making the most of the
time one hasin light of beliefs and doubts. The beliefs and doubts outline the possibilities of what one
can become and what one can do in the time remaining. Those who bear witness to suffering report ultimately a sense of a hard-won serenity, a peacefulness
that comes from knowing that one was there and
one did what one could, even as the joys and sorrows of life continuously unfold.
Hermeneutic Method
and Evaluation Method
The Human Becoming Hermeneutic Method (Cody,
1995c; Parse, 1998) was developed in congruence
with the assumptions and principles of Parses
theory, drawing on works by Bernstein (1983),
Gadamer (1976, 1989), Heidegger (1962), Langer
(1967), and Ricoeur (1976). Gadamers work in particular guided the explication of the method. This
method is intended to guide the interpretation of
texts in light of the human becoming perspective,
possibly giving rise to new understandings of human
experiences as manifest in the emergent meanings
that are the findings of a hermeneutic study. In
Codys work in developing the method, the herme-
Explication of the Human Becoming Perspective

of the Hermeneutic Processes of Discoursing,
Interpreting, and Understanding
Explication
Meaning
Discoursing is the interplay of shared and unshared meanings through which beliefs are
appropriated and disappropriated. A text, as something written and read, is a form of discourse.
Author and reader are discoursing whenever the text is read (Cody, 1995, p. 275).
Rhythmicity
Interpreting is expanding the meaning moment through dwelling in situated openness with the
disclosed and the hidden. Interpreting a text is constructing meanings with the text through the
rhythmic movement between the language of the text and the language of the researcher (Cody,
1995, p. 275).
Transcendence
Understanding is choosing from possibilities a unique way of moving beyond the meaning moment.
Understanding a text is interweaving the meaning of the text with the pattern of ones life in a chosen
way (Cody, 1995c, p. 276).
251
neutic processes of discoursing, interpreting, and

understanding were explicated within a human becoming perspective, informed by important works
by the authors above. Each of these key processes is
associated with one of the three central themes of
the Human Becoming Theory. The processes are described briefly in Table 156. Cody (1995c) used the
method to interpret a body of poetry by Walt Whitman (1983). A study in progress will examine the
concept of mendacity in relation to the refusal to
bear witness, in Tennessee Williamss play, Cat on
a Hot Tin Roof. The possibilities for textual interpretation using the Human Becoming Hermeneutic
Method are manifold.
The preproject-process-postproject evaluation
method is described in detail in Parses 1998 work,
The Human Becoming School of Thought. The purpose of this method is to evaluate the changes that
take place when the human becoming theory is
adopted in a given venue as the guide to practice.
NURSING LEADERSHIP FROM A

HUMAN BECOMING PERSPECTIVE:
ONE LEADERS STORY
The Human Becoming school of thought (Parse,
1981, 1995, 1998) prepares nurses to assume positions of leadership for the purpose of enhancing the
quality of human care in all settings. The knowledge
base of the theory enables leaders to create and nurture opportunities for staff to change their attitudes,
values, and approaches in practice and research.
Parses Theory of Human Becoming helps professionals move toward a more participative, client-
centered model of service delivery. Knowledge

framed by human becoming constitutes the leaders
unique contribution to a community of health-care
professionals. The nurse leaders views coexist with
multiple other views and beliefs about health care. It
is precisely the diversity of ideas and purposes that
generate the dynamic culture of comprehensive and
compassionate human care.
In the broadest sense, leadership guided by the
human becoming theory means working toward creating a particular culture of care. Culture of care, as
defined here, refers to the assumptions, values, and
meanings expressed and shared in the language patterns of a group of people. In general, the changes
that are invited include changing from telling and
teaching to listening and dialoguing, changing from
trying to control patients decisions to facilitating
choices, and changing from judging and labeling differences among people to respecting and representing differences. Like all cultures, the human becoming culture coexists with other cultures of the
community. For instance, in hospital settings other
cultures include those of medicine and management.
The Human Becoming Theory provides the foundation for leaders to invite others to explore the values, intentions, and desires that shape human care
and professional practice. The leading process is not
about educating staffmeaning it is not about giving
information. Rather, leading is about a process of
guided discovery that surfaces insights about self and
human becomingthe insights are the windows of
change. Personal insights coupled with new knowledge can dramatically change practice and the quality of relationships that staff have with individuals,
families, and groups.
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252
Processes of Leading in Change

Leading in a community involves processes of explicating, visioning, discovering, confirming, and disclosing. These processes happen in the context of
discussions about human care and meaningful service.
Explicating involves a process of examining the
assumptions, values, and meanings embedded in current practices. For example, this includes examination of the assumptions and values of the traditional
nursing process multisystem assessments, and prescription. Nurses reLeading is about a process quire opportunities to
consider the meanings
of guided discovery that of words like dysfuncsurfaces insights about self tional, manipulative,
unrealistic, and nonand human becomingthe compliant. The Human
insights are the windows Becoming school of
thought offers an alterof change.
native framework for all
professionals to think
about the human-universe process and its connections with practice and human care. The outcome of
explicating includes clarification of the values and assumptions of different processes of care and service.
Visioning is the process whereby staff imagine
the forms and patterns that could constitute human
care. The predominant questions that invite discourse and insight here are what if questions: What
if individuals were considered to be the experts
about their own health and quality of life? What if
nurses were required to listen to individuals meanings and values in order to know how to care and be
helpful? What if people themselves led the healthcare team and selected members of disciplines they
wanted involved in their care? What if records were
kept at the bedside and patients and families were
the ones who monitored access to the record, documented their experiences, and evaluated care? What
if there were no assessment tools to evaluate patients coping styles, degree of compliance, or patterns of decision making? What if nurses considered
themselves accountable for their practice to patients
and families? These sorts of questions invite staff to
think outside of familiar patterns of practice.
Discovering happens as staff see the familiar in a
new light. Nurses glimpse contrasting realities and
views in discourse with others who discuss alternative ideas. Insights occur in flashes that shed light on
how reality in practice could be shaped. The process
of discovery can be both exciting and unsettling.
There is risk in opening oneself to see things in a
new way. Discovery changes everything in a cascading flow of understanding. Leaders can invite and
nurture discovery, but ultimately it is a self-directed
process that is lived by each person considering and
choosing or not choosing to change.
Confirming is a process of seeking personal and
organizational coherence with the values clarified in
the process of visioning. Nurses seek coherence
with cherished values in dialogue with others. Confirming new values is facilitated in standards of practice that specify expectations in the nurse-person
process. As members of a self-regulating discipline,
nurses have the authority to study and define the
knowledge that will guide their practice and research activities. Standards concretize the values
chosen to guide practice and clarify the purpose of
nursing in any organization.
Disclosing happens through actions taken and
words spoken as staff integrate and share their new
realities in the context of day-to-day relationships
with patients and families. Disclosing is about presenting self to colleagues and to patients and families
as a professional with intent and direction. Disclosing also happens through storytelling as members of
the staff share their experiences with others. Telling
stories of changing realities in practice and research
perpetuates the living of new values and is the primary way nurses and other professionals propel the
ongoing journey of change.
The way these processes get lived out in any community of professionals will be unique, yet common
patterns are recognizable among different groups. In
order to demonstrate the complexity of changing a
culture of care, the author offers a glimpse of the
processes as they are being lived by nurses at a large
teaching hospital in Toronto, Canada. Sunnybrook
Health Science Centre is an 1100 bed hospital with
both acute and long-term care services. There are approximately 1300 nurses. The Aging Program, with
approximately 550 beds, employs registered nurses
(RNs) and registered practical nurses (RPNs) who
work in a primary care model. The acute care programs employ RNs to deliver care in a variety of delivery models.
The First 5 Years

The opportunity began with an invitation and acceptance, by the author, of a leadership role in nursing
at Sunnybrook Health Science Centre. The leadership
role was newly formed and the expectation was that
the chief nurse would participate with staff to embark on a journey to create a new culture of practice
consistent with a philosophy of patient-focused care
and the Human Becoming school of thought. The
253
leaders of Sunnybrook were committed to the basic

tenets of the operational model called patientfocused care. These tenets include decentralized
program management, simplified processes like charting by exception, multiskilled service workers, and
patient empowerment. Additionally, the hospital
management team made a commitment to support
the principles of shared governance, meaning they
endorsed the position that all staff were entitled to a
clearly defined scope of responsibility, a meaningful
process of accountability, and continuous opportunity for learning and development. The overall intent
of the various initiatives was to improve the quality
of patient experiences in a compassionate and efficient system that values excellence in all aspects of
care.
In addition to efforts to get to know the staff of
the organization and their usual practices related to
patient care, the first year was characterized by two
main activities. The first was to begin explicating the
assumptions and values that characterized patient
care in the health-care center. The explicating happened in discussions with many different groups and
through written documents. A newsletter was published to begin the process of questioning ideas
about human health and the way that health-care
professionals approached patients. For example, one
newsletter focused on explicating sacred cows
meaning unexamined practicesin nursing and in
health care in general. Another newsletter challenged the assumption that patients were not capable of leading the health-care team. These newsletters prompted discussions of the values and
assumptions that guide activities in practice.
A second major activity during the first year was
to establish a nursing council that could support and
facilitate nursings mandate to define standards that
would guide a new process of care. The nursing
council consists of approximately 50 nurses who
represent the diverse roles in nursing. Staff nurses
were supported in attending a 4-hour council meeting once a month. It was in council that the process
of explicating the assumptions and values of traditional nursing practice intensified. Various strategies
were used to facilitate discourse, including videos,
patient stories, and discussion of journal articles that
presented human science views of nursing. The
leaders intent during this time was to inspire reflection and introduce creative tension through the presentation of diverging views about patient care. The
council was the first group at Sunnybrook to participate in the process of visioning and the clarification
of values for guiding the nurse-person process. It is
through reflection and openness that nurses dis-
254
cover insights about themselves as professionals and

about the process of human becoming.
A critical decision from the beginning was to anchor all discussions of practice and values against the
backdrop of patients lived experiences in healthcare systems. The patients and familys experiences,
as presented in videos and in the literature, are critical to sustaining the impetus for change. Valuable
video resources on the topic of patient experiences
include Not My Home (Deveaux & Babin), Real
Stories (Deveaux & Babin), Through the Patients
Eyes (Picker), and The Grief of Miscarriage (Pilkington), to name a few. Simply stated, people want to
be listened to, to be regarded as knowing participants, to be respected for their unique lives and
meanings, to have meaningful dialogue, and to have
their choices and wishes integrated in plans of care.
These basic requests are consistent with what the
human becoming theory offers professional staff.
Also critical during this time were discussions to
help nurses clarify their shared and unique responsibilities in a multidisciplinary setting. In a hospital,
nurses are responsible for many medical and technological activities and these must be carried out with
skill and knowledge. But nurses also have a unique
practice that happens in the nurse-person process,
and it is in this realm that nursing science informs
and guides practice. Patterns of thinking and acting,
as well as ones attitude and intention in practice, are
complex and multidimensional. Nursing practice
transcends multiple realms of responsibility, yet
there is coherence amid the apparent dissonance of
diverging paradigms. Nurses who practice in ways
consistent with the Human Becoming Theory are actually more vigilant and attentive to the medical and
technological responsibilities, because they are genuinely concerned in a different way about the person
as a unitary human being. As a leader in a large system, this author has learned well that instances of serious mishaps in a hospital could often be avoided if
professionals truly listened to people and trusted
their knowing of potential or impending danger and
concern.
The second year at Sunnybrook was marked by
the development of a new role and the creation of
standards that defined a new process of practice for
nurses. The new role, called the Professional Practice
Leader (PPL), was created for the purpose of providing the staff with a mentor and guide for changing
the culture of care in ways that were consistent with
the Human Becoming Theory (Bournes & Das Gupta).
The PPL was hired by program directors in order to
work directly with staff on patient care units. All disciplines identified PPLs. In nursing there were 12
PPLs selected based on their masters preparation in

nursing and a commitment to the human science
paradigm and the assumptions and values of the human becoming theory.
The standards of practice developed by members
of the council flow from a philosophy that specifies a
commitment to view human beings as unitary, irreducible persons who choose unique meanings of
health and quality of life. The standards confirm a
certain set of values in a coherent nursing process. At
Sunnybrook, the standards emphasize dialogue and
clarify expectations about how nurses will be with
others (Mitchell, 1998a). The standards guide nurses
and help them be with patients and families for the
purposes of clarifying individuals perspectives, concerns, needs, priorities, and wishes linked to their
health care and quality of life. Nurses are responsible
for presenting each persons reality in team meetings
and in patient records. The standards also specify expectations for actions and evaluation based on the
patients experience and changing medical concerns.
The professional practice leaders created many
ways of working with staff in order to facilitate the
questioning, reflecting, and learning required for
change. Learning modules were developed, as were
competencies linked to changing expectations in
practice. Perhaps most effective was the ongoing development of an 8-week course in which staff met
for 2 to 3 hours a week in small groups to participate
in the guided discovery process. More than 300
nurses and other staff, including allied health professionals, managers, and volunteers, have chosen to
take the course. Evaluations of the courses indicate
that staff find the course changes their ways of thinking about patients, which changes what happens in
their relationships with patients and families. Staff report that patients say they are more satisfied with the
care and service at Sunnybrook.
Other structures and systems must also change if
staff are to be supported to practice in ways consistent with the human becoming theory. For example,
documentation of patient care changes from an observed interpretation of patient behavior to a representation of the patients experience from the
patient/family perpective. This change in documentation is dramatic. For instance, a record in the problem-based, observed behavior model may include a
notation like, Patient refusing to take medications;
confused, upset, and occasionally yelling out. In a
culture in which patients are respected as leaders of
their care, the same occasion might prompt this
note: Mr. B. states he is feeling sick from taking his
pills. He would like to speak with the doctor but
does not know how to reach him; requests nurse to
contact doctor. Mr. B. states that he wants to lie quietly but is too uncomfortable to do so. He plans to
call his wife.The nurse guided by standards of practice consistent with Human Becoming records the
patients experiences and the actions taken based on
Mr. B.s concerns and wishes. Follow-up actions with
Mr. B. include a discussion to explore and clarify
what he is experiencing, an evaluation of Mr. B.s
medical status, notifying the physician of any change,
ongoing contact, and helping Mr. B. to lie quietly and
contact his wife.
Policies also require evaluation to determine their
consistency with the philosophy of patient care. For
example, a policy at Sunnybrook for the care of patients who wander was rewritten to be more consistent with the guiding philosophy. The policy
changed in the ways patients were approached and
your thoughts
255
in the attention to the consequences of labeling

someone as a wanderer, from the patients perspective. Hospitals are challenged to find ways to protect
patients from harm while simultaneously respecting
them as human beings with unique meanings and
wishes. Other policies, such as visiting hours and
consents, have also been influenced by a change in
patient philosophy.
The process of disclosing happens day by day in
the practice and research activities that take place
across the Sunnybrook campus. A research program
guided by the Human Becoming Theory has grown
over the years, and researchers are building a knowledge base of lived experiences as described by patients, residents, and families who give of their time
to teach us. Multiple studies on quality of life have
helped practitioners understand their patients differently, and this has changed practice. For example, a
study on quality of life for persons living with diabetes has greatly enhanced understanding about the
decisions people make to adhere to strict regimes of
care and the relief and help that comes from sometimes breaking those regimes (Mitchell, 1998b). Other
studies include the experience of living with persistent pain and quality of life for persons admitted for
psychiatric care (Fisher & Mitchell, 1998). Studies in
process include quality of life for families living with
Alzheimers disease, the lived experience of waiting,
the experience of being listened to, the experience
of grieving a loss, and the experience of feeling at
home, to name a few. The purpose of all these studies is to enhance understanding so that professionals
can change what they know, which changes practice.
Hospital-based practice consistent with the Human Becoming Theory is proving to be a consistent
and valuable model for many professionals. Nurses
and others are speaking about how their experience
of practice is different from before. The outcomes
are reflected in patterns of enhanced staff morale
and greater patient satisfaction.
Challenges of Change
During the past 2 years, the efforts of the chief nurse
and the PPLs, along with the support of managers
and other leaders, have continued to support this
valued change in how staff relate with patients and
families. The change has not been easy, but the outcomes are consistently positive and increasingly desired by staff. The nature of the change with all its obstacles and opportunities requires some additional
attention in this brief report.
It became evident early on that the change for
many staff was fraught with fear and uncertainty. A
commonly expressed fear related to the reality that
256
staff had depended so much on the objective assessment to guide what they said with patients that they
did not know how to approach patients just to dialogue and learn from them about their values, meanings, and wishes. Staff did not know how to facilitate
dialogue in ways that helped patients describe their
realities. Supporting the staffs efforts to learn how
to be with others required mentoring about how to
ask questions that invite dialogue and that seek
depth and clarity without directing and interpreting
what people say. Experience with facilitating dialogue was one of the main initiatives in the 8-week
patient-focused care course offered to staff.
Additionally, many staff rejected outright the idea
that the philosophy and practice model being suggested were possible in a fiscally constrained environment. No time was a commonly heard response
when staff were first introduced to the change. Initially staff thought that the expectations to listen and
to attend to patients concerns, needs, and wishes
were to be added on to what was currently being
done. The phrase no timehas not yet prioritized the
values of the philosophy. However, what becomes
evident to those who decide to change their practice
is that it does not take longer to think differently; indeed, staff report that it saves time to work with patients in this way.
Staff begin to see that what happens when the
professional-patient relationship is cocreated. They
realize that when they think and act differently with
patients, different things happen. For instance, in
the problem-based model of practice, patients may
have been called difficult or manipulative if they did
not conform to expectations. But when staff change
their expectations, from expecting compliance to facilitating choice, a different dialogue and a different
dynamic unfold. Each staff person must experience
this change before he or she comes to know the new
dynamic. It also helps to realize that difficult situations still happen in a culture of care that respects
people as leaders and teachers. People still have
some requests that cannot be met, and people still
make choices that are different. The thing that changes
in this model is the way staff are with patients and
families when struggles and differences arise.
Another important obstacle to change is the reality that some staff do not want to relinquish the control they believe they have over patients. This is true
despite the reality that patients indicate they have to
figure out how to live with new situations and that
figuring out comes from their lived experience, not
medical directives. That people do not do what experts tell them to do has posed a problem for many
providers of health care. Rather than looking at the
assumptions and values that guide practice, professionals have spent time and money to continue to
study how to increase compliance. Patients have
consistently indicated that what they want from professionals is meaningful dialogue and answers to their
questions so that they can work through their options and choices. Unsolicited advice is not wanted
and effectively closes the door on meaningful dialogue.
A commonly heard answer to the invitation to
change is I already do it. This statement clearly conveys the person is not open to exploring or considering what is being offered. Traditional health care
education over the past 3 to 4 decades has ensured
a problem-based, holistic, multisystem assessment
model of care. This is true even in disciplines that are
closely linked to things like recreation and social living. The various health-care disciplines grew up in a
model that only knew bio-psycho-social-spiritualrecreational assessments and problems. Indeed, it
was the problem-based, reductionistic model that
gave birth to the various groups of professionals.
When staff say they already practice in a way consistent with the Human Becoming Theory, their assertion usually rests on the reality that they are caring
within a traditional holistic model. What staff do not
realize is that practice consistent with the human becoming perspective is not about being kind and caring while assessing patients to identify problems in
bio-psycho-social-spiritual patients. Only staff who
are willing to see the difference will change in practice, and this willingness is self-defined and selfdirected.
Some professionals who resist change ridicule
those who are changing. Others try to instill fear
about what the consequences will be if staff do not
try to control patients. These forms of resistance represent a rhythm of change. It has helped staff at Sunnybrook to discuss these issues and to hear about the
moral courage required to swim against the powerful
current of the status quo. It is very difficult to stand
out as different and to do so can be isolating. It can
also be liberating. The thing that makes it worthwhile is the difference it makes for patients and families who tell staff what it means to have care in the
new model. Staff find the strength to go on in the relationships they have with the patients and families
and through relationships with others who share
their values.
There are many aspects of this journey that cannot be conveyed in this brief account. Staff at Sunnybrook are still on the way to a different place. Some
staff report that their practice will always be different because they are different. The learning that hap-
pens and the discoveries that come to light with this

experience change views of human relating and quality of life.
Practice consistent with the Human Becoming
Theory is transformative. Some staff choose to study
the theory so that the source of their transforming
can continue in more depth and with more clarity.
All staff will hopefully have the chance to learn
something about their own values and intentions in
practice. Whether or not the journey will continue
on the current path is not known. Sunnybrooks
management team, especially the president and
CEO, have provided essential support for this innovation, as have members of the board of the hospital.
The professionals and other staff who have accepted
the invitation to think and be different are the ones
leading the change. The support and courage of the
staff at Sunnybrook have created a special opportunity to push the boundaries of what it means to practice when the goal is enhancing the quality of human
care from the perspective of those who enter a large
hospital system.
From a very personal perspective, the work of being a leader in such an open and innovative system
has been a gift. Bearing witness to the joys and the
struggles is work worthy of great commitment and
energy. There have been some dark days, but I realize
this is not my project
to control. My work is
The South Dakota Board of
to try to create the opportunities for others Nursing model, based on
to choose and to try to
Parses Theory of Human
create new processes
that support human Becoming, focuses on
science in an environ- quality of life from the
ment that has been
dominated by natural persons/communitys perscience. Both sciences spective, with quality of
must exist if healthcare systems hope to nursing education, nursing
achieve compassion- care, and nursing practitionate and effective models of care. The work ers addressed in the model.
at Sunnybrook has
forged meaningful relationships in my life and has
melded in my memory the power of human beings to
change and transcend in order to serve humankind.
A NURSING REGULATORY
DECISIONING MODEL
The South Dakota Board of Nursing has developed a
model of decisioning based on the Human Becoming
Theory. The board of nursing made explicit in the
257
model its belief that [n]ursing regulation, as integral

to the profession, must establish models for Decisioning which provide a systematic focus on the
discipline of nursing as it relates to the mission of
public protection (Bunkers, Damgaard, Hohman, &
Vander Woude, 1998, p. 2).
The South Dakota Board of Nursings Regulatory

Decisioning Models theoretical foundation is based
on Parses human becoming school of thought, values held by the board of nursing, and tenets of public policy making. The decisioning model focuses on
quality of life from the persons and/or communitys
258
perspective with quality of nursing education, quality of nursing care, and quality of the nursing practitioner being addressed in the model (see Fig. 154).
In operationalizing the decisioning model, the belief system of the board of nursing is lived in its valuing of vision, integrity, commitment, courage, flexibility, and collaboration. These values are defined
from a human becoming perspective, are interconnected with the three principles of the Human
Becoming Theory, and illuminate the themes of understanding the meaning of lived experience; recognizing paradoxical patterns of relating; and moving
beyond to new ways of being. Tenets of public policy
making, including choice, diversity, history, economics, and law, are interwoven with these values and
themes in framing standards for quality education,
quality care, and quality of the practitioner (Bunkers,
Damgaard, Hohman, & Vander Woude, 1998).
South Dakotas nursing theorybased Regulatory
Decisioning Model is an avenue for developing nursing theorybased education, practice, and research.
The model can serve as a vehicle for the advancement of nursing scholarship in developing a nursing
sciencebased profession (Bunkers, Damgaard, Hohman, & Vander Wouden, 1998).
The staff of the board of nursing in South Dakota

studied with a Parse scholar for 3 years while creating
the decisioning model. The membership of the board
of nursing engaged in study of the Human Becoming
Theory while implementing the model in their regulatory decisioning process. Nursing theorybased regulatory decisioning based on Parses Human Becoming
school of thought will seek to sculpt a new path for the
future of nursing.
THE HUMAN BECOMING THEORY

IN TEACHINGLEARNING
A process model of teachinglearning is supported
by Parses Human Becoming school of thought. From
a human becoming perspective, Bunkers and colleagues (1998, 1999) defined teachinglearning as
an all at once process of engaging with others in
coming to know. Eight teachinglearning processes,
emphasizing the notion that teachinglearning is a
dynamic interactive human encounter with ideas,
places, people, and events, are listed in Fig. 155.
These eight teachinglearning processes include expanding imaginal margins, naming the new, going
259
with content-process shifts, abiding with paradox,

giving meaning, inviting dialogue, noticing the now,
and growing story (Bunkers et al., 1998, 1999).
Bunkers and colleagues (1999) write:
Expanding imaginal margins involves focusing on the imaging process. . . . Expanding
imaginal margins while engaging with others
in coming to know coshapes what one will
learn. In imaging valued possibilities one is
already moving with those possibilities. . . .
Naming the new concerns itself with languaging. Naming the new in the process of engaging with others in coming to know cocreates
the meaning of the moment. . . . Going with
content-process shifts involves a synthesis of
ideas with action. . . . Going with contentprocess shifts while engaging with others in
coming to know involves the intentionality of
focusing on the unity of idea-action while participating in relationship. . . . Abiding with
paradox involves recognizing the contradictions in life. . . . Abiding with paradox in the
process of engaging with others in coming to
know involves honoring the tensions of contradiction and living in the questions. . . . Giving meaning involves ascribing value to ideas
and lived experiences. . . . Giving meaning in
the process of engaging with others in coming
to know involves creating ones personal reality in light of choosing a personal stance toward ideas and experience. Giving meaning
forms the purpose of ones life. . . . Inviting
dialogue consists of generating an atmosphere
for conversation while being attentive to of-
fered information. . . . Inviting dialogue in the

process of engaging with others in coming to
know involves participating in discerning discourse while focusing on understanding
unique patterns of evolving. Such understanding uncovers diverse realities. . . . Noticing the
now means being present to what was, is, and
will be in human evolving. This presence involves an attentive, being with the other. . . .
Noticing the now in the process of engaging
with others in coming to know involves living
an attentive presence with others as possibility
becoming actuality. It involves reflecting on
how one moves moment to moment in relationship with others as transforming occurs. . . .
Growing story involves giving meaning to abstract concepts with narrative description. Storytelling reflects the unity and multidimensionality of human experience. . . . Growing
story in the process of engaging with others in
coming to know immerses the community in
meaning-making and comprehending personal
realities. Meaning-making with storying unveils the wholeness of lived experience.
Bunkers teachinglearning processes are grounded
in the principles of Parses Theory of Human Becoming. The themes of meaning making, recognizing and
participating with shifting paradoxical rhythms, and
moving beyond with hopes and dreams manifest
themselves in these intuitive-rational processes of
coming to know. People who embrace this human
becoming perspective of teachinglearning participate in fostering the unique unfolding of human potential (Bunkers et al., 1999).
your thoughts
260
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586616). Nashville, TN: Broadman Press.
Whitman, W. (1983). Leaves of grass. New York: Bantam. (Original [7th ed.] published in 1892)
Chapter 16
Margaret A. Newman
Health as Expanding Consciousness
Introducing the Theorist: The Unfolding of Margaret
Newmans Theory of Health as Expanding Consciousness
The Debut of Margaret Newmans Theory
Uniqueness and Wholeness of Pattern
A New Paradigm Emerges
Sequential Configurations of Pattern Evolving Over Time
Insights Occurring as Choice Points of Action Potential
The Mutuality of the Nurse-Client Interaction in the Process
of Pattern Recognition
Hermeneutic Dialectic Method of Research
The Health as Expanding Consciousness Research Process
Theory as Moving Intuition and Evolving Insights
References
Margaret Dexheimer Pharris
I dont like controlling, manipulating other people.

I dont like deceiving, withholding, or treating
people as subjects or objects.
I dont 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)
If nursing is to fulfill its social commitment to promote the betterment of the human condition, it must
be ready to respond to the ever-increasing complexity of the way people relate to each other and to the
environment. Over the past century weve seen a
rapid increase in energy interchange around the
globe. During the twentieth century the major explanations of morbidity and mortality have moved from
microbial agents to behavioral choices, emotional
struggles, and environmental stresses; and now they
are shifting increasingly back to microbial agents but
with behavioral, emotional, and environmental underpinnings. The advent of the atomic bomb has
shown all people of the Earth that our fates are intricately intertwined. Weve watched TV images projected from outer space of our small, round earthly
home, and come to realize that borders are a human
construct. The Berlin Wall has come down. Transglobal travel has become commonplace. Some people wake up in Tokyo, Japan, and that very night go
to sleep in Kampala, Uganda; whereas others wake
up in Bogot, Colombia, and go to sleep in Paris,
France. On the Upper West Side of New York City, a
man runs in place on a treadmill to burn excess calories, while the people in Central America who toiled
harvesting his coffee and most of the food he ate for
lunch try to conserve energy for their lean, hungry
bodies. The garbage of
New York City is
There is movement of the
shipped to Guatemala,
life process toward higher where it is used to fertilize food, most of
consciousness. Each client
which is shipped to
situation manifests an the United States. The
underlying pattern that is global economy transfers both nourishment
unique and whole; the and disease around
nurseclient interaction is the world in a matter
of hours. Where the
a mutual process. resources for computers exist, we have instant Internet communication across the globe with
friends, colleagues, family, and people weve never
264
met. We stand in amazement as we watch borders

and barriers fall away and concepts of space, movement, and time take on new dimensions. These
events and relationships have transformed us as a
people. Nursing, with its social mandate of caring
for people as they strive for health, has also undergone a transformation. Nursing theorist Margaret
Newman has been a guiding voice in that process.
Margaret Newmans Theory of Health as Expanding Consciousness (HEC) argues that there is movement of the life process toward higher consciousness,
that each client situation manifests an underlying pattern that is unique and whole, and that the nurse
client interaction is a mutual process (Newman,
1994a). Newmans theory emanates from a Rogerian
unitary perspective, later termed the unitary-transformative scientific paradigm, which views the nature of reality as a whole, and the nature of change,
as transformative (Newman, Sime, & Corcoran-Perry,
1991).
INTRODUCING THE THEORIST:

THE UNFOLDING OF MARGARET
NEWMANS THEORY OF HEALTH
AS EXPANDING CONSCIOUSNESS
The foundation for the Theory of Health as Expanding Consciousness was laid prior to the time Margaret Newman entered nursing school at the University of Tennessee in 1959 (Newman, 1997c). After
graduating from Baylor University, she went home to
Memphis to work and to care for her mother, who
had amyotropic lateral sclerosis (ALS), a degenerative
neurological disease that progressively diminishes
the ability of all muscles except those of the eyes to
move. Caring for her mother was transformative for
Margaret Newman. This experience provided her
with two profound realizations: that simply having a
disease does not make you unhealthy (i.e., health is
not the opposite of disease, but rather can be present in the midst of disease), and that time, movement, and space are in some way interrelated. The restrictions of movement that Margarets mother
experienced immobilized her in terms of time and
space and effectively did the same to Margaret,
whose movement was necessarily restricted because
of her commitment to caring for her physically immobilized mother (Newman, 1997c).
Later, when Newman decided to pursue doctoral
studies in nursing, she was drawn to New York University (NYU), where she would be able to study
with Martha Rogers, whose Science of Unitary Hu-
your thoughts
man Beings resonated with Newmans conceptualizations of nursing and health (Newman, 1997b). In her
doctoral work at NYU, Newman (1982, 1987) began
studying movement, time, and space as parameters
of health, but did so out of a logical positivist scientific paradigm. She designed an experimental study
that manipulated participants movement and then
measured their perception of time. Her results
showed a changing perception of time across the life
span, with subjective time increasing with age. Although her results seemed to support what she later
would term health as expanding consciousness, at
that time she felt they did little to inform or shape
nursing practice (Newman, 1997a).
It soon became evident to Newman that the positivist perspective, which isolated, broke apart, and
sought to individually manipulate inextricable aspects of the human health experience, was too simplistic and ineffectual in shedding light on that
which she sought to understand. This was a point of
transformation for Margaret Newman. It was a time
when she realized that the old paradigm was not
serving her desire to understand the human experience of health and her commitment to providing a
comprehensive guide for nursing practice.
Newmans paradigmatic transformation occurred
as she was delving into the works of Martha Rogers
and Itzhak Bethov, while at the same time reflecting
on her own personal experience (Newman, 1997b).
Several of Martha Rogers assumptions became central in shaping Margaret Newmans theoretical perspective (Newman, 1997b). First, Rogers saw health
and illness as a unitary process of the whole, which
was congruent with Margaret Newmans earlier experience with her mother and with her patients.
People can experience health when they are physically or mentally ill. Health is not the opposite of illness, but rather health and illness are both manifestations of a greater whole.
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 posited that there is interpenetration between the fields of person, family, and environment.
Person, family, and environment are not separate
entities, but rather an interconnected, unitary
whole. In defining
field, Rogers wrote:
The responsibility of the
Field is a unifying
concept. Energy signi- nurse is not to make peofies the dynamic na- ple well, or to prevent them
ture of the field. A
field is in continuous from getting sick, but to asmotion and is infinite sist them to recognize the
(Rogers, 1990, p. 29).
Rogers defined the power that is within them
unitary human being to move to higher levels of
as [a]n irreducible,
indivisible, pandimen- consciousness.
sional energy field
identified by pattern and manifesting characteristics
that are specific to the whole and which cannot be
predicted from knowledge of the parts (Rogers,
1990, p. 29). Finally, Rogers saw the life process as
showing increasing complexity. This assumption,
along with the work of Itzhak Bentov (1978), which
viewed life as a process of expanding consciousness,
helped to shape Margaret Newmans conceptualization of health and eventually her theory.
Chapter 16 Margaret A. Newman Health as Expanding Consciousness
265
THE DEBUT OF MARGARET

NEWMANS THEORY
In 1977, when Margaret Newman was teaching nursing theory development at Penn State, she received
an invitation to speak at a nursing theory conference.
It was in preparing for that presentation, entitled Toward a Theory of Health, that the Theory of Health
as Expanding Consciousness (HEC) began to take
shape. In her address (Newman, 1978) and in a written overview of the address (Newman, 1979), Newman outlined the basic assumptions that were integral to her theory. Drawing 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 as well as states where disease is not
present;
disease, when it manifests itself, can be
considered a manifestation of the underlying
pattern of the person;
the pattern of the person manifesting itself as
disease was present prior to the structural and
functional changes of disease; and
health is the expansion of consciousness
(Newman, 1979).
Her presentation drew thunderous applause as
she ended with [t]he responsibility of the nurse is
not to make people well, or to prevent their getting
sick, but to assist people 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 meaningful in the practice of nurses
in many countries throughout the world. Nurses
wanted to go beyond combating diseases; they
wanted to accompany their patients in the process of
discovering meaning and wholeness in their lives.
Margaret Newmans proposed theory would serve as
a guide for them to do so.
After identifying the basic assumptions of the
HEC theory, the next step for Margaret Newman 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
uniqueness and wholeness of the pattern in each
client situation, the sequential configurations of pattern evolving over time, the movement of the life
process toward expanded consciousness, insights
occurring as choice points of action potential, and
266
the mutuality of the nurseclient interaction in the

process of pattern recognition (Newman, 1997a).
UNIQUENESS AND
WHOLENESS OF PATTERN
Margaret Newman (1979, 1986, 1994a), like Martha
Rogers (1970, 1990), sees human beings as unitary
energy fields that are inseparable from the larger unitary field that combines person, family, and community all at once. A nurse operating out of the unitary
being perspective does not think of mind, body,
spirit, and emotion as separate entities, a conceptualization that focuses on parts rather than on the undivided whole.
Nursings historical alignment with medicine and
social sciences fostered a fragmented, particulate
view of reality. In the seventeenth century, medicine
was propelled toward treating only the physical aspect of human beings when Ren Descartes, a philosopher and founding father of modern medicine,
made a deal with the Roman Catholic pope so that
he could get the human bodies he needed for dissection. Descartes agreed to concentrate only on the
physical body and not have anything to do with the
soul, the emotions, or the mind, for they were under
the jurisdiction of the church. This deal set the tone
for two centuries of medical practice, which became
aimed at treating diseases and ignoring the wholeness of patients. Nursing, by association, got temporarily caught up in this fragmented perspective.
As nurses moved into research to test nursing
theory and improve nursing practice, they drew
heavily on research methodologies used by medical
and social science, which entailed isolation, quantification, and manipulation of variables aimed at predicting cause and effect. The medical model focused
on the body and causal explanations of illness (i.e., A
causes B, or atherosclerotic plaque causes heart attacks). The social science model took a systems approach, which looked at the interrelationships between variables and their effect on a specified
outcome (i.e., A + B + C + D are interrelated in their
effect on E; or diet, exercise, smoking, family history, and lifestyle are interconnected in their effect
on heart attacks). Margaret Newmans theory (1979,
1990, 1994a, 1997a, 1997b) proposes that we cannot isolate, manipulate, and control variables in order to understand the whole of a phenomenon. The
nurse and client form a mutual partnership to attend
to the pattern of meaningful relationships and experiences in the clients life, as well as the meaning of
the heart attack, and through the insight gained, the
your thoughts
client undergoes an expansion of consciousness. We

must use a methodology that does not divide peoples lives into fragmented variables, but rather attends to the nature and meaning of the whole (Newman, 1994a, 1997a, 1997b).
Research methodologies must be consistent with
our theory and paradigmatic view. The old paradigm
proposes methods that are analogous to trying to appreciate a loaf of warm bread by analyzing flour, water, salt, yeast, and oil. No matter how much we
come to know these ingredients separately, we will
not know the texture, smell, taste, and essence of
the loaf of bread that has just come out of the oven.
The whole is greater than the sum of its parts and exhibits unique qualities that cannot be fully comprehended by looking at parts. Individual qualities of
the whole, however, do give us some understanding
of the nature of the whole. For example, the smell of
the loaf of bread provides one insight into its nature,
the texture provides another, and so on. A nurse
practicing out of the HEC theoretical 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
persons underlying pattern.
A NEW PARADIGM EMERGES

In an attempt to acknowledge and define the various
scientific paradigmatic perspectives and to eliminate
some of the confusion regarding the nature of the
discipline of nursing, Margaret Newman, Marilyn
Sime, and Sheila Corcoran-Perry (1991) collaborated
on an article to define the overarching focus of the
discipline of nursing and its prevailing paradigms.
They defined the focus of the discipline of nursing to

be caring in the human health experience, which
they saw as the common umbrella under which
three distinct paradigmatic perspectives fell. The paradigmatic perspectives they defined were the particulate-deterministic, the interactive-integrative, and
the unitary-transformative (with the first word indicating the nature of reality and the second word indicating the nature of change in each paradigm).
The particulate-deterministic paradigm holds that
phenomena are isolatable, reducible entities with definable, measurable properties. Relationships between entities are seen as orderly, predictable, linear,
and causal (i.e., A causes B). In this perspective,
health is dichotomized with clearly defined characteristics that are either healthy or unhealthy.
The interactive-integrative perspective, which
stems from the particulate-deterministic, views
reality as multidimensional and contextual.
Multiple antecedents Each person exhibits a disand probabilistic rela- tinct pattern, which is contionships are believed
to bring about change stantly unfolding and
in a phenomenon out- evolving as it responds to
come (i.e., A + B + C +
the person-environment inD are interrelated in
their effect on E). Re- teractions. Pattern is inforlationships may be remation depicting the whole
ciprocal, and subjective data are seen as of a persons relationship
legitimate.
with the environment.
The unitary-transformative perspective
is distinct from the other two. Here a phenomenon is
seen as a unitary, self-organizing field embedded in a
267
larger self-organizing field. It is identified by pattern

and by interaction with the larger whole (Newman,
Sime, & Corcoran-Perry, 1991, p. 4). Change is unpredictable and unidirectional, always moving toward a higher level of complexity. Knowledge is arrived at through pattern recognition and reflects
both the phenomenon viewed and the viewer.
Newman, Sime, and Corcoran-Perry (1991) concluded that the knowledge generated by the particulate-deterministic paradigm and the interactiveintegrative was relevant to nursing, but that the
knowledge gained by using the unitary-transformative paradigm was essential to the discipline of nursing. In a later work, 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 different paradigms. Newman states:
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 oneway 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 moving, evolving, transforminga process. (Newman, 1997a, p. 37)
SEQUENTIAL CONFIGURATIONS OF
PATTERN EVOLVING OVER TIME
Essential to Margaret Newmans theory is the belief
that each person exhibits a distinct pattern, which is
constantly unfolding and evolving as it responds to
the person-environment interactions. Pattern is information that depicts the whole of a persons relationship with the environment and gives an understanding of the meaning of the relationships all at once
(Endo, 1998; Newman, 1994a). Pattern is a manifestation of consciousness, which Newman (1994a) defines as the informational capacity of the system to
interact with its environment.
In explaining 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 order (the unseen underlying pattern) (New-
268
man, 1997b). That which is explicate is a manifestation of the underlying implicate pattern. In other
words, there is information 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, vital
signs. There is also information about their underlying pattern in all that they tell us about their experiences and perceptions, including stories about their
life, recounted dreams, and portrayed meanings. An
example from this writers research (Dexheimer
Pharris, in progress) involves a 16-year-old young
man in an adult correctional 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 look at
what was meaningful in his life, the process seemed
to be blocked, with the pattern not emerging and little insight being gained. He spoke of how he felt he
had lost himself several years back. One week he
walked into the room and his movements seemed
more controlled and labored; he sat with his arms
cradling his abdomen and his chest expanded as
though it 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 reflected that he seemed
to be exerting a great deal of energy keeping in
something that was erupting within him. With this
insight, he suddenly opened up and began talking
about a very painful family history of sexual abuse
that had been kept secret for many years. It became
obvious that the experience of covering up the
abuse had been so all-encompassing that it was suppressing his pattern. This young man had reached a
choice 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 movements
had become smooth and sure, his complexion had
cleared up, he was becoming able to reflect on his
insights, and he no longer was involved in the chaos
and fighting in his cellblock. In their subsequent
work together, this young man and the nurse were
able to distinguish between his implicit pattern,
which had become clear, and the impact that keeping the abusive experience a secret had had on him
and on other members of his family. Since that time,
this person has been able to transcend previous limitations and has become involved in several efforts to
help others, both in and out of the prison environment, and has achieved great success academically.
your thoughts
That which is underlying makes itself known in

the physical realm, and nurses operating out of the
HEC theory are able to sense it and mobilize the insight of their patients into expanded levels of consciousness through pattern recognition. Another example, at the community level, arose out of the work
of Frank Lamendola and Margaret Newman (1994)
with people with HIV/AIDS. They found that the experience of HIV/AIDS opened the participants to suffering and physical deterioration and at the same
time introduced greater sensitivity and openness to
themselves and to others. Drawing on the work of
cultural historian William Irwin Thompson, systems
theorist Will McWhinney, 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, ideologies, 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 relationship. (Lamendola & Newman, 1994, p. 14)
In making the appeal that AIDS calls us to a reconceptualization of the nature of the self and greater interconnectedness on the interpersonal, community,
and global level, Lamendola and Newman quoted
Thompson (1989, p. 99), who states 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.
The HEC perspective sees disease as an explication of the underlying implicit pattern of the person,
family, or community. Disease can be part of the process of expanding consciousness (Newman 1994a,
1997a, 1997b). To provide a metaphorical illustration
of how disease can be an explication of the underlying implicit pattern, Newman (1994a) uses Bohms
image of a fish tank with two video cameras focused
on itone from the narrow side of the tank and the
other from the broad side. If two television screens
were projecting the two images, they would project
very different views of the movements of the fish,
but the observer would get a sense of the underlying
pattern. So, too, it is with disease and states of
healththey are both explicit projections of the underlying pattern of the person or of the community.
INSIGHTS OCCURRING AS CHOICE

POINTS OF ACTION POTENTIAL
Disease and other traumatic life events cause a disruption that can help a person, a family, or a community move into an expanded level of consciousness.
To explain this phenomenon, Newman draws on the
work of Ilya Prigogine (1976), whose Theory of Dissipative Structures asserts that a system 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 timethe patient who is lost
to his work and has no time for his family or himself,
and then suddenly has a heart attack, an experience
that causes him to reflect on how he is using his energy and as a result his life pattern changes to be-
269
come more creative, relational, and meaningful; or

the person diagnosed with a terminal illness that
causes her to reevaluate what is really important, attend to it, and then to state that for the first time she
feels as though she is really living. The expansion of
consciousness is an innate tendency of human beings; however, some experiences and processes
precipitate more rapid transformations. Nurse researchers operating out of the HEC theory have
clearly demonstrated how nurses can create a mutual
partnership with their patients to reflect on the
evolving pattern of their life. The insights gained in
this process lead to an awakening and transformation
to a higher level of consciousness (Dexheimer
Pharris, in progress; Endo, 1998; Jonsdottir, 1998;
Lamendola, 1998; Lamendola & Newman, 1994;
Litchfield 1993, 1997; Moch, 1990; Newman, 1995;
Newman & Moch, 1991; Noveletsky-Rosenthal, 1996;
Tommet, 1997).
The disruption brought about by the presence of
disease, illness, and traumatic or stressful events creates an opportunity for transformation to a higher,
expanded level of consciousness (Newman, 1997b).
This disrupted state presents a choice point for the
person either to 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 draws on Arthur
Youngs (1976) Theory of Evolution of Consciousness. Young suggests 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 comes a choice
point and a reversal of the losses of freedom, ending
with total freedom and unrestricted choice. These
stages can be conceptualized as seven equidistant
points on a V shape. Beginning at the uppermost
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 collective, with no
need for initiative because everything 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 selfs 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) describes the fifth
stage, decentering, as being characterized by a
shift
270
. . . from the development of self (individuation) to dedication to something greater than

the individual self. The person experiences
outstanding competence; their works have a
life of their own beyond the creator. The task
is transcendence of the ego. Form is transcended, and the energy becomes the dominant featurein terms of animation, vitality, a
quality that is somehow infinite. Pattern is
higher than form; the pattern can manifest itself in different forms. In this stage the person
experiences the power of unlimited growth
and has learned how to build order against
the trend of disorder. (Newman, 1994b, pp.
4546)
Newman (1994b) goes on to state that few experience the sixth stage, unbinding, or the seventh
stage, real freedom, unless they have had these experiences of transcendence characterized by the
fifth stage. Newman proposes a strong corollary between her Theory of Health as Expanding Consciousness and Youngs Theory of the Evolution of Consciousness in that we come into being from a state
of potential consciousness, are bound in time, find
our identity 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 consciousness (Newman
1994b, p. 46).
HEALTH AS EXPANDING
CONSCIOUSNESS
The process of expanding consciousness is characterized by the evolving pattern of the personenvironment interaction (Newman, 1994a). Consciousness is much more than just cognitive thought.
Margaret Newman defines consciousness as:
. . . the information of the system: The capacity of the system 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 thinking and feeling, but also all the information embedded in the nervous system, the
immune 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 interacts
with the information of the environmental system. (Newman, 1994a, p. 33)
To illustrate consciousness as the interactional capacity of the person-environment, Newman (1994a)

draws on the work of Bentov (1978), who presents
consciousness on a continuum ranging from rocks, on
one end of the spectrum (which have little interaction
with their environment), to plants (which draw nutrients and provide carbon dioxide), to animals (which
can move about and interact freely), to humans (who
can reflect and make in-depth plans on how they want
to interact with their environment), and ultimately to
spiritual beings on the other end of the spectrum.
Newman sees death as a transformation point, with a
persons consciousness continuing to develop beyond
the physical life, becoming a part of a universal consciousness after death (Newman, 1994a).
Nurses and their clients know that there has been
an expansion of consciousness 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 consciousness. These deeper, more meaningful relationships may be interpersonal, or relationships with the wider community. The nurse and
client may also see movement through Youngs spectrum of evolving consciousness referred to earlier,
where people transcend their own egos, dedicate
their energy to something greater than the individual
self, and learn to build order against the trend of disorder. In speaking of her experience with cancer,
Chris Forth (1999) writes that it has illuminated for
me much of what is good in this world. It has allowed me to experience all that I hold precious in
myself and those around me. It has encouraged me
to find those things that are truly important and
urged me to renew my participation in making our
world a better place. It has presented me with a walk
between life and death and a chance to see how right
it is that they coexist. I will continue to live fully until my soul decides to fly free.
THE MUTUALITY OF THE

NURSECLIENT 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 out of the HEC perspective involves being

fully present to the client without judgements, goals,
or intervention strategies. It involves being Nursing from the HEC perrather than doing. It is spective involves being
caring in its deepest,
most respectful sense. fully present to the client,
It is a mutual process without judgements, goals,
of uncovering for
meaning. The nurse or intervention strategies.
client interaction be- It is important that the
comes like a pure renurse sense his or her
flection pool through
which both the nurse own pattern.
and the client get a
clear picture of their pattern and come away transformed by the insights gained.
To illustrate the mutually transforming effect of
the nurseclient interaction, Newman (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 clients, just as clients are
changed by their interactions with nurses. This mutual transformation extends to the surrounding environment and relationships of the nurse and client.
In the process of doing this work, it is important
that the nurse sense his or her own pattern. Newman states: We have come to see nursing as a process of relationship that co-evolves as a function of
the interpenetration 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 ones own pattern is
an essential starting point for the nurse. In her book
Health as Expanding Consciousness, Newman
(1994a, pp. 107109) outlines a process of focusing
to aid nurses as they begin working out of 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 client. The nurses consciousness, or pattern, becomes like the vibrations of a tuning fork that resonates at a centering frequency and
the client has the opportunity to resonate and tune
to that frequency during their interactions (Newman, 1994a; Quinn, 1992). The nurseclient relationship ideally continues until the client finds his or her
own rhythmic vibrations without the need of the
tuning fork. In other words, in the context of their
interaction, the nurse and client get in touch with
271
their center, their power; and the interaction continues until the client is able to center by himself or
herself.
HERMENEUTIC DIALECTIC
METHOD OF RESEARCH
Margaret Newman describes her research methodology as hermeneutic dialectichermeneutic in that it
focuses on meaning, interpretation, and understanding; and dialectic in that both the process and content are dialectic (Newman, 1997b). Guba and Lincoln (1989, p. 149) describe the dialectic process as
representing a comparison and contrast of divergent
views with a view to achieving a higher synthesis of
them all in the Hegelian sense. Hegel proposed that
opposite points of view can come together and fuse
into a new, synthesized view of reality (Newman,
1994a). It is in the contrast that pattern can be appreciated. For example, one cannot fully comprehend joy unless one has fully comprehended sorrow,
and vice versa. Although they seem to be opposites,
these two emotions are two manifestations of human
connectedness. If you want to see a dark pattern
more clearly, you would put it against a light background. The dialectic aspect of this methodology
permits a nurse to be present to a client whose life
circumstances are very different from those of the
nurse. For example, the pattern recognition interaction for a homeless 16-year-old teenage boy from Bordeaux, France, with a female nurse from a very intact, loving family in Nigeria may provide clearer
insight than with a young male nurse from Bordeaux,
because less will be assumed and taken for granted.
The Nigerian nurse will have to ask more clarifying
questions and seek to understand that which has not
been her experience. This clarifying process, if done

in an open, caring, and nonjudging manner, provides
great insight for both participants in the pattern
recognition process as they realize their interconnectedness. Because the nurse-client interaction is
focused on attending to meaning, it transcends barriers of culture, gender, age, class, race, education,
and ethnicity. The nurse is tapping into a way of relating that runs deeper than these barriers. The HEC
theory focuses on the interconnectedness and common humanity of all people.
THE HEALTH AS
EXPANDING CONSCIOUSNESS
RESEARCH PROCESS
The process of pattern recognition for research purposes has been proposed in an appendix of Health
as Expanding Consciousness (Newman, 1994a, pp.
147149). It is summarized as follows:
The Interview: After the study has been explained
and informed consent obtained, the data collection process begins with the nurse asking the
participant a simple, open-ended question such
as, Tell me about the most meaningful people
and events in your life. The interview proceeds
in a nondirectional manner, with the nurse asking clarifying questions if necessary. The nurse researcher focuses on being fully present and sensing intuitively what to say or ask. Pauses are
respected and attended to.
Transcription: Soon after the interview is completed, the nurse researcher transcribes the tape
of the interview, including only the information
that seems relevant to the participants life pat-
your thoughts
272
tern, but noting separately any information that

was omitted, in case it becomes relevant after
subsequent interviews.
The Narrative: The nurse researcher then organizes
the transcribed data into a chronological narrative, highlighting the most significant events and
persons. Pattern shifts and sequential patterns of
significant relationships are noted.
Diagram: A diagram is drawn of the sequential patterns of relationships and transformation points.
Although optional, this step has been found to be
helpful in visualizing the pattern of the whole.
Follow-up: At the second interview the diagram (or
other visual portrayal) is shared with the participant without any causal interpretation. The participant is given the opportunity to comment on
what has been portrayed. This dialectic process is
repeated in subsequent interviews, with data
added to the narrative and the diagram redrawn
until no further insight can be reached about the
pattern of personenvironment interaction. The
pattern emerges in terms of the energy flow, for
example, blocked, diffused, disorganized, and repetitive. It is important not to force pattern
recognition; sometimes no signs of pattern recognition emerge, and if so, that characterizes the
pattern for that particular person.
Application of the Theory: The HEC theory is applied throughout the process. It is the theory that
guides the interaction. The theory is pervasive in
the unfolding and grasping of insights. After completion of the interviews, the data are analyzed
more intensely in light of the Theory of Health as
Expanding Consciousness. Youngs spectrum of
consciousness is applied and the quality and complexity of the sequential patterns of interaction
are evaluated. Similarities of pattern among participants are identified in terms of themes.
Newman (1994a, 1997a, 1997b) has clearly stated
that this research is research as praxis, meaning
that the researcher is an active participant in the
research and helps the
Research as praxis: The participant understand
the meaning of his or
researcher is an active her situation and its poparticipant in the research tential for action (Newman, 1997a). In this reand helps the participant search, the researcher is
understand the meaning of also a practitioner. Newman states: Not only is
his or her situation and its
our science a human
potential for action. science, but, within the
context of a practice
discipline, it is a science of praxis. This kind of

theory is embodied in the investigator-nurse. It informs the situation being addressed by making a difference in the situation, as well as being informed by
the data of the situation (Newman, 1994b, p. 155).
THEORY AS MOVING INTUITION

AND EVOLVING INSIGHTS
In some ways, writing a chapter about Margaret
Newmans theory of nursing is like trying to convey
the experience of a symphony by presenting only
pages of the musical score. Only really well-trained
musicians could hear the music in their minds, because they have been immersed in these sounds for
many years. They understand the written symbols
and are able to bring them to life. So, too, the words
on these pages in and of themselves are one-dimensional and present only a glimpse of the spirit of
what is trying to be conveyed; however, they represent a multidimensional reality and will become
more clearly understood by those willing to immerse
themselves in the praxis of the theory. The HEC
theory has many dimensions: It is a lived experience,
it has transformative power, and it is evolving. Newman states: Theory for nursing practice is more than
the application of single-dimension theories in specific practice situations. It is a matter of the nurses
being transformed by the theory and thereby becoming a transforming partner in interaction with
clients (Newman, 1994b, p. 156).
Margaret Newmans Theory of Health as Expanding Consciousness is being used throughout the
world, but it has been more quickly embraced and
understood by nurses from indigenous 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.
Margaret Newman challenges nurses to take what
theyve learned from nursing theory as it exists and
to go further. She states: [T]heory is moving intuition, evolving insights (Newman, 1997d, p. 9).
Newman sees the dialogic nature of the theory to
be (as Bohm, 1980, has suggested): [I]t is meaning
flowing through . . . the meaning is fluid and blends
with each persons thinking once it has been shared.
Nurses who are interested in practicing and doing
research out of the Health as Expanding Consciousness perspective would do well to read the book
Health as Expanding Consciousness (Newman,
1994a), and to enter into dialogue with other nurses
practicing from the Health as Expanding Conscious-
273
ness theoretical perspective. There is also a web site

with current works emanating from the Health as Expanding Consciousness theory. The website address
is: www.tc.umnj.edu/~hoym0003/. The theory is being tested by nurses in many countries who are coming into a deeper understanding of the transformative power of Health as Expanding Consciousness
research and practice for nurses, their clients, and
their communities.
References
Bentov. I. (1978). Stalking the wild pendulum. New
York: E. P. Dutton.
Bohm, D. (1980). Wholeness and the implicate order.
London: Routledge & Kegan Paul.
Dexheimer Pharris, M. (in progress). Life patterns of
adolescent males convicted of murder. Unpublished doctoral thesis, University of Minnesota,
Minneapolis.
Endo, E. (1998). Pattern recognition as a nursing intervention with Japanese women with ovarian cancer.
Forth, C. (1999, February 28). Illuminated by cancer.
Minneapolis Star Tribune, p. A25.
Guba. E. G., & Lincoln, Y. S. (1989). Fourth generation
evaluation. Newbury Park, CA: Sage Publications.
Jonsdottir, H. (1998). Life patterns of people with
chronic obstructive pulmonary disease: Isolation
and being closed in. Nursing Science Quarterly,
11(4), 160166.
Lamendola, F. (1998). Patterns of the caregiver experiences of selected nurses in hospice and HIV/AIDS
care. Unpublished doctoral thesis, University of
Minnesota, Minneapolis.
Lamendola, F., & Newman, M. A. (1994). The paradox
of HIV/AIDS as expanding consciousness. Advances
in Nursing Science, 16(3), 1321.
Litchfield, M. C. (1993). The process of health patterning in families with young children who have been
repeatedly hospitalized. Unpublished masters thesis, University of Minnesota, Minneapolis.
Litchfield, M. C. (1997). The process of nursing partnership in family health. Unpublished doctoral thesis, University of Minnesota, Minneapolis.
Moch, S. D. (1990). Health within the experience of
breast cancer. Journal of Advanced Nursing, 15,
14261435.
Newman, M. A. (1978). Nursing theory. (Audiotape of
an address to the 2nd National Nurse Educator Conference in New York.) Chicago: Teachem Inc.
Newman, M. A. (1979). Theory development in nursing. Philadelphia: F. A. Davis.
Newman, M. A. (1982). Time as an index of expanding
consciousness with age. Nursing Research, 31,
290293.
Newman, M. A. (1986). Health as expanding consciousness. St. Louis, MO: Mosby.
274
Newman, M. A. (1987). Aging as increasing complexity.

Journal of Gerontological Nursing, 12, 1618.
Newman, M. A. (1990). Newmans theory of health as
praxis. Nursing Science Quarterly, 3, 3741.
Newman, M. A. (1994a). Health as expanding consciousness (2nd ed.). Boston: Jones & Bartlett (formerly, New York: National League for Nursing
Press).
Newman, M. A. (1994b). Theory for nursing practice.
Newman, M. A. (1995). Recognizing a pattern of expanding consciousness in persons with cancer. In
A developing discipline (pp. 159171). Boston:
Jones & Bartlett (formerly, New York: National
League for Nursing Press).
Newman, M. A. (1997a). Experiencing the whole.
Advances in Nursing Science, 20(1): 3439.
Newman, M. A. (1997b). Evolution of the theory of
health as expanding consciousness. Nursing Science
Quarterly, 10(1), 2225.
Newman, M. A. (1997c). Margaret Newman: Health as
expanding consciousness. In Fuld Institute for Technology in Nursing Education, The Nurse Theorists:
Portraits of Excellence [CD-ROM]. Athens, OH:
FITNE, Inc.
Newman, M. A. (1997d). A dialogue with Martha
Rogers and David Bohm about the science of unitary
human beings. In Madrid, M. (Ed.), Patterns of
Rogerian knowing (pp. 310). New York: National
Newman. M. A., & Moch, S. D. (1991). Life patterns of
persons with coronary heart disease. Nursing Science Quarterly, 4, 161167.
Newman, M. A., Sime, A. M., & Corcoran-Perry, S. A.
(1991). The focus of the discipline of nursing. Advances in Nursing Science, 14(1), 16.
Noveletsky-Rosenthal, H. T. (1996). Pattern recognition in older adults living with chronic illness.
Unpublished doctoral thesis, Boston College.
Prigogine, I. (1976). Order through fluctuation:
Self-organization and social system. In Jantsch, E.
& Waddington, C. H. (Eds.), Evolution and consciousness (pp. 93133). Reading, MA: AddisonWesley.
Quinn, J. F. (1992). Holding sacred space. The nurse as
healing environment. Holistic Nursing Practice,
6(4), 2636.
Rogers, M. E. (1970). An introduction to the theoretical basis of nursing. Philadelphia: F. A. Davis.
age. Nursing Science Quarterly, 5(1), 2734.
Thompson, W. I. (1989). Imaginary landscape: Making worlds of myth and science. New York: St.
Martins Press.
Tommet, P. A. (1997). Nurse-parent dialogue: Illuminating the pattern of families with children who
are medically fragile. Unpublished doctoral thesis,
University of Minnesota, Minneapolis.
Young, A. M. (1976). The reflexive universe: Evolution
of consciousness. San Francisco, CA: Robert Briggs
Associates.
Chapter 17
Part 1
Imogene M. King
Theory of Goal Attainment
Worldview: Conceptual System and Middle-Range Theory of
Goal Attainment
Initial Ideas: The Beginning
Philosophy of Science
Design of a Conceptual System
Summary
References
Imogene M. King

My beginnings as the youngest of three children
started in a small midwestern community in a family
filled with love and joy. As children, we learned that
honesty and respect for each individual were valued.
My parents were always available to support and
guide us as we set goals. We learned that goal-setting
helped us make positive decisions in our journey
through life. We were taught at home to look at the
consequences of our decisions before finalizing
plans. We learned how to work hard and play hard
and to know the difference. Many of these values
were reinforced in formal education; the details may
be found in a book edited by Thelma Schorr and Ann
Zimmerman, entitled Making Choices, Taking
Chances (1990).
Postsecondary education experiences included a
diploma in nursing from St. Johns Hospital School of
Nursing in St. Louis; the baccalaureate and masters
degrees in nursing from St. Louis University; and the
doctor of education from Teachers College, Columbia
University, New York. Postdoctoral study included
work in advanced statistics, systems research, and
computers. Continuing education is an ongoing process. My avocation includes nursing history in the
context of world history, and philosophy with emphasis on science and ethics. To this day, I enjoy life that
includes music, the theater, golf, and swimming. In
addition, I am an artist and work in oils and acrylics.
The majority of nursing experience, which spans
over 50 years, included clinical practice of nursing
adults in hospitals. While working my way through
college, I worked in a physicians office, as a school
nurse, and as an occupational health nurse. I have always believed that as a teacher one must also be an
excellent practitioner so my experience as a teacher
of nursing at undergraduate and graduate levels included practice. I taught at Loyola University, Chicago; the Ohio State University; and the University of
South Florida, advancing from assistant professor to
full professor and now as professor emeritus.
Multiple honors and awards have been given to
me and can be reviewed in Whos Who in America,
American Women, and Whos Who in Nursing. The
most recent are the Jessie Scott Award for Leadership, presented by the American Nurses Association
at the 100th anniversary convention in 1996, and an
honorary doctor of science degree in 1998. My peers
at the house of delegates at the Florida Nurses Association voted in 1996 to give me lifetime membership.
The University of Tampa Department of Nursing
named the annual research award given to students
the Imogene M. King Research Award. I was honored
276
at the 75th anniversary convention of Sigma Theta

Tau International with a research grant named for me
and with a program that presented a description of
me as a caring individual.
A question that continues to be asked is: What
contribution do you think you have made to the
nursing profession? My response is: I have taught
thousands of students who have become leaders and
practitioners, teachers and researchers. In addition, I
have been involved in the scientific movement in
nursing and have developed a conceptual system
from which a theory of goal attainment has been derived, including a transaction process model leading
to outcomes. These ideas are useful for measuring
practice-based outcomes.
WORLDVIEW: CONCEPTUAL
SYSTEM AND MIDDLE-RANGE
THEORY OF GOAL ATTAINMENT
by Imogene M. King
Continuous discoveries in telecommunications and
technology, and a daily bombardment of information
about world events bring complexity to ones life
that is unprecedented in history. Instant communication reminds us that we live in an information
processing world of systems: A system is defined
as a series of functional components connected by
communication links exhibiting purposeful goaldirected behavior (King, 1996). As individuals, we
are born, grow, and develop within each nation. Nations make up the world society. A sense of a global
community can be understood as we view the interactions of individuals and groups with linguistic, ethnic, and religious differences. The commonality in
this worldview is the human being. How is this
global community and health care related to theory
construction and testing in research in nursing?
The commonality in my worldview is human beings who communicate and interact in their small
groups within their nations social systems, that is,
human environments as well as physical environments. Three dynamic interacting systems, shown in
Figure 171, represent individuals as personal systems, groups as interpersonal systems, and large
groups as social systems that make up most societies
in the world (King, 1981). These systems represent
interconnected links for information processing in a
high-tech world of health care and nursing. This conceptual system provides one approach to structure a
world community of human beings. Human beings
are the recipients of nursing care.
SOCIAL SYSTEMS
(Society)
INTERPERSONAL SYSTEMS
(Group)
PERSONAL
SYSTEMS
(Individuals)
Howland Systems Model (Howland, 1976) and the

Howland and McDowell conceptual framework
(Howland & McDowell, 1964). The levels of interaction in these authors work influenced my ideas relative to organizing a conceptual frame of reference for
nursing, as shown in
Figure 171. Because The goal of nursing is to
concepts offer one approach to structure help individuals and
knowledge for nurs- groups attain, maintain,
ing, a comprehensive
review of nursing lit- and regain a healthy state.
erature provided ideas
for me to identify five comprehensive concepts as a
basis for a conceptual system for nursing. The overall
concept is a human being, commonly referred to as
an individual or a person. Initially, I selected abstract concepts of perception, communication, interpersonal relations, 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 the nature of knowledge
(epistemology).
Figure 171 Kings conceptual system.
A review of my ideas about developing theoretical

knowledge for nursing is presented in this chapter. A
process for developing a conceptual system is explained. The method used to derive a theory of goal
attainment from my conceptual system is demonstrated. The use of this conceptual system and
Theory of Goal Attainment in practice, education, research, and administration is described in many
nurses publications. The application of this theory is
also discussed in the second part of this chapter.
INITIAL IDEAS: THE BEGINNING

My first theory publication made pronouncements
about the problems and prospect of knowledge development in nursing (King, 1964). Over 30 years
ago, the problems were identified as: (1) lack of a
professional nursing language; (2) nursing phenomena appeared to be atheoretical; and (3) concept
development was limited. The nursing informatics
movement continues to identify a professional nursing language system (King, 1998). Theories and conceptual frameworks have identified theoretical approaches to knowledge development and utilization
of knowledge in practice. Concept development is a
continuous process in the nursing science movement (King, 1988).
My rationale for developing a schematic representation of nursing phenomena was influenced by the
PHILOSOPHY OF SCIENCE
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 philosophy of science gained
momentum in the 1950s, although its roots date to
an earlier period. This philosophy refuted logical
positivism and reductionism and proposed the idea
of isophomorphism 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 General
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 holistic approach to study nursing phenomena as
an open system and frees ones thinking from the
parts versus whole dilemma. In any discussion of the
nature of nursing, the central ideas revolve around
the nature of human beings and their interaction
with internal and external environments. During this
journey through a wilderness of ideas, I began to
conceptualize a theory for nursing. However, because a manuscript was due in the publishers office,
Chapter 17 Imogene M. King Theory of Goal Attainment
277
I organized my ideas into a conceptual system (formerly called a conceptual framework) and the result was the publication of a book entitled Toward a
Theory of Nursing (King, 1971).
DESIGN OF
A CONCEPTUAL SYSTEM
A conceptual system provides structure for organizing 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 concepts. In addition, the next
step in this process was to review the research literature in the discipline in which the concepts had
been studied. For example, the concept of perception has been studied in psychology for many years.
The literature indicated that most of the early studies
dealt with sensory perception. Around the 1950s,
psychologists began to study interpersonal 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 continued this search of literature
for knowledge of each of the concepts in my framework. An update on my conceptual system was published in 1995 (King, 1995).
Process for Developing a Concept

Searching for scientific knowledge in nursing is
an ongoing dynamic process of continuous identification, development,
Kings theory uses con- and validation of relevant concepts (King,
cepts of self, perception, 1975). What is a concommunication, interac- cept? A concept is an
organization of refertion, transaction, role, and
ence points. Words
decision making. are the verbal symbols
used to explain events
and things in our environment 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
used by me to develop knowledge and taught to
more than 1000 graduate students in the past 30
years is as follows:
1. Review, analyze, and synthesize research literature related to the concept.
278
2. From the above review, identify the characteristics (attributes) of the concept.
3. From the characteristics, write a conceptual definition.
4. Review literature to select an instrument or develop an instrument.
5. Design a study to measure the characteristics of
the concept.
6. Decisions are made on selection of 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 a theory to show
relationships.
Kings Conceptual System

Twelve conceptsself, body image, role, perception,
communication, interaction, transaction, growth and
development, power, authority, organization, and
decision makingwere identified from my analysis
of nursing literature (King, 1981). The concepts that
provided substantive knowledge about human beings were placed within the personal system, those
related to groups were placed within the interpersonal system, and those related to large groups that
make up a society were placed within the social system. However, knowledge from all of the concepts is
used in nurses interactions with individuals and
groups within social organizations, such as the family, the educational system, and the political system.
Knowledge of these concepts came from my synthesis of research in many disciplines. These concepts
are abstract. It is difficult to apply a conceptual system, which is someones abstraction of reality. 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, or education, or administration. In
addition, the concepts provide ideas for research in
nursing.
One of my goals was to identify what I call the
essence of nursing. That brought me back to the
question: What is the nature of human beings? A vicious circle? Not really! Because nurses are first and
foremost other human beings and give nursing care
to 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 represents
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, several dissertations, by
Frey (1995), Sieloff (1995), and Killeen (1996), have
derived theories from my conceptual system.
THEORY OF GOAL
ATTAINMENT
Generally speaking, the goal of nursing care 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 selected from that system. Remember my question: What is the essence of nursing? The concepts of self, perception, communication,
interaction, transaction, role, and decision making
were selected. Self is an individual whose perception
and role influence that persons communication, interaction, and decision making in small and large
groups. So, what is the health-care system within
which nurses function? Is it a social system of indi-
viduals and groups interacting to achieve goals related to health? A transaction model, shown in Figure
172, was developed that represented the process
whereby individuals interact to mutually set goals
that result in goal attainment (King, 1981).
As the twenty-first century begins, cost containment appears to be the primary goal of health-care
administrators and insurance companies. If the goals
and the means to achieve them are mutually agreed
upon by nurses and patients, 99% of the time, goals
will be achieved (King, 1989b). Goal attainment represents outcomes. Outcomes indicate effective nursing care. Nursing care is a critical element to provide quality care that is also cost-effective. Using the
transaction process model is one way to achieve this
goal.
Transaction Process Model

The model shown in Figure 172 is a human process
than can be observed in many situations when two
or more people interact, such as in the family and
in social events (King, 1996). As nurses, we bring
knowledge and skills that influence our perceptions,
communications, and interactions in performing the
functions of the role. Stop reading now and engage
someone in conversation. Then analyze your behavior to determine whether you used this process. In
your role as a nurse, after interacting with a patient,
279
your thoughts
sit down and write down your behavior and that of

the patient. It is my belief that you can identify your
perceptions, mental judgments, 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 not? 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 the process, nurses have a scientific
base for practice that can be articulated clearly and
documented to show quality care. How can a nurse
document this transaction model in practice?
Documentation System
A documentation system was designed to implement
the transaction process that leads to goal attainment
(King, 1984a). Most nurses use the nursing process
of 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 information and make a judgment. A transaction is made when the nurse and patient decide
mutually on the goals to be attained, agree on the
means to attain goals that represent the plan of care,
and then implement the plan. Evaluation determines
whether or not goals were attained. If not, you ask
why not, and the process begins again. The documentation is recorded directly in the patients chart.
The patients record indicates the process used to
achieve goals. On discharge, the summary indicates
280
goals set and goals achieved. One does not need multiple forms to complete 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 patients 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 transaction process provides a scientifically based process to help nurses
implement federal laws such as the Patient SelfDetermination Act. It is my humble opinion that
every student should be taught this transaction process as we move into the twenty-first century. In addition, every practicing nurse should be taught this
process. This is what is meant when nurses say we
must articulate the scientific basis for our practice.
This process is also useful in education in the student-teacher relationship. In addition, the process is
very useful in staff-administrator relationships. How
can one measure goal attainment?
Goal Attainment Scale

Analysis of nursing research literature in the 1970s
revealed that very few instruments were designed for
nursing research. In the late 1980s, the faculty at the
University of Maryland, experts in measurement and
evaluation, applied for and received a grant to conduct conferences to teach nurses to design reliable
and valid instruments. 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 patient data to plan and implement nursing care.
In summary, a systematic approach to develop a
conceptual system from which a theory was derived
has been explained. This has provided one approach
to structure scientific knowledge and use a process
that leads to outcomes. The Transaction Process
Model in the Theory of Goal Attainment indicates a
way in which goal attainment may be predicted. A
documentation system and goal attainment scale
were constructed to implement the nursing process
as method and the transaction process as theoretical
knowledge to accompany the method.
Use of Kings Conceptual

System and Theory
There has been no change in the conceptual system
or theory except to add the concept of coping in the
personal system. The word spiritual was added to
my assumptions about human beings. This was in my
original manuscript in 1971 but was accidentally
omitted in the publication (King, 1995).
Over the years of presenting my ideas at theory
conferences throughout the world, nurses have asked
many excellent questions, which I have tried to answer. Initially, the questions pertained to How do I
implement this in practice?This motivated me to design the documentation system to show the relationship between the nursing process as method and my
nursing process as theory. Prior to presenting this at a
national meeting, several staff nurses tested this and
suggested this system be implemented in practice. I
reminded the nurses that they were not applying a
theory, but were applying the knowledge of the concepts of the theory. This has become a repetitive
statement of mine; that is, one cannot apply an abstraction, which is what conceptual frameworks,
models, and theories represent. What one applies is
the knowledge of the concepts of the structure and
process proposed in the abstractions. The last thing I
had to do before retiring from a full-time teaching position was to design an instrument to measure goal attainment. The use of my ideas in practice, education,
administration, and research is shown in articles in a
variety of nursing journals.
Nursing Education
My first faculty position following completion of a
doctor of education degree at Teachers College, Columbia University, New York, in 1961, was appoint-
ment as an assistant professor at Loyola University,

Chicago. Because my area of study was curriculum
and instruction, I was selected to chair a faculty committee to develop a curriculum leading to a master of
science degree in nursing. This was one of the first
masters programs that used a nursing framework to
design a curriculum. The theoretical model was designed by a nurse as part of a dissertation from the
University of California (Kaufman, 1958). The model
was composed of three conceptstime, stress, and
perception. Needless to say, this approach to develop a new graduate program appeared to be revolutionary in 1961. This activity provided the impetus
for me to reflect on my knowledge of curriculum and
instruction, and also to think about structure for organizing undergraduate and graduate nursing programs. The rest is history and is recorded in my
books and articles over the past 30 years (King,
1986a).
In the 1970s the professional nursing staff at the
National League for Nursing conducted conferences
to disseminate information about the curriculum
process for developing or revising a baccalaureate
nursing program (King, 1978). The major components in a curriculum discussed at these conferences
were a philosophy, conceptual framework, course
objectives, and evaluation of the curriculum (National League for Nursing, 1978).
The scope of knowledge is so vast that it is impossible to teach students everything they need to learn
to begin to practice nursing today and tomorrow. It
is imperative that nursing curricula be based on a
conceptual framework. Such curricula must be structured to provide students with the essential concepts, skills, and values that serve as foundations and
as catalysts to continue to learn after graduation (National League for Nursing, 1978).
As a participant observer who provided administrative support for a faculty engaged in constructing
a new undergraduate curriculum, I witnessed the development of a curriculum that moved nursing education into the future (Daubenmire & King, 1973).
This baccalaureate nursing curriculum, based on my
conceptual framework, was published in 1989. According to Daubenmire (1989, p. 167), [T]he curriculum model and conceptual framework implemented in 1970 based on Kings theory have
remained essentially the same for about 15 years except for updating knowledge from year to year.
Kings framework, continues to provide a viable curriculum strategy. A curriculum model which is conceptually based allows for updating content and
skills without the necessity for major curriculum
change.
281
your thoughts
One of the criteria used to develop nursing curricula in colleges and universities is a clear statement of
a philosophy consistent with the institution offering
the nursing program. The philosophy is essential for
faculty to identify a conceptual framework and program objectives. A study was conducted in order to
identify the major terms used in stated philosophies
in nursing programs to attempt to describe the philosophical foundations of nursing. A random sample of
schools of nursing, stratified by type of program and
by region of the country, was selected from the National League for Nursings published list of accredited baccalaureate, associate degree, and diploma
nursing programs. A pilot study was conducted from
which a classification resulted in the formation of 12
categories (King, 1984b). A table of random numbers
was used to select 20% of the schools within each category, distributed according to region and type of
program. The conclusion reported differences in use
of the terms man,health,perception,role,social
systems, and God by type of program. Use of the
terms man,role,social systems, and God differed
by location of the program in a university, community
college, and hospital. The findings of this national survey provided some information about similarities and
differences in major terms used in statements of philosophy. The terms nursing, environment, and interpersonal relations did not differ significantly,
which indicated a few commonalities in those three
programs. However, differences in statements of philosophy imply differences in curricula, which in turn
provide different kinds of education for different
kinds of nursing practice. This study, done over 15
years ago, raised the questions: What is the philosophy of nursing education? Has a philosophy of nursing education changed historically?
282
A publishing company asked me to write a curriculum book. In the 1980s, articulation between associate degree nursing programs and baccalaureate
programs seemed to be a problem. Using my conceptual framework, I designed a hypothetical baccalaureate degree program and an associate degree
program to begin to identify differences and commonalities, because the same structure was used. My
idea was to show clear and reasonable articulation
between the two programs when the same conceptual framework is used. It would be interesting for a
faculty group to design a curriculum in a university
today that offers both a baccalaureate and an associate degree program to test out this hypothetical curriculum (King, 1986b).
In 1988 a colleague discussed with me the complexity and variety in health care and nursing, and
we agreed that a conceptualization of substantive
knowledge for curriculum development was essential in order to move into the twenty-first century. We
explored ideas about a philosophy of nursing education, a conceptual framework that identified interacting systems, individuals, groups, and social systems
and the concepts that identified substantive knowledge. Examples of objectives were cited that reflected our philosophy and conceptual framework. A
process of interactions that leads to transactions and
goal attainment was explored. We agreed that the use
of my conceptual framework and Theory of Goal Attainment provided an approach to develop a curriculum that is an open system based on a general system
framework and theory. When curricula are developed that identify common concepts (knowledge),
skills, and professional values, the practice of professional nursing will be the center of health care in
the twenty-first century. Increased technology and
knowledge require a conceptually based curriculum

for the future (Gulitz & King, 1988).
Practice
In the past 10 years, nurses have published their use
of my conceptual system and Theory of Goal Attainment in practice. Some nurses have used knowledge
of the concepts to implement theory-based practice
(Coker & Schreiber, 1989; Hanna, 1995; Messmer,
1995; Smith, 1988).
The goal of nursing is to help individuals and
groups attain, maintain, and regain a healthy state:
In nursing situations where the goal of life and
health cannot be achieved, as in a terminal illness,
nurses give care and help individuals die with dignity (King, 1971). My systems framework has described a holistic view of the complexity in nursing
within various groups, in different types of health
care systems. This framework differs from other conceptual schema in that it is concerned not with fragmenting human beings and the environment but
with human transactions in different types of environments (King, 1995). A few examples from the literature are given.
Family Health
The use of my conceptual system and Theory of Goal
Attainment in family health was suggested (King,
1983). The family is usually the immediate social environment in which individuals grow and develop
and learn through interactions to set goals. Nurses
work with families and with individual members of
families. The family is seen as a social system, a group
of interacting individuals. The family is also viewed as
an interpersonal system. For example, nurses perception of family members and family members perception of the nurse influence their responses in situations and their openness in giving information.
Congruence in perceptions of nurse and family members helps in assessing a situation to identify concerns and/or problems in the interpersonal system.
Knowledge of a concept of role is essential and related to growth and development, and to stress in
family environments. Two cases were presented and
the use of the Theory of Goal Attainment was described in each situation.
Community Health
At the Eighth Annual Community Health Nursing
Conference (1984) in North Carolina (King, 1984b),
I presented the use of my conceptual system and
Theory of Goal Attainment in community health
nursing. Community health nursing involves a variety of populations within a variety of social systems.
For example, school nurses must understand the education system. Occupational health nurses must understand the political system, the economic system,
and the belief system in a community. Some nurses
have used the Transaction Process Model in the
Theory of Goal Attainment in community health programs as they interact and set goals with interdisciplinary teams to manage health care (Hampton,
1994; Sowell & Fuszard, 1989; Sowell & Lowenstein,
1994). Nurses in community health focus on different populations. In this sense, they are relating to
the interpersonal systems in the framework. This is
done within a variety of social systems in the community. Although the focus is groups, nurses work
with individuals for whom they provide services. My
conceptual system (Fig. 171) shows the interactions of the three systems in community health.
Use in Hospitals
Two case studies were presented to demonstrate
nurses use of the transaction process and knowledge
of the concepts of perception, communication, interaction, and role (King, 1986b). Nurses in a Canadian hospital used the framework to structure the delivery of nursing care. They determined that nurses
could identify the published nursing diagnoses in
1990 with the concepts in the framework (Coker et
al., 1990). Nurses in Canada in which two hospitals
were involved at a distance from each other used the
conceptual framework to design a system for delivery of nursing care (Fawcett, Vaillancourt, & Watson,
1995). A director of nursing research and education
in a large municipal hospital in the United States reported the implementation of theory-based nursing
practice using my conceptual system (Messmer,
1995). Theory-based practice in an emergency department used my framework and Theory of Goal Attainment (Benedict & Frey, 1995). The Theory of
Goal Attainment was used in adult orthopedic nursing (Alligood, Evans, & Wilt, 1995).
The transaction process was used in short-term
group psychotherapy settings. Laben and colleagues
(Laben, Dodd, & Sneed, 1991) stated that my interactive systems approach of goal attainment is an ideal basis for short-term group psychotherapy. This group
used my theory with inpatient juvenile sexual offenders, offenders in maximum security, and community
parolees.
Research
A sample of studies that have been published that
test the Theory of Goal Attainment is cited. In addition, several dissertations have derived theories from
my conceptual system.
283
Several nurses have tested the theory in research

in aging, parenting, psychiatric-mental health, and
ambulatory care (Alligood et al., 1995; Benedict &
Frey, 1995; Norris & Hoyer, 1993; Woods, 1994).
Nurses in Japan, Sweden, and Canada have conducted studies in their cultures to test the Theory of
Goal Attainment (Coker et al., 1990; Kameoka, 1995;
Rooke, 1995).
A theory of power for nursing administration was
developed by Sieloff (1995). Frey (1995) proposed a
theory of family, children, and chronic illness and
continues to test it in research. Killeens dissertation
(1996) studied patient-consumer perceptions and responses to professional nursing care resulted in an
instrument that measures patient satisfaction.
Continuous Quality Improvement

Continuous quality improvement in nursing and
health care is a reality. Three major categories have
been suggested as a way to develop a program. These
elements are: (1) structure, (2) process, and (3) outcomes. Structure provides an overall organization of
the program. Process relates to nursing activities.
Outcomes are separate from but related to performance criteria for evaluation of nursing care and
nurses performance. My conceptual system provides
structure for a continuous quality improvement program (King, 1994). The Transaction Process Model in
my Theory of Goal Attainment gives a process that
leads to goal attainment that represents outcomes.
Outcomes indicate effective nursing care. An example was given to document effectiveness of nursing
care if one uses a goal-oriented nursing record (King,
1984a). The record system is an information system
based on my Theory of Goal Attainment. The record
system can be designed and adapted to most healthcare systems. For nurses, it was designed to gather
data from assessments of the patient, make a nursing
diagnosis, construct a goal list, write orders for nursing care, and write mutually agreed-upon goals and
means to attain them. Goals that are achieved are
outcomes and represent effective nursing care. Elements in the goal-oriented nursing record are: (1)
data base, (2) goal list, (3) nursing orders, (4) flow
sheets, (5) progress notes, and (6) discharge summary. This information system can be designed for
any patient population and for current and future
computerization of records in a health-care system.
Summary
The health-care system in the United States is in constant flux in an attempt to restructure health-care de-
284
livery. How can a conceptual system and the Theory

of Goal Attainment provide the structure, process,
and outcomes that represent a way to manage and
deliver quality health care for all citizens? My conceptual system and transaction process in the Theory
of Goal Attainment provides one approach to accomplish the goal of access and quality in the following
ways:
1. For interaction between nurses and health-care
professionals and between health-care agencies
for continuity of care, respect for roles and responsibilities of each health profession; for case
management, and collaborative and integrated
practice.
2. Essential knowledge to assess, diagnose, plan, implement, and evaluate care.
3. For common discourse among health professionals and between nurses and nursing personnel.
4. A framework within health-care systems and between health care providers and agencies.
5. Direct measure of outcomes resulting in quality
care and cost-effective care; that is, goals are set
and goals are attained.
6. A systematic and efficient documentation system.
7. One valid and reliable assessment instrument to
assess activities of daily living as a basis for goalsetting.
8. For continuity of care within and between healthcare agencies.
9. Results in satisfaction for patients, families, physicians, and administrators.
When knowledge of the concepts and the transaction process has been used in hospitals, homes, nursing homes, and community health agencies, nurses
have been motivated to seek additional knowledge in
formal educational programs.
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 system will be structured using my conceptual system. Entry into the system will
be via nurses assessment so individuals are directed
to the right place in the system for nursing care, medical care, social services information, 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 Attainment, and Transaction Process Model will continue to
serve a useful purpose in delivering professional nursing care. The ideas have been tested in research and
in practice, and knowledge of the concepts has been
used by nurses in education and practice. The relevance of evidence theorybased practice, using my
theory, has been shown to join the art of nursing of
the twentieth century to the science of nursing in the
twenty-first century.
References
Alligood, M., Evans, G. W., & Wilt, D. L. (1995). Kings
interacting system and empathy. In Frey, M. A., &
Sieloff, C. L. (Eds.), Advancing Kings systems
framework and theory of nursing (p. 64). Thousand Oaks, CA: Sage.
Benedict, M., & Frey, M. A. (1995). Theory-based practice in the emergency department. In Frey, M. A., &
framework and theory of nursing (p. 327). Thousand Oaks, CA: Sage.
Coker, E. A., & Schreiber, R. (1989). King at the bedside. The Canadian Nurse, 24.
Coker, E., Fradley, T., Harris, J., Tomarchio, D., Chan, V.,
& Caron, C. (1990). Implementing nursing diagnoses within the context of Kings conceptual
framework. Nursing Diagnosis, 1, 107.
Daubenmire, M. J. (1989). A baccalaureate nursing curriculum based on Kings conceptual framework. In
Riehl-Sisca, J. (Ed.), Conceptual models for nursing
practice (p. 167). New York: Appleton & Lange.
Daubenmire, M. J., & King, I. M. (1973). Nursing process models: A systems approach. Nursing Outlook,
21, 512.
Fawcett, J. M., Vaillancourt, V. M., & Watson, C. A.
(1995). Integration of Kings framework into nursing
practice. In Frey, M. A., & Sieloff, C. L. (Eds.), Advancing Kings systems framework and theory of
goal attainment (p. 176). Thousand Oaks, CA:
Sage.
Frey, M. A. (1995). Toward a theory of families, children, and chronic illness. In Frey, M. A., & Sieloff,
and theory of nursing (p. 109). Thousand Oaks,
CA: Sage.
Gulitz, E. A., & King, I. M. (1988). Kings general system model: Application to curriculum development.
Hampton, D. C. (1994). Kings theory of goal attainment as a framework for managed care implementation in a hospice setting. Nursing Science Quarterly, 7, 170.
Hanna, U. M. (1995). Use of Kings Theory of Goal Attainment to promote adolescents health behavior.
In Frey, M. A., & Sieloff, C. L. (Eds.), Advancing
Kings system framework and theory of goal attainment (p. 239). Thousand Oaks, CA: Sage.
Howland, D. (1976). An adaptive health system model.
In Werley, H. H., et al. (Ed.), Health systems research:The systems approach (p. 109). New York:
Springer Publishing.
Howland, D., & McDowell, W. (1964). A measurement
of patient care: A conceptual framework. Nursing
Research, 13(4), 320324.
Kameoka, T. (1995). Analyzing nurse-patient interactions in Japan. In Frey, M. A., & Sieloff, C. L. (Eds.),
Advancing Kings system framework and Theory

of Goal Attainment (p. 251). Thousand Oaks, CA:
Sage.
Kaufman, M. (1958). Identification of a theoretical basis for nursing practice. Unpublished doctoral dissertation, University of California, Los Angeles.
Killeen, M. (1996). Patient-consumer perceptions and
responses to professional nursing care: Instrument
development. Unpublished doctoral dissertation,
University of Michigan, Detroit.
King, I. M. (1964). Nursing theory: Problems and
propect. Nursing Science Quarterly, 2, 294.
King, I. M. (1968). A conceptual frame of reference for
nursing. Nursing Research, 17, 2731.
King, I. M. (1971). Toward a theory of nursing. New
York: John Wiley.
King, I. M. (1975). A process for developing concepts
for nursing through research. In. Verhonick, P. J.,
(Ed.), Nursing Research (p. 25). Boston: Little,
Brown.
King, I. M. (1978). How does the conceptual framework provide structure for the curriculum? In Curriculum process for developing or revising a baccalaureate nursing program. New York: National
League for Nursing, pp. 2334.
King, I. M. (1981). A theory of goal attainment: Systems, concepts, process. New York: Wiley.
King, I. M. (1983). Kings Theory of Goal Attainment.
In Clements, I. W., & Roberts, F. B. (Eds.), Family
health:A theoretical approach to nursing care
(p. 177). New York: Wiley.
King, I. M. (1984b). A theory for nursing: Kings conceptual model applied to community health nursing.
In Conceptual models of nursing applications in
community health nursing (p. 14). Chapel Hill,
NC: Department of Public Health Nursing.
King, I. M. (1984a). Effectiveness of nursing care: Use
of a goal oriented nursing record in end stage renal
disease. American Association of Nephrology Nursing and Technology, 11(11), 60.
King, I. M. (1984c). Philosophy of nursing education:
A national survey. Western Journal of Nursing Research, 6, 387.
King, I. M. (1986a). Curriculum and instruction in
nursing. Norwalk, CT: Appleton-Century-Crofts.
King, I. M. (1986b). Kings Theory of Goal Attainment.
In Fry, P. (Ed.), Case studies in nursing theory
(p. 197). New York: National League for Nursing.
King, I. M. (1988). Concepts: Essential elements of
theories. Nursing Science Quarterly, 1(1),
2224.
King, I. M. (1989a). Kings general systems framework
and theory. In Riehl-Sisca, J. P. (Ed.), Conceptual
models for nursing practice (p. 149). Norwalk, CT:
Appleton & Lang.
King, I. M. (1989b). Kings systems framework for nursing administration. In Henry, B., et al. (Eds.), Dimensions of nursing administration:Theory, research, education (p. 35). Cambridge, England:
Blackwell Scientific.
King, I. M. (1989c). Measuring health goal attainment
in patients. In Waltz, C. F., & Strickland, O. L. (Eds.),
Measurment of nursing outcomes (p. 108). New
York: Springer Publishing.
King, I. M. (1990). Health the goal for nursing. Nursing
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King, I. M. (1992). Kings Theory of Goal Attainment.

King, I. M. (1994). Quality of life and goal attainment.
King, I. M. (1995). The theory of goal attainment. In
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(p. 23). Thousand Oaks, CA: Sage.
King, I. M. (1996). The Theory of Goal Attainment in research and practice. Nursing Science Quarterly, 9,
61.
King, I. M. (1998). Nursing informatics: A universal
nursing language. The Florida Nurse, 46, 1.
Laben, J., Dodd, D., & Sneed, L. (1991). Kings Theory
of Goal Attainment applied in group therapy for inpatient juvenile sexual offenders, maximum security
state offenders and community parolees. Issues in
Mental Health Nursing, 12, 52.
Messmer, P. (1995). Implementation of theory-based
nursing practice. In Frey, M. A., & Sieloff, C. L.
(Eds.), Advances in Kings systems framework and
Theory of Goal Attainment (p. 294). Thousand
Oaks, CA: Sage.
National League for Nursing. (1978). Curriculum process for developing or revising a baccalaureate
nursing program. New York: National League for
Nursing.
Norris, D. M., & Hoyer, P. J. (1993). Dynamism in practice: Parenting within Kings framework. Nursing
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Northrop, F. C. S. (1969). The logic of the sciences and

the humanities. Cleveland: Meridian.
Rooke, L. (1995). Focusing on Kings theory and systems framework in education by using an experiential learning model: A challenge to improve the quality of nursing care. In Frey, M., & Sieloff, C. L.
(Eds.), Advancing Kings systems framework and
Theory of Goal Attainment (p. 178). Thousand
Oaks, CA: Sage.
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Theory of Goal Attainment (p. 35). Thousand Oaks,
CA: Sage.
Smith, M. C. (1988). Kings theory in practice. Nursing
Sowell, R. L., & Fuszard, A. H. (1989). Inpatient nursing care management as a strategy for rural hospitals: A case study. Journal of Rural Health, 5, 201.
Sowell, R. L., & Lowenstein, A. (1994). Kings theory as
a framework for quality: Linking theory to practice.
Nursing Connections, 7(2), 1931.
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Woods, B. C. (1994). Kings theory in practice with elders. Nursing Science Quarterly,7, 58.
Chapter 17
Part 2
Application of Kings Work

to Nursing Practice
Review of the Literature
Summary
References
Christina Leibold Sieloff

Maureen Frey
Mary Killeen
Since the first publication of Dr. Imogene Kings

work, nursings 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 theory further expanded her work. Although there were few publications in the 1970s and
1980s, today new publications are a continuous occurrence. In 1995, Frey and Sieloff collected a sample of the ongoing work related to Kings systems
framework and theory.
Although this chapter summarizes the application
of Dr. Kings work within nursing, it is limited to
published applications. This eliminates current
works in progress or planned applications. In addition, in reviewing the literature, it has been noted
that many publications apply concepts or ideas from
Kings work, such as the achievement of goals or perceptions, without referencing Dr. King. Therefore, it
is believed that the application of Kings work is far
more extensive than the literature would lead the
reader to believe. Thus, the authors suggest that the
application of Dr. Kings work is currently pervasive
throughout nursing in the United States. In todays
practice environment, the concepts of cultural diversity and cultural competence are identified as
critical to the delivery of client-focused or -centered
care. Hence, it is particularly relevant to identify the
application of Dr. Kings work as documented in several different countries in addition to the United
States: namely, Canada, Japan, and Sweden. Again,
these countries, with their variety of cultures, are
the only countries being identified in publications
that specifically reference Dr. Kings work. It is expected that many other cultures would find Dr.
Kings work equally valuable in improving the quality
of patient care.
This section of the chapter will not analyze or
evaluate the work of Dr. King or its application. The
purpose is to describe the state of the art in terms of
the work being done
The literature reviewed re- in relation to the
application of Kings
ports use of Kings interact- conceptual framework
ing systems framework as and theory in a variety of areas: practice,
a guide to nursing practice. administration, education, and research.
Frey and Sieloffs (1995) work, as well as nursing
knowledge development from a review of the literature, will be summarized and briefly discussed. Finally, recommendations will be made for future
knowledge development in relation to Kings systems framework and theory, particularly in relation
288
to the importance of application within an evidencebased practice environment.
REVIEW OF THE LITERATURE

Application of Interacting
Systems Framework
In conducting the literature review, the authors began with the broadest category of applicationapplication within the interacting systems framework.
All other application could be discussed within the
interacting systems framework because the framework provides the basis for concept development
and theory development and testing. However, this
section will address only those applications that apply Kings interacting systems framework to nursing
care situations. Other applications will be discussed
in the remainder of the chapter. Because a conceptual framework is, by nature, very broad and abstract, it can only serve to guide, rather than prescriptively direct, nursing practice. Hence, the
literature discussed here used Kings interacting systems framework in order to guide nursing practice.
Coker et al. (1995) used the framework to guide the
implementation of nursing diagnosis in a large community hospital. Fawcett, Vaillancourt, and Watson
(1995) used the framework to guide nursing practice
in a large tertiary care hospital.
In contrast, several authors used the framework
to guide nursing practice with specific patient populations. Doornbos (1995) explored family health in
families with chronically mentally ill family members. Hobdell (1995, p. 132) examined the relationship between chronic sorrow and accuracy of perception of a childs cognitive development in parents
of children with neural tube defects. Sharts-Hopko
(1995) used concepts within Kings framework to
study health status as perceived by women during
the menopause transition. Table 171 delineates applications related to Kings interacting systems framework.
Concept Development
within the Framework
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 original work. Such explication further
assists the development of nursing knowledge as it
enables the practicing nurse to understand more easily the application of the concept within specific
practice situations. Examples of concepts developed
TABLE 17-1
Application of the Interacting Systems Framework
Topic
Author(s)
Year
Anxiety
LaFontaine
1989
Autonomy
Glenn*
1989
Change
DeFeo
1990
Child health
Steele
1981
Chronic mental illness
Doornbos
1995
Communication
Daubenmire, Searles, and Ashton
1978
Community assessment
Hanchett
1988
Community
Hanchett
Myks Babb, Fouladbakhsh, and Hanchett
King
Asay and Ossler
1990
1988
1984
1984
Continuing education
Brown and Lee
1980
Education
Daubenmire
King
Gulitz and King
King
Froman and Sanderson
Daubenmire and King
1989
1989
1988
1986
1985
1973
Family therapy
Gonot
1986
Menopause
Sharts-Hopko
Heggie and Gangar
1995
1992
Neural tube defect
Hobdell
1995
Nursing administration
Elberson
Sieloff
1989
1995
Nursing diagnosis
Byrne-Coker, Fradley, Harris, Tomarchio, and Caron
1990
Operating room
Gill, Hopwood-Jones, Tyndall, Gregoroff, LeBlance, Lovett,

Rasco, and Ross
1995
Patient education
Spees
Martin
King and Tarsitano
1991
1990
1982
Perception
Bunting
1988
Reproductive health
Davis and Dearman
1991
Smoking
Kneeshaw
1990
Social support
Frey
1989
Theory-based practice
Messmer
1995
1992
1991
1990
West
Byrne and Schreiber
*Indicates thesis or dissertation
Chapter 17 Sieloff, Frey, and Killeen Application of Kings Work to Nursing Practice
289
Concept Development within the Framework
TABLE 17-2
Topic
Author(s)
Year
Advocacy
Bramlett, Gueldner, and Sowell
1990
Autonomy
Glenn*
1989
Coping
King
1983
Empathy
Alligood, Evans, and Wilt
1995
Health
King
1990
Health (social system)
Sieloff
1995
Health (systems)
Winker
1995
Power
Hawkes
1991
Quality of life
King
1993
Social support
Frey
1989
Space
Rooke
1995
Transaction
Binder*
1992
from within Kings work include the following: empathy (Alligood, Evans, & Wilt, 1995), health of a
social system (Sieloff, 1995b), health of systems
(Winker, 1995), and space (Rooke, 1995b). Table
172 further details applications related to concept
development within Kings framework (1981).

Dr. Kings work is unique in that, in addition to the
interacting systems framework, she developed the
Theory of Goal Attainment, in 1981. This theory has
found great application to nursing practice. One
of the reasons for such a broad application is the
fact that the theory focuses on a concept relevant
throughout all nursing situationsthe attainment of
client goals. From a review of the literature, it can be
demonstrated that the application of the Theory of
Goal Attainment (King, 1981) is documented in several categories: (1) general application of the theory,
(2) exploring a particular concept within the context
of the Theory of Goal Attainment, (3) exploring a particular concept related to the Theory of Goal Attainment, and (4) application of the theory in nonclinical nursing situations. The Theory of Goal Attainment
has been generally applied in a variety of nursing
practice areas. Alligood (1995) applied the theory
290
to orthopedic nursing with adults, whereas Hanna

(1995) used the theory in the promotion of the
health behaviors of adolescent clients. Short-term
group psychotherapy was the focus of theory
application for Laben, Sneed, and Seidel (1995). In
contrast, Benedict and Frey (1995) examined the
use of the theory within the delivery of emergency
care.
The Theory of Goal Attainment (King, 1981) is
also used when nurses wish to explore a particular
concept within a theoretical context. Perceptual
congruency between nurses and clients was explored by Froman (1995).
Nurses also use the Theory of Goal Attainment
(King, 1981) to examine concepts related to the
theory. This application was demonstrated by
Kameoka (1995) as she analyzed nurse-patient interactions in Japan.
Finally, the theory has been applied in nonclinical
nursing situations. Rooke (1995b) applied the theory
and framework in nursing education. Messmer (1995)
used the theory in implementing theory-based nursing practice. And Jolly and Winker (1995) applied
the theory to organizations. In summary, Table 173
chronicles applications of Kings Theory of Goal
Attainment.
TABLE 17-3
Application of the Theory of Goal Attainment
Topic
Author(s)
Year
Adolescent health behavior
Hanna
Hanna
1995
1993
Anxiety
Birth
La Fontaine
Swindale
Smith
1989
1989
1988
Cardiac rehabilitation
McGirr, Rukhorm, Salmoni, OSullivan, and Koren
1990
Case management
Sowell and Lowenstein
1994
Coma
Ackerman, Brink, Clanton, Jones, Moody, Pirlech,

Price, and Prusinsky
1989
Diabetes
Husband
1988
Emergency room
Benedict and Frey
1995
Hughes
1983
Family
Rawlins, Rawlins, and Horner

King
1990
1989
1986
1983
Group psychotherapy
Laben, Sneed, and Seidel

Laben, Dodd, and Sneed
1995
1991
Health promotion
Calladine
1996
Hospitals
Messmer
1995
HIV
Kemppainen
1990
Interactions
Kameoka
1995
Managed care
Hampton
1993
Neurofibromatosis
Messmer and Neff Smith
1986
Nursing care effectiveness
King
1984
Nursing situations
Nagano and Funashima

Rooke and Norberg
1995
1988
Oncology
Lockhart*
Porter
1992
1991
Organ donation
Richard-Hughes
1997
Organizations
Jolly and Winker
1995
Parenting
Norris and Hoyer
1994
Perceptual congruence
Froman
1995
291
Continued
TABLE 17-3
Topic
Author(s)
Year
Psychosis
Kemppainen
1990
Psychotherapy
DeHowitt
1992
Quality of life
King
1993
Recovery
Hanucharurnkui and Vinya-nguag
1991
Reproductive health
Hanna
1993
Role strain
Temple and Fawdrey
1992
Senior adults
Woods
Jonas
1994
1987
Theory-based practice
Messmer
West
1992
1991
Transactions
Monti*
1992
Transcultural critique
Husting
1997
Development of Middle-Range
Theories within the Framework
Development of middle-range theories is a part of the
natural growth in application of a conceptual framework. Middle-range theories, clearly developed from
within a conceptual framework, accomplish several
goals:
1. Such theories can be directly applied to nursing
situations, whereas a conceptual framework is
usually too abstract for such direct application.
2. Validation of middle-range theories, clearly developed within a particular conceptual framework,
lends validation to the conceptual framework itself.
In addition to the Theory of Goal Attainment (King,
1981), several middle-range theories have been
developed from ideas
within Kings interSeveral middle-range
acting systems frametheories have been devel- work, using each of
oped from Kings interact- the systems defined
within that framework.
ing systems framework. In terms of the personal system, Brooks
and Thomas (1997) used Kings framework to derive
a theory of perceptual awareness. The focus was to
292
develop the concepts of judgement and action as

core concepts in the personal system. Other concepts in the theory included communication, perception, and decision making.
In relation to the interpersonal system, several
middle-range theories have been developed regarding
families. Doornbos (1995) addressed family health in
terms of families with young chronic mentally ill individuals. Frey (1995) developed a middle-range theory
regarding families, children, and chronic illness, and
Wicks (1995) delineated a middle-range theory regarding the broader concept of family health.
In relation to social systems, Sieloff (1995a) developed the Theory of Departmental Power to assist in
explaining the power of groups within organizations. This theory reformulated selected concepts
from the Strategic Contingencies Theory of Departmental Power (Hickson, Hinings, Lee, Schneck, &
Pennings, 1971) within Kings framework to propose
concepts that contribute to a departments power capacity and its actualized power. Table 174 lists middle-range theories developed within Kings framework (1981).
Instrument Development
Instrument development is needed through nursing
knowledge in order to assist nurses and researchers
in measuring concepts relevant to nursing phenom-
TABLE 17-4
Development of Middle-Range Theories within the Framework
Topic
Author(s)
Year
Departmental power (revised to group power)
Sieloff
1998*
1996*
1995
Families, children, and chronic Illness
Frey
1995
1993
Family health
Wicks
1995
Family health (families with young chronic mentally ill individuals)
Doornbos
1995
Perceptual awareness
Brooks and Thomas
1997
Satisfaction, client
Killeen*
1996
*Indicates thesis or dissertation or research in progress
ena. However, instruments are frequently developed

as part of an overall research study rather than serving as the main focus of the study. Within the context
of a larger study, rather than as the outcome of a research project, reports regarding these instruments
are often not as extensive as they should be in order
to facilitate the further growth of nursing knowledge. Hence, review of the literature identified only
two instruments specifically designed within Kings
framework. King (1988) developed the Health Goal
Attainment instrument designed to detail the level of
attainment of health goals by individual clients. The
Family Needs Assessment Tool was developed by
Rawlins, Rawlins, and Horner (1990). Table 175
provides a listing of instruments that were developed
in relation to Kings work.
Clients Across the Life Span

Additional evidence of the scope and usefulness of
Kings framework and theory is its use across a broad
TABLE 17-5
range of patient populations. When reviewing the literature in terms of whether Kings work has been
applied to clients across the life span, the following
categories were used: (1) infants; (2) children; (3)
adolescents; (4) adults, young; (5) adults; and (6)
adults, mature. The application of Kings work was
evident in all categories. Several applications have
targeted high-risk infants (Frey & Norris, 1997; Norris & Hoyer, 1993; Syzmanski, 1991). Interestingly,
these each considered personal systems (infants), interpersonal systems (parents, families), and social
systems (the nursing staff and hospital environment).
Clearly, a strength of Kings framework and theory is
their utility in encompassing complex settings and
situations.
Frey (1993, 1995, 1996) developed and tested relationships among multiple systems with children
and youth with insulin-dependent diabetes and
asthma. Ongoing testing is being done with children
and adolescents with HIV/AIDS and adolescents in
Instrument Development Related to Kings Work
Topic
Author(s)
Year
Family Needs Assessment Tool
1990
Health goal attainment
King
1988
Nursing Care Survey (client-consumer perceptions and

responses to professional nursing care)
Killeen
1996
Sieloff-King assessment of group power within organizations
Sieloff
1998
293
primary care settings (Frey, personal communication, 1998). In addition, Hobdell (1995) applied the
framework to children with neural tube defects.
Hanna (1993, 1995) applied Kings work in nursing situations with adolescent client populations.
Hanna (1993) investigated the effect of nurse-client
interactions on oral contraceptive adherence in adolescent females and worked with adolescents in primary-care settings in order to better understand health
actions (1995).
The systems framework and Theory of Goal Attainment have been used to guide practice with adults
with a broad range of illness conditions. In relation
to adult clients, the literature is divided into: (1)
young adults, (2) adults, and (3) mature adults.
Doornbos (1995) used Kings work in her study of
young adults experiencing chronic mental illness.
Examples of applications focusing on adults include cardiac disease (McGirr, Rukholm, Salmoni,
OSullivan, & Koren, 1990; Sirles & Selleck, 1989),
diabetes (Husband, 1988), renal procedures (Hanucharurnkui & Vinya-nguag, 1990), elective minor
surgery (Swindale, 1989), and orthopedic surgery
(Alligood, 1995). Gender-specific work included
Sharts-Hopkos (1995) use of concepts within the
systems framework to study the health status of
women during menopause transition, and Martins
(1990) application of the framework to cancer
awareness among males.
Several of the applications with adults have targeted the mature adult, thus demonstrating considerable contribution to the nursing specialty of gerontology. Kohler (1988) used the framework to
increase elderly clients sense of shared control over
health and health behaviors. Kenny (1990) also addressed the role of the elderly in their care. Despite
using similar populations and a similar focus, these
applications were quite different, with Kohler using
the nursing process and Kenny using concepts from
the Theory of Goal Attainment. Both approaches and
foci are likely to lead to better health outcomes for
the clinical group. In addition, Woods (1994) proposed the Theory of Goal Attainment in order to decrease chronic health problems among nursing home
residents. Clearly, these applications show how the
complexity of Kings framework and theory increases
its usefulness for nursing (refer to Table 176).
Client Systems
A major strength of Kings work is that it can be used
with virtually all client populations. 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 (phe-
294
nomenon of concern). The focus of care or interest

can be an individual (personal system) or group (interpersonal or social system). Application of Kings
work across client systems would then logically be
divided into the three systems identified within
Kings interacting systems framework (1981): personal (the individual), interpersonal (small groups),
and social (large groups/society). Use with personal
systems has included both patients and nurses. Patients as personal systems were the focus of applications by DeHowitt (1992), Frey and Norris (1997),
Hanucharurnkui and Vinya-ngaug (1990), Husband
(1988), Kemppainen (1990), Kenny (1990), and
McGirr, Rukholm, Salmoni, OSullivan, and Koren
(1990). Levine, Wilson, and Guido (1988) considered critical care nurses as the personal system of interest, as did Brooks and Thomas (1997).
When the focus of interest moves from an individual to include interaction between two people, an interpersonal system is involved. Interpersonal systems often, but not always, include clients and
nurses. Examples of applications to nurse-client
dyads and larger groups include Messmer and Neff
Smiths (1986) approach to nursing with clients with
neurofibromatosis, Swindales (1989) exploration of
nurses role in reducing anxiety in hospitalized
clients, and Kohlers (1988) application to nurses
and elderly clients. Martin (1990) used the systems
framework to develop and test an educational intervention about cancer with males in the work setting.
Laben, Dodd, and Sneed (1991) applied the Theory
of Goal Attainment to group psychotherapy with
inpatient juvenile offenders. Temple and Fawdry
(1992) used the Theory of Goal Attainment to examine role strain when the caregiver of an elderly patient is also a nurse.
In relation to interpersonal systems, or small
groups, many publications focus on the family, such
as Davis (1987), Frey and Norris (1997), Gonot
(1986), Hobdell (1995), Norris and Hoyer (1993),
Sirles and Selleck (1989), Syzmanski (1991), and
Wicks (1995). Gonot proposed the systems framework as a model for family therapy. Davis considered
individuals, parent dyads, and families when addressing the problem of infertility. Sirles and Selleck used
the systems framework to examine the impact of cardiac disease on the family. Syzmanski (1991) focused
on the Theory of Goal Attainment in planning care
with families of premature infants. Frey and Norris
used both the systems framework and Theory of Goal
Attainment in planning care with a similar population and setting.
Kings systems framework and Theory of Goal Attainment have a long history of application, and use,
TABLE 17-6
Application to Clients across the Life Span
Topic
Author(s)
Year
Infants
Frey and Norris

Norris and Hoyer
Syzmanski
1997
1993
1991
Children
Scott
Frey
1998
1996
1995
1995
1993
1989
1981
Hobdell
Frey
Steele
Adolescents
Hanna
Binder*
Hughes
1995
1993
1992
1991
1983
1978
Adults, young
Doornbos
1995
Adults
Ollsson and Forsdahl

Alligood
Froman
Jones, Clark, Merker, and Palau
Kameoka
Rooke
Sharts-Hopko
Norris and Hoyer
Hanna
DeHowitt
Heggie and Gangar
Hobdell
Lockhart*
Kemppainen
Martin
Glenn*
OShall*
Sirles and Selleck
Swindale
1996
1995
1995
1995
1995
1995
1995
1995
1994
1993
1992
1992
1992
1992
1991
1990
1990
1990
1990
1989
1989
1989
1989
Husband
Smith
Jonas
Pearson and Vaughan
King and Tarsitano
King
Strauss
Brown and Lee
1988
1988
1986
1987
1986
1982
1984
1981
1980
1978
295
TABLE 17-6
Continued
Topic
Author(s)
Year
Adults, mature
Allan*
Rooke
Woods
Tawil*
Temple and Fawdry
Zurakowski*
Kenny
Miller
Kohler
Jonas
King
Rosendahl and Ross
1995
1995
1995
1994
1993
1992
1991
1990
1990
1988
1987
1983
1982
with large groups or social systems (organizations,

communities). One of the earliest applications was
the use of the framework and theory to guide continuing education (Brown & Lee, 1980) and nursing
curricula (Daubenmire, 1989; Gulitz & King, 1988).
More contemporary applications address models of
care. For example, the framework and Theory of
Goal Attainment serve as the basis for practice in several acute-care settings (Byrne & Schreiber, 1989;
Fawcett, Vaillancourt, & Watson, 1995). Several applications proposed the Theory of Goal Attainment as
the practice model for case management (Hampton,
1994; Tritsch, 1996). These latter applications are especially important, as they may be the first use of the
framework by other disciplines.
Within organizations, Jolly and Winker (1995) applied the Theory of Goal Attainment in the context of
an organizational structure. A theory of departmental

power has been developed (Sieloff, 1995a). Messmer
(1995) implemented theory-based nursing practice,
based on Kings work, in a large, urban public hospital. Educational settings, also considered as social
systems, have also been the focus of application of
Kings work (Brown & Lee, 1980; Daubenmire,
1989; Daubenmire & King, 1973; Froman & Sanderson, 1985; Gulitz & King, 1988). Table 177 consolidates applications of Kings work to various client
systems.
Phenomena of Concern to Clients

Within Kings work, it is obviously critically important for the nurse to focus on, and address, the phenomenon of concern to the client. Without this
emphasis on the clients perspective, mutual goal-
your thoughts
296
TABLE 17-7
Application to Various Client Systems
Topic
Author(s)
Year
Personal systems
Brooks and Thomas

Frey and Norris
Hanna
Jackson, Pokorny, and Vincent
DeHowitt
Kemppainen
Kenny
Husband
Kohler
Levine, Wilson, and Guido
Smith
Jonas
Pearson and Vaughan
King
Hughes
King and Tarsitano
1997
1997
1993
1993
1992
1990
1990
1990
1990
1988
1988
1988
1988
1987
1986
1984
1983
1982
Interpersonal systems
OShall*
1989
Interpersonal systems (families)
Frey and Norris

Norris and Hoyer
Frey
Temple and Fawdry
Spees
Syzmanski
Dispenza*
Sirles and Selleck
Frey
Davis
Gonot
King
Strauss
1997
1994
1993
1992
1991
1991
1990
1990
1989
1989
1987
1986
1986
1983
1981
Interpersonal systems (groups)
Woods
Monti*
1994
1992
1991
Interpersonal systems (nurse-client)

DeHowitt
Houfek
Temple and Fawdry
Rundell
Martin
Swindale
Kohler
Messmer and Smith
1995
1992
1992
1992
1991
1990
1989
1988
1986
1978
Interpersonal systems (stepfamilies)
Omar*
1990
Social systems
Brown and Lee
1980
297
TABLE 17-7
Continued
Topic
Author(s)
Year
Social systems (aggregates)
Norgan, Ettipio, and Lasome
1995
Social systems (communities)
Temple and Fawdry

Hanchett
Hanchett
Myks Babb, Fouladbakhsh, and Hanchett
Asay and Ossler
King
1992
1990
1988
1988
1984
1984
Social system (education)
Daubenmire
Gulitz and King
Brown and Lee
Daubenmire and King
1989
1988
1985
1980
1973
Social system (nursing unit)
Rundell
1991
Social systems (organizations)
Tritsch
Fawcett, Vaillancourt, and Watson
Jolly and Winker
Messmer
Sieloff
Fitch, Rogers, Ross, Shea, Smith, and Tucker
Schreiber
West
Byrne-Coker, Fradley, Harris,
Tomarchio, and Caron
Kenny
Byrne and Schreiber
Elberson
Hampton
LaFontaine
1996
1995
1995
1995
1995
1991
1991
1991
1990
1990
1989
1989
1989
1989
setting could not occur. Clients will not work toward

goals that they do not value. King noted (1981) that
nurses and clients may not always have the same
goals, or agree with clients on ways to achieve goals.
In the literature, information regarding client phenomena of concern has been categorized by disease
classification or client complaint or problem. Such
categorization could often be perceived as having either a negative focus, or a medical rather than a nursing focus. In addition, this type of categorization
could hinder nurses working within a health promotion or health education model. Therefore, for the
purpose of this section of the chapter, client phenomena of concern was selected as a more neutral
terminology that would enable nurses in all settings
to see clearly the broad application of Kings work to
their practice situations. Table 178 summarizes applications related to client phenomena of concern,
and groups these applications, primarily identified
298
by disease or medical diagnosis, as illness management.

One area that certainly binds clients and nurses is
health. Improved health is clearly the desired end
point or outcome of nursing care and something to
which clients aspire. Review of the focus, or outcome, of nursing care as addressed in published applications tends to support the goal of improved
health directly and/or indirectly. Health status is explicitly the outcome of concern in research and practice applications by Doornbos (1995), Frey (1995,
1996), Smith (1988), and Woods (1994). Several applications used health-related terms or limited dimensions of health. For example, Kohler (1988) focused on increased morale and satisfaction. Swindale
(1989) focused on reducing anxiety, and DeHowitt
(1992) focused on well-being.
Health promotion has also been an emphasis for
the application of Kings ideas. Health behaviors
TABLE 17-8
Application to Client Concerns
Topic
Author(s)
Year
Care of self
Autonomy
Birth

Glenn*
Husband
Smith
1991
1989
1988
1988
Goal-setting
Tritsch
1996
Health promotion
Calladine
Hanna
Sharts-Hopko
Hanna
Heggie and Gangar
Kohler
Norris and Hoyer
Hanna
OShall*
Villeneuve and Ozolins*
DeHowitt
Dispenza*
1996
1995
1995
1993
1992
1988
1993
1993
1989
1991
1992
1990
Frey
1996
1995
1995
1994
1988
Body weight
Menopause
Morale
Parenting
Reproductive health
Role
Sexual counseling
Stress
Health status
Doornbos
Woods
Smith
Illness management
Asthma
Anxiety
Bronchopneumonia
Cardiac rehabilitation
Cardiovascular
Carpal tunnel syndrome
Chronic illness
Chronic obstructive pulmonary disorder
Coma
Diabetes
End-stage renal disease

HIV
High-risk infants
Hypertension
Nephrology
Neural tube defects
Neurofibromatosis
Oncology
Frey
Swindale
Pearson and Vaughan
McGirr, Rukhorm, Salmoni, OSullivan, and Koren
Sirles and Selleck
Norgan, Ettipio, and Lasome
Wicks
Wicks
Ackerman, Brink, Clanton, Jones, Moody, Pirlech,
Price, and Prusensky
Frey
White-Linn*
Husband
Jonas
King
Kemppainen
Syzmanski
Woods
Hobdell
Lockhart*
Temple and Fawdry
Porter
Martin
Alligood
1995
1989
1986
1990
1989
1995
1995
1995
1989
1995
1988
1994
1988
1987
1984
1990
1991
1994
1991
1995
1986
1995
1992
1992
1991
1990
1995
299
Continued
TABLE 17-8
Topic
Author(s)
Year
Kameoka
Temple and Fawdry
Murray and Baier
Doornbos
DeHowitt
Gonot
Schreiber
Kemppainen
Rosendahl and Ross
Woods
1995
1993
1992
1991
1996
1995
1995
1991
1990
1990
1982
1982
1994
Risky health behaviors

Smoking
Frey
Kneeshaw
1996
1990
Well-being
DeHowitt
1992
Illness management, continued

Orthopedic
Ostomy
Pain management
Psychiatric
Terminal illness
were Hannas (1995) focus of study. The health status

of clients experiencing menopause was explored by
Sharts-Hopko (1995). The experience of parenting
was studied by Norris and Hoyer (1993). Sexual
counseling was the focus of work by Villeneuve and
Ozolins (1991).
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 systems framework
and theory are often directed toward patient and
group behaviors that influence health. Several authors have directly or indirectly focused on patients
caring for themselves (Hanucharurnkui & Vinyanguag, 1991; Husband, 1988). Hanna (1993, 1995)
focused on health behaviors with the intent of health
promotion with adolescents. Tritsch (1996) focused
on goal-setting behaviors. Frey (1995, 1997), Frey and
Denyes (1989), and Frey and Fox (1990) looked at
both health behaviors and illness management behaviors in several groups of children with chronic
conditions. In addition, Frey (1996) expanded her research to include risky behaviors.
As stated previously, in relation to illness management, diseases or diagnoses are often identified as
the focus of the nursing application. Asthma was the
client concern addressed by Frey (1995). Diabetes,
another chronic illness affecting clients across the
life span, has been studied by Frey (1995) and Hus-
300
band (1988). Chronic illness in general was the focus

of Wicks in 1995. Clients with HIV infections were
involved in work by Kemppainen (1990).
Several additional areas demonstrate a cluster of
application of Kings work. Infants and children were
populations of focus for several practice applications
of Kings work. Syzmanski (1991) used Kings work
to explore nursing situations with high-risk infants.
Hobdell (1995) worked with parents of children
with neural tube defects. Frey (1995) explored the
experience of chronic illness of children within
families.
Clients experiencing a variety of psychiatric concerns have also been the focus of work, using Kings
conceptualizations (DeHowitt, 1992; Doornbos, 1995;
Kemppainen, 1990; Laben, Sneed, & Seidel, 1995;
Murray & Baier, 1996; Schreiber, 1991). Clients concerns ranged from psychotic symptoms (Kemppainen, 1990) to families experiencing chronic mental illness (Doornbos, 1995) and clients in short-term
group psychotherapy (Laben, Sneed, & Seidel, 1995).
Table 178 delineates applications related to clients
phenomena of concern.
Nursing Specialties
An area that frequently divides nurses is their area of
specialty. However, by using a consistent framework
across specialties, nurses would be able to focus
more clearly on their commonalities, rather than
highlighting their differences. A review of the litera-
TABLE 17-9
Application within Nursing Specialties
Topic
Author(s)
Year
Administration
Olsson and Forsdahl

Winker*
Sieloff
Batchelor*
Hampton
Elberson
Glenn*
King
OShall*
1996
1996
1995
1994
1994
1989
1989
1989
1989
Cardiovascular
Woods
1994
Case management
1994
Chronic illness
White-Linn*
1994
Continuing education
Brown and Lee
1980
Critical care
Scott
Norris and Hoyer
1998
1994
Education
Brooks*
Rooke
Daubenmire
King
Asay and Ossler
Brown and Lee
Daubenmire and King
1995
1995
1989
1986
1985
1984
1980
1973
Education, client
King and Tarsitano
1982
Endocrinology
Frey
Husband
Jonas
1989
1988
1987
Forensic
1991
Genetics
1988
Gerontology
Rooke
Woods
Temple and Fawdry
Kenny
Jonas
1995
1994
1992
1990
1987
Hospice
Woods
1994
Medical-surgical
Froman
Rooke
1995
1995
Mother-child
Dawson*
Omar*
1996
1990
Nephrology
King
1984
301
Continued
TABLE 17-9
Topic
Author(s)
Year
Oncology

Lockhart*
Porter
1995
1992
1991
Orthopedics
Alligood
Kameoka
1995
1995
Neurology
1986
Nurses
Olsson and Forsdahl

Kneeshaw
1996
1990
Political action
Krassa*
1994
Psychiatric/Mental health
Murray and Baier

Doornbos
DeHowitt
Schreiber
Kemppainen
Gonot
1996
1995
1995
1992
1991
1990
1986
Quality improvement
Killeen* (client satisfaction)

OConnor* (client satisfaction)
1996
1990
Respiratory
Davis and Dearman

Pearson and Vaughan
1991
1986
Reproductive health
Hanna
1993
Surgery
Gill, Hopwood-Jones, Tyndall, Gregoroff, LeBlanc, Lovett, Rasco, and Ross

Rooke
Porteous and Tyndall
King and Tarsitano
1995
1995
1994
1982
1978
ture clearly demonstrates that Dr. Kings framework

and related theories have application within nursing
specialties (see Table 179). This application is evident whether one is reviewing traditional specialties of medical-surgical (Froman, 1995; Gill et al.,
1995; King & Tarsitano, 1982; Porteous & Tyndall,
1994; Rooke, 1995b) or psychiatric nursing (DeHowitt, 1992; Doornbos, 1995; Laben, Sneed, & Seidel, 1995; Murray & Baier, 1996). The application of
Kings work is also evident in the nontraditional specialties of forensic nursing (Laben, Dodd, & Sneed,
1991) and/or nursing administration (Elberson,
1989; Hampton, 1994).
Work Settings
An additional source of division within the nursing
profession is the work sites where nursing is prac-
302
ticed and care is delivered. As the delivery of health

care moves from the more traditional site of the
acute care hospital to community-based agencies and
clients homes, it is ever more important to highlight
commonalities across these settings rather than emphasize their differences, and important to identify
that Kings framework and Theory of Goal Attainment
continue to be applicable. Although many applications tend to be with nurses and clients in traditional
settings, successful application has been shown
across other, including newer and nontraditional,
settings. From hospitals (Jacono, Hicks, Antonioni,
OBrien, & Rasi, 1990; Levine, Wilson, & Guido,
1988; Messmer, 1995) to nursing homes (Woods,
1994), and clinics (Frey, 1995; Gonot, 1986), Kings
framework and related theories provide a foundation
on which nurses can build their practice interven-
TABLE 17-10
Application within Nursing Work Settings
Topic
Author(s)
Year
Clinics
Hanna
DeHowitt
Porter
Kemppainen
Frey
Husband
Gonot
1993
1992
1991
1990
1989
1988
1986
Community

Temple and Fawdry
King
1994
1992
1984
Home health
Rosendahl and Ross
1982
Hospitals
Frey and Norris

Olsson and Forsdahl
Tritsch
Hampton
Norris and Hoyer
Messmer
West
Kemppainen
Kenny
LaFontaine
Levine, Wilson, and Guido
Jonas
Pearson and Vaughan
King
Rosendahl and Ross
1997
1996
1996
1995
1995
1994
1993
1993
1993
1993
1992
1991
1991
1990
1990
1989
1988
1987
1986
1984
1982
1978
Hospitals, community
Coker, Fradley, Harris, Tomarchio, Chan, and Caron

Byrne-Coker, Fradley, Harris, Tomarchio, Chan, and Caron
Byrne and Schreiber
Schreiber
1995
1990
1989
1991
Hospitals, public
Messmer
1995
Hospitals, urban
Messmer
King and Tarsitano
1995
1982
Intensive care units
Scott
Rooke
Norris and Hoyer
Jacono, Hicks, Antontoni, OBrien, and Rasi
1998
1995
1994
1990
Nursing homes
Woods
Zurakowski*
1994
1991
Step-down units
Rundell
1991
303
tions. Table 1710 lists applications within a variety

of nursing work settings.
Nursing Process and Related Languages

Within the nursing profession, the nursing process
has consistently been used as the basis for nursing
practice. Kings framework and Theory of Goal Attainment have been tied to the process of nursing. Although many published applications have broad reference to the nursing
process, several deKings work has been
serve special recogniapplied with nurses and tion. First, Dr. King
herself (1981) clearly
clients in traditional setlinked the Theory of
tings as well as in newer, Goal Attainment to
nontraditional settings. nursing process and
theory and nursing
process as method.
Application of Kings work to nursing curricula further strengthened this link. Other explicit examples
of integration with the nursing process are those by
Woods (1994) and Frey and Norris (1997). Additionally, Frey and Norris drew parallels between the
transaction process, nursing process, and critical
thinking process.
In addition, over time, nursing has developed
standardized nursing language (SNL) that is being
used to assist the profession to improve communication both within and external to the profession.
These languages include the Nursing Diagnoses,
Nursing Interventions, and Nursing Outcomes. Although these languages were developed after many
of the original nursing theorists had completed their
original works, nursing frameworks such as Kings
interacting systems framework (1981) can still find
application and use in the SNLs. And it is this type of
application that further demonstrates the frameworks utility across time. For example, Coker et al.
(1995) implemented nursing diagnoses within the

context of Kings framework. Table 1711 provides a
listing of applications of Kings work in relation to
the nursing process and nursing languages.
Application to Health
Care Beyond Nursing
When originally developing the interacting systems
framework, King borrowed from knowledge external to nursing, and used a systems framework perspective to assist in explaining nursing phenomena.
This use of knowledge across disciplines occurs frequently and can be very appropriate if both disciplines perspectives are similar and reformulation occurs. Because of Kings 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 Kings work could
find application beyond situations that are nursingspecific. Two specific examples of the above include
the application of Kings work to case management
(Hampton, 1994; Sowell & Lowenstein, 1994; Tritsch,
1996) and 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 todays health-care environment. Table 1712 details applications of Kings work
beyond nursing.
Multicultural Applications
Multicultural applications of Kings interacting systems framework and related theories are many. Such
applications are particularly critical as a frequent limitation expressed regarding theoretical formulations
are their culture-bound nature. Theoretical formulations originating in the United States, such as those
Application within the Nursing Process and Related Languages
TABLE 17-11
Topic
Author(s)
Year
Documentation
King
1984
Nursing diagnoses

1995
1990
Nursing process
Frey and Norris

Calladine
Woods
Schreiber
1997
1996
1992
1991
304
TABLE 17-12
Application to Health Care beyond Nursing
Topic
Author(s)
Year
Advocacy
Bramlett, Gueldner, and Sowell
1990
Case management
Tritsch
Hampton
1996
1994
1994
Managed care
Hampton
1994
of Dr. King, may not be perceived as readily applicable to non-Western cultures. In the case of the interacting systems framework and related theories, this
is not the case. Several authors specifically addressed
the utility of Kings framework and theory for transcultural nursing. Spratlen (1976) drew heavily from
Kings framework and theory to integrate ethnic cultural factors into nursing curricula and develop a culturally oriented model for mental health care. Key elements derived from Kings work were the focus on
perceptions and communication patterns that motivate action, reaction, interaction, and transaction.
Rooda (1992) derived propositions from the Theory
of Goal Attainment as the framework for a conceptual model for multicultural nursing. Again, perception and the influence of culture on perception were
identified as strengths of Kings theory.
Cultural relevance has also been demonstrated in
reviews by Frey, Rooke, Sieloff, Messmer, and Kameoka (1995), and Husting (1997). Although Husting
identified that cultural issues were implicit variables
throughout Kings framework, particular attention
was given to the concept of health, which, according to King (1990), acquires meaning from cultural
values and social norms.
Undoubtedly the strongest evidence for the cultural utility of Kings conceptual framework and
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: Canada (Coker et al., 1995), Japan
(Funashima, 1990; Kameoka, 1995; Kameoka & Sugimori, 1992), and Sweden (Rooke, 1995a, 1995b). In
Japan, a culture very different from the United States
with regard to communication style, Kameoka (1995)
used the classification system of nursepatient interactions, identified within the Theory of Goal Attainment (King, 1981), to analyze nursepatient interactions. In addition to research and publications
regarding the application of Kings work to nursing
practice internationally, publications by and about

Dr. King have been translated into Japanese (King,
1976, 1985; Kobayashi, 1970).
The variety of countries, including both Western
and Eastern cultures, where the theory has been applied clearly demonstrates not only the current multicultural application of Kings work, but also future
potential applications in other countries around the
world. Dr. King has traveled extensively to many
countries around the world to speak and consult
with nurses regarding their application of her work.
This multicultural interest also led to the establishment of the King International Nursing Group (K. I.
N. G.), based at Oakland University, Rochester,
Michigan. The K. I. N. G. is an international nursing
group, the primary mission of which is the improvement of nursing care and contribution to the science
of nursing through the advancement of Kings interacting systems framework for nursing and related
theories. Table 1713 lists applications of Kings
work in countries outside the United States.
Recommendations for Knowledge

Development Related to Kings
Framework and Theory
Obviously, nursing knowledge development has resulted from applications of Kings framework and
theory. However, nursing, as all sciences, is evolving. Additional work continues to be needed. Based
on a review of the applications discussed above, recommendations for future knowledge development
focus on: (1) the need for evidenced-based nursing
practice that is theoretically derived; (2) the role of
the research based on Kings work in evidence-based
nursing practice; (3) Kings concepts in the nursing
process within standardized nursing language; and
(4) the future impact of managed care, continuous
quality improvement, and technology on Kings concepts. From this discussion, specific research questions for the future can be derived.
305
Multicultural Application
TABLE 17-13
Topic
Author(s)
Year
Documentation
King
1984
African-American
Richard-Hughes
1997
Canada

Porteous and Tyndall
Porter
Schreiber
Byrne and Schreiber
1995
1994
1990
1991
1991
1991
1989
England
Pearson and Vaughan
1986
Japan
Kameoka
Kusaka
1995
1995
1991
Norway
Olsson and Forsdahl
1996
Sweden
Rooke
Rooke and Norberg
1995
1995
1988
Frey, Rooke, Sieloff, Messmer, and Kameoka

Rooda
King
Spratlen
1995
1992
1990
1976
Multicultural approach
Evidence-based Practice
Derived from Theory
What is evidence-based practice and how will evidence-based nursing practice evolve? Even though
Florence Nightingale realized the importance of using evidence to guide practice 135 years ago, the
field of medicine takes credit for the current trend to
evidence-based practice. Evidence-based medicine
(EBM) means that practicing physicians are expected
to base their clinical decisions on the evidence
from all the best studies rather than expert opinion
and past practice (Davidoff, 1995). Standards for
gathering the evidence, the tools for analyzing evidence, and the role of client preferences in clinical
decision making have become more important than
in the past. Rules for evaluating the scientific merit
of studies evolved from the concept of rules of evidence in the legal profession. Evidence-based health
care, evolving at lightning speed since the establishment of the Cochran Collaboration (Jadadd &
Haynes, 1998) in 1993, compares to the Human
Genome Project in its impact on modern medicine,
according to Naylor (1995).
306
Nursing as a discipline also continues to evolve in

the use of scientific evidence. Titler (1998, p. 1), a
nurse, defines evidence-based practice as the conscientious and judicious use of current best evidence
to guide health care decisions. Similar to evidencebased medicine, nursing must attend to what is important for nursing. The questions practicing nurses
address and the types of research that provide these
answers are likely to be different from the questions
of our physician colleagues and the randomized controlled trials (RCT) research design that is the gold
standard for medicine.
Another factor that distinguishes nursing from
medicine is the use of nursing theory to guide research. Theoretically based nursing problems, nursing interventions, and nursing outcomes are the
sources of research questions that generate clinical
evidence with usefulness for nursing practice.
Theory invention is the work of King and other
nurses interested in expanding the quality of nursing
practice. The purpose of theory-informed research
applied to practice is ultimately to improve the quality of practice. Fawcett (1978, p. 56) made the link
between research and theory explicit in discussing
the development of the body of nursing knowledge

as a science and the need to advance the discipline of
nursing: Theory should guide all phases of the research process, from choice of a research issue to
dissemination of results.
Though the direct application of theory to practice is often implied, theory cannot be directly applied to practice. King (1971, p. 157) succinctly
stated: [T]heory, because it is abstract, cannot be
immediately applied to nursing practice or to concrete nursing education programs. When empirical
referents are identified, defined, and described,
theory is useful and can be applied in concrete situations. Theory can influence nurses outlooks and
philosophies, but it cannot be used directly in practice. For theory to be ultimately applied to practice,
theory needs to guide nursing research. Subsequent
research findings, informed by a theory perspective,
can be directly applied to practice.
Nurses often wonder why they should include a
theory component when formulating research. Is
this really necessary? they ask. The answer is, emphatically, yes! Nursing research, providing the underpinning for evidence-based nursing practice,
needs to be theory-related research. Evidence-based
demands more rigorous standards for research. Nursing might add theory as a necessary criterion based
on the added critical thought process required.
Theory building or theory testing using Kings systems framework and related theories makes repeated
investigations of theoretically based problems more
fruitful as research results accumulate. Science is
built stronger and better when questions and answers build upon each other. Evidence-based nursing
practice that is based on theoretically derived research findings has improved the potential for closing the gap between nursing research and practice.
Readers of this chapter are interested in the applicability of nursing research, specifically using
Kings systems framework and related theories toward practice. From an evidence-based practice and
Kings perspective, the profession must implement
three strategies to apply theory-based research findings effectively. First, nursing as a discipline must
develop rules of evidence in evaluation of quality
research that reflect the unique contribution of nursing to health care. For example, qualitative methods
uniquely reflect nursings paradigm (Leininger, 1985)
and can be conducted as rigorously as quantitative
research. Second, the nursing rules of evidence must
include heavier weight for research that is derived
from, or adds to, nursing theory, for the reasons discussed previously. Third, the nursing rules of evidence must reflect higher scores when nursings
central beliefs are affirmed in the choice of variables.

Nursing science as a unique body of knowledge is
largely dependent on discovery or verification of key
concepts. Kings work on the concepts of client and
nurse perceptions and the achievement of mutual
goals has been assimilated and accepted as core beliefs of the discipline. This third strategy of use of
concepts central to nursing has clear relevance for
evidence-based practice when using Kings concepts
such as perception.
Perceptions, according to King (1981), reflect
each persons representation of reality. Observers of
medical and nursing practice would no doubt agree
that perceptions are emphasized in the nursing paradigm rather than the medical paradigm. Perceptions
are not routinely valued in the medical quantitative
paradigm of research, which relies on objective reality independent of the researcher. Rather, perceptions fit more with the nursing naturalism paradigm
concerned with understanding situations. Therefore,
acceptable research evidence in nursing requires a
research philosophy and designs that answer different research questions than medicine. Research
guided by King on client and nurse perceptions in
achieving nursing-sensitive client outcomes generates particularly relevant research questions for nursing. For example, What are clients perceptions and
experiences in out-client versus in-patient surgery?
Furthermore, the nature of health- and disease-related events and client exposure to those events
needs to be studied using nursing-specific concepts
like Kings so nurses may effectively influence nursing situations. Likewise, research with theory-based
concepts associated with nursing interventions
(communication, interactions, transactions) should
weigh higher in merit when judging nursing effectiveness research.
One definition of evidence-based medicine
(Cook, 1998, pp. 2425) includes the caregivers and
consumers points of view: Evidence-based medicine is a style of practice and teaching that seeks to
explicitly integrate knowledge of pathophysiology,
caregiver experience, and client preferences with
clinical research evidence within the restraints of local health care systems. However, this idealistic view
of medicine is everyday reality for nursing practice.
Research conducted with a King theoretical base is
well positioned to apply to nurse caregivers and nurse
administrators (Sieloff, 1996) and client-consumers
(Killeen, 1996) as part of an evolving definition of evidence-based nursing practice. For example, King
(1971) addressed client preference, a possible part of
an evidence-based nursing definition, as satisfaction.
In an update of the concept of satisfaction, King sub-
307
mits that satisfaction is a subset of her central concept of perceptions (Killeen, 1996). A nursing perspective for evidence-based health care will, no
doubt, include many concepts initially defined by
King that now are well integrated into nursings belief system and culture.
Kings Concepts, the Nursing Process,

and Standardized Nursing Languages
The steps of the nursing process have long been integrated within Kings systems framework and Theory
of Goal Attainment (Daubenmire & King, 1973;
Gulitz & King, 1988; Husband, 1988; Jonas, 1987;
Pearson & Vaughan, 1986; Woods, 1994). In these
process applications, based in King, assessment, diagnosis, and goal-setting occur, followed by actions
based on the nurse-client goals. The evaluation component of the nursing process refers back to the original goal statement(s). With the use of standardized
nursing language, the nursing process will be further
refined; standardized terms for diagnoses, interventions, outcomes, and so on should potentially improve communication among nurses internally and
externally. (Note: standardized nursing language
refers to the six ANA-recognized languages: nursing
diagnosis as defined by the North American Nursing
Diagnosis Association [NANDA], Nursing Interventions Classification [NIC], Nursing Outcomes Classification [NOC], Home Health Care Classification
Client Care Data Set, the Omaha System, and the
Ozbolt System.)
Whatever the setting, client population, or specialty, a common language of nursing diagnosis, interventions, and outcomes streamlines written and
verbal nursing communication. The use of a nationally standardized language and classification system,
with accepted coding, would allow for the aggregation of data internally for organization reports and
nursing administration research. Externally, nursing
would be in a strong position to add more comprehensive data to community and national databases.
Using SNLs allows middle-range theory development to build on concepts unique to nursing, such as
those concepts of King directly applied to the nursing process: action, reaction, interaction, transaction, goal-setting, and goal attainment. Beigen and
Tripp-Reimer (1997) suggested middle-range theories be constructed from the concepts in the taxonomies in the nursing languages focusing on outcomes. However, it is not necessary to build sterile
new theories based on taxonomies of nursing languages focusing on phenomena of diagnoses, interventions, and client outcomes, as suggested by
Biegen and Tripp-Reimer (1997). Alternatively, Kings
framework and theory could be used as a theoretical
basis for these phenomena and assist in knowledge
development in nursing in the next millennium.
The use of SNLs will also standardize how the
nursing process is taught and used. No universal
agreement has been evident in the number of components or the labels for the steps of the nursing process. With the advent of SNLs, recent terminology includes outcome identification as a step following
assessment and diagnosis (McFarland & McFarland,
1997, p. 3). Baseline outcomes identification, with
measurable indicators, is essential to describe nursing-sensitive client outcomes (Johnson & Maas,
1997). Kings concept of mutual goal-setting is analogous to the outcomes identification step, because
your thoughts
308
Kings concept of goal attainment fits with the evaluation of client outcomes in the nursing process. King
(1981, p. 177) states: [O]utcomes are identified as
goals attained.
In addition, Kings concept of perception (1981)
lends itself well to the definition of client outcomes.
Johnson and Maas (1997, p. 22) define a nursingsensitive client outcome as a measurable client or
family caregiver state, behavior, or perception that is
conceptualized as a variable and is largely influenced
and sensitive to nursing interventions.This is fortuitous 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 findings could be compared across settings, and contributes to knowledge development. Therefore,
Kings concept of mutually set goals could be studied
as expected outcomes and Kings Theory of Goal Attainment could be conceptualized as attainment of
expected outcomes in the application of the nursing
process using SNLs.
Impact of Managed Care, Performance

Improvement, and Technology on
Kings Concepts
As previously discussed, research on health care beyond nursing is evolving. With managed care, nursing is increasingly involved with developing care
planning tools and critical pathways protocols and
guidelines collaboratively with other disciplines.
King has always promoted cooperation and collaboration among disciplines (1981). In the managed-care
environment, personal, interpersonal, and social systems need to include an expanded conceptualization
of Kings concept of goal-setting. Personal and professional goal-setting, nurse-client/consumer dyad
goal-setting, nurse task force goal-setting, and nurse
leader-organization goal-setting are examples of
broader applications common in nursing situations
for today and tomorrow.
Multidisciplinary care conferences are examples
of situations where goal-setting among professionals
occurs, with multidisciplinary care conference as a
label for an indirect nursing intervention within the
Nursing Interventions Classification. Some of the activities listed under this label reflect Kings concepts:
establish mutually agreeable goals [mutual goalsetting]; solicit input for client care planning, revise
client care plan, as necessary, discuss progress toward goals [explore means to achieve goal, agree on
means to achieve goal]; and provide data to facilitate
evaluation of client care plan [evaluation of goal attainment]. The products of multidisciplinary care
conferences are guidelines to assist in clinical decision making. Many times guidelines have agendas
of cost-saving, decreasing malpractice exposure, or
other combinations of purposes. In contrast, if guidelines were based on a single overall purpose of client
goal attainment, a surer path to quality care might
ensue.
The continuous quality improvement movement
as developed by Deming (Walton, 1986) is rooted in
the scientific method and used for improving a systems performance in providing care. In the years
to come, a framework that binds methods together
within the continuous improvement effort in organizations is essential. One possible framework could
be derived from King. In 1971 (p. 177), King stated
that effectiveness of health care can be evaluated.
Kings contribution to quality improvement is the
Theory of Goal Attainment that provides knowledge
of process and outcomes (1971, p. 157). In continuous quality improvement, alternatives to the status
quo are sought. Many of the better practices in nursing are not in common use. Furthermore, wide variations in nursing practice exist within hospitals and
across the country (Jacox, 1993). The success of
nurses and others in improving care within systems
is dependent on how we approach improvement
(Kilo, Kabcenell, & Berwick, 1998). The gap between what we know and how we practice calls us
to use the practice-ready reservoirs of scientific evidence and nursing knowledge, related to King as
summarized in this chapter, in nursings approach to
continuous improvement.
King (1997) is keeping pace with the world of
technology in the form of health-care informatics and
exploring the impact of nursing knowledge and
positing that her conceptual system provides the
structure of health-care informatics. Specifically, she
recommends using her concepts of self, role, power,
authority, decisions, time, space, communication,
and interaction, with an emphasis on goal-setting
and goal attainment as the theoretical basis for nursing informatics. With this forward-looking direction
set by the theorist, nurse scholars need to further
evaluate the use of Kings concepts and possibly redefine them in future contexts. For example, the
concepts of interactions and transactions occur without visual perceptions in the emerging area of telenursing. Expansion of these and other concepts is
potentially possible from examining other ways of
knowing clientsfor example, enhanced intuitive
skills.
309
Summary
An essential component in the analysis of conceptual
frameworks and theories is the consideration of adequacy (Ellis, 1968). Adequacy depends on the three
interrelated characteristics of scope, usefulness, and
complexity. 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 relationships and focus. King fully intended her conceptual system for nursing to be useful in all nursing situations. Likewise, the Theory of
Goal Attainment has broad scope since interaction is
a part of every nursing encounter. Although evaluation of the scope of Kings framework and theory has
resulted in mixed reviews (Austin & Champion,
1983; Carter & Dufour, 1994; Frey, 1996; Jonas,
1987; Meleis, 1985), the nursing profession has
clearly recognized its scope and usefulness. In addition, the varity of practice applications evident in the
literature clearly attest to the complexity of Kings
work. As researchers continue to integrate Kings
theory and framework with the dynamic health-care
environment, future applications will further demonstrate the adequacy of Kings work in terms of nursing practice.
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313
Chapter 18
Sister Callista Roy
The Roy Adaptation Model
The Roy Model as a Framework for Research
Cognitive Adaptation Processing
Self-Consistency
Application of the Model (Research Exemplar):
Elderly Patients with Hearing Impairment
Nursing Practice Implications of the Research
Application of Exemplar
Summary
References
Sister Callista Roy and Lin Zhan

Sister Callista Roy is a highly respected nurse theorist, writer, lecturer, researcher, and teacher who
currently holds the position of professor and nurse
theorist at the Boston College School of Nursing. It is
often said that her name is the most recognized
name in the field of nursing today worldwide, and
she is one of our greatest living thinkers. Dr. Roy
shakes her head on hearing these premature epitaphs and notes that her best work is yet to come. As
a theorist, Dr. Roy often emphasizes her primary
commitment to define and develop nursing knowledge and regards her work with the Roy Adaptation
Model as one rich source of knowledge for clinical
nursing. At the beginning of a new century, Dr. Roy
has provided an expanded, values-based concept of
adaptation based on insights related to the place of
the person in the universe. She hopes her redefinition of adaptation, with its cosmic philosophical and
scientific assumptions, will become the basis for developing knowledge that will make nursing a major
social force in the century to come.
Dr. Roy credits her major influences in personal
and professional growth as her family, her religious
commitment, and her teachers and mentors. Dr. Roy
was born in Los Angeles, California, on October 14,
1939. Her middle name, Callista, is the feminine form
of Callistus, the Saint of the Day from the Roman
Catholic calendar, who was a pope and martyr. She
was the oldest daughter of a family of seven boys and
seven girls. A deep spirit of faith, hope, love, and
commitment to God and service to others was central in the family. Her mother was a licensed vocational nurse and instilled the values of always seeking
to know more about people and their care and of
selfless giving as a nurse. Dr. Roy notes that she also
had excellent teachers in parochial schools, high
school, and college. At age 14 she began working at a
large general hospital, first as a pantry girl, then as a
maid, and finally as a nurses aid. After a soul-searching process of discernment, she entered the Sisters
of Saint Joseph of Carondelet, of which she has been
a member for 40 years. Her college education began
with a bachelor of arts degree with a major in nursing at Mount St. Marys College, Los Angeles; followed by masters degrees in pediatric nursing and
sociology at the University of California, Los Angeles,
and a Ph.D. in sociology at the same school. Later,
Dr. Roy had the opportunity to be a clinical nurse
scholar in a 2-year postdoctoral program in neuroscience nursing at the University of California at San
Francisco. Important mentors in her life have in-
316
cluded Dorothy E. Johnson, Ruth Wu, Connie Robinson, and Barbara Smith Moran.
Dr. Roy is still best known for developing and
continually 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 recent
publications that Dr. Roy considers of great significance are The Roy Adaptation Model (2nd edition),
written with Heather Andrews (Appleton & Lange);
and The Roy Adaptation Model-based Research:
Twenty-five Years of Contributions to Nursing Science, published as a research monograph by Sigma
Theta Tau. The latter is a critical analysis of the 25
years of model-based literature, which includes 163
studies published in 46 English-speaking journals,
and dissertations and theses. This project was completed by the Boston-Based Adaptation Research Society in Nursing (BBARNS), a group of scholars
founded by Dr. Roy in the interest of advancing nursing practice by developing basic and clinical nursing
knowledge based on the Roy Adaptation Model.
One of Dr. Roys major activities includes cochairing the annual Knowledge Conferences hosted by
the Boston College School of Nursing in 1996, 1997,
1998 and the major International Knowledge Conference scheduled for October 2000, with cohosts from
around the world. Dr. Roy has been a major speaker
throughout North America and around 25 other
countries over the past 30 years on topics related to
nursing theory, research, curriculum, clinical practice, and professional trends for the future. She received a Fulbright Senior Scholar Award from the Australian-American Educational Foundation for travel to
Australia, where she gave speeches and talked with
colleagues in several regions. She has played a major
role in at least 30 research projects. Results of research and papers on nursing knowledge have appeared in Image: Journal of Nursing Scholarship,
Nursing Science Quarterly, Scholarly Inquiry for
Nursing Practice, and other journals. Her current
clinical research continues her long-time interest in
neuroscience. Since her days as a nursing student in
the 1960s, Dr. Roy has been fascinated by the neurosciences, which she calls the frontier of knowledge
development. She is currently continuing her research on cognitive adaptation and nursing interventions with patients who have sustained head injuries,
as well as promoting adaptation of patients with
chronic neurologic conditions.
Dr. Roy has been the recipient of many 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 practice; and honorary
doctorates from Eastern Michigan University, Alverno
College in Milwaukee, and St. Josephs College in
Standish, Maine. The Sister Callista Roy Lectureship
was established at the Department of Nursing at
Mount St. Marys College in Los Angeles and has been
an annual event. Dr. Roy has also received the outstanding Alumna Award and Carondelet Medal from
Mount St. Marys, where she holds a concurrent position as research professor in nursing at her alma
mater.
The Roy Adaptation Model has been in use for
about 30 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 chapter is to describe
the use of the model in developing knowledge for
practice, with particular emphasis on research with
the elderly. A study of cognitive adaptation and selfconsistency in the elderly with hearing impairment
provides an exemplar of both some of the key concepts of the model and a research design to test the relationships among the concepts. Specifically, the
study provides a test of a generic proposition derived
from the Roy Adaptation Model. A brief review of the
Roy Adaptation Model is provided, with emphasis on
recent developments of the theoretical work and its
use in nursing research. Then the theoretical and empirical concepts of cognitive adaptation processing
and self-consistency are described in greater detail. Finally, the problem, design, and findings of an exemplar research project with the elderly are discussed.
THE ROY MODEL AS A

FRAMEWORK FOR RESEARCH
The Roy Adaptation Model (Roy, 1984, 1988a,
1988b; Roy & Andrews, 1991, 1999; Roy & Roberts,
1981) provides the framework for programs of nursing research, particularly the constructs for the research exemplar involving elderly patients with hearing impairment.
Assumptions
The models philosophical assumptions are rooted in
the general principles of humanism, and in what Roy
has termed veritivity and cosmic unity (Roy & Andrews, 1999). Scientific assumptions for the model
have been based on general systems theory and adaptation-level theory (Roy & Corliss, 1993). More recently, the assumptions have been extended to include Roys redefinition of adaptation for the
twenty-first century (Roy & Andrews, 1999). The cosmic unity stressed in Roys vision for the future emphasizes the principle that people and the earth have
common patterns and integral relationships. Rather
than the system acting to maintain itself, the emphasis shifts to the purposefulness of human existence
in a universe that is creative.
Major Concepts
Humans, both individually and in groups, are viewed
as holistic adaptive systems, with coping processes
acting to maintain adaptation, and to promote person and environment transformations. The coping
processes are broadly described within the regulator
and cognator subsystems for the individual, and the
stabilizer and innovator subsystems for groups.
Through these coping processes, persons as holistic
adaptive systems interact with the internal and external environment, transform the environment, and
are transformed by it. A particular aspect of the internal environment is the adaptation level. This is the
name given to the three possible conditions of the
human life processes of the human adaptive system:
integrated, compensatory, and compromised (Roy &
Andrews, 1999). Processing of the internal and external environment by the coping subsystems results
in human behavior. Four categories for assessing behaviors are termed adaptive modes. Initially developed to describe human systems as individuals (Roy,
1971), the modes have been expanded to include
groups, and are termed physiologic-physical, selfconcept-group identity, role function, and interdependence (Roy & Andrews, 1999). Central to Roys
theoretical model is the belief that adaptive responses support health, which is defined as a state
and a process of being and becoming integrated and
whole.
Uses in Research
Roy has described strategies for knowledge development based on the model and a structure of knowledge to guide research (Roy & Andrews, 1999).
Knowledge development strategies that she has integrated through decades of work include model construction; theory development (including concept
analysis, synthesis, and derivation of propositional
statements); philosophic explication; and research,
qualitative, quantitative, and instrument development. The structure for knowledge includes the
Chapter 18 Sister Callista Roy The Roy Adaptation Model
317
broad categories of the basic and clinical science of

nursing.
Basic nursing science discovers knowledge about
persons and groups from a nursing perspective that
can provide understandings for practice. The clinical
science of nursing investigates specifically the role of
the nurse in promoting adaptation and human and
environment transformations. Within the
Adaptive responses
basic science, the insupport health, which is vestigator studies the
defined as a state and a person or group as an
adaptive system, inprocess of being and cluding: (1) the adapbecoming integrated tive processes; that is,
cognator and regulaand whole. tor activity, stabilizer
and innovator activity,
stability of adaptation level patterns, and dynamics of
evolving adaptive patterns; (2) the adaptive modes;
that is, their development, interrelatedness, and cultural and other influences; and (3) adaptation related
to health, particularly person and environment interaction and integration of the adaptive modes. Topics
for research in the clinical science of nursing include: (1) changes in cognator-regulator or stabilizerinnovator effectiveness; (2) changes within and
among the adaptive modes; and (3) nursing care to
promote adaptive processes, particularly in times of
transition, during environmental changes, and during acute and chronic illness, injury, treatment, and
technologic threats.
In a recent text (Roy & Andrews, 1999), Roy summarized her own research within the structure of
knowledge. In her earlier work, Roy (1975, 1977)
used three methods to explore how the cognator
coping processes act to promote adaptation and how
they relate to the adaptive modes. Two inductive processes involved content analysis of patient interviews before diagnostic tests and recordings of the
nursing process done by students in 10 schools
where the Roy Adaptation Model was the basis of
their curricula. A total of 41 different coping processes were inferred from the two sets of data and refined with literature review. Samples of the cognator
processes include selective attentiondifferential focus on a good outcome and affective isolation. The
second major research effort, again within the basic
science of nursing, used a systematic controlled
comparison of survey data collected in six hospitals
across the United States. One purpose within the
larger study aims was to examine levels of wellness
in relation to levels of adaptation. For the 208 patients of the sample, some of the measures of physio-
318
logic adaptation were related to levels of wellness,

but no evidence was found of a relationship between
psychosocial adaptation and measures of levels of
wellness. There was, however, such a relationship in
the least acute care setting and for patients with
longer hospital stays. Thus, it was suggested that
adaptation is a process that takes place over time.
Further, Roy (1977) noted that the measures of levels
of wellness were limited and not entirely consistent
with the dynamic and holistic concept of health as
defined by the model.
Roys more recent research is related to clinical
nursing science. A model of cognitive information
processing was developed (Roy, 1988b) and a program of research initiated to contribute to further understanding of cognitive processes; that is, how people take in and process environmental interactions
and how nurses can help people use these processes
to affect their health status positively. Cognitive recovery from head injury was the focus of the research. The first study used a repeated measures design to describe changes in cognitive performance
over 6 months of recovery for 50 patients (Roy,
1985). Nursing intervention protocols were then developed for use during the first month, which is considered the critical period for recovery. The initial
pilot study of nine matched pairs shows some
promising trends. Graphs of recovery curves on all
nine measures showed earlier improvement of performance in the treated group as compared with the
matched group that did not receive the planned nursing interventions to promote cognitive recovery
from head injury (Roy & Hanna, 1999). Another aspect of Roys current clinical research focuses on relating cognitive abilities and adapting to chronic illness. This work has included development of an
instrument, the Cognitive Adaptation Processing
Scale (CAPS), which is described later in this chapter.
The use of the Roy Adaptation Model for nursing
research is strikingly demonstrated by a research synthesis project conducted by The Boston-Based Adaptation Research Society in Nursing (BBARNS). Roy
worked with seven other scholars for about four
years to develop a method to conduct a review and
synthesis of research based on the Roy Adaptation
Model, to identify and locate the literature from a 25year period, to conduct the critical analysis, and
present the findings in a research monograph (Roy et
al., 1999). From 1970 through 1994, a total of 163
studies met the inclusion criteria. Only English-language publications were included. The sample included 94 articles in 44 different research and specialty journals from five continents. In addition,
there were 77 dissertations and theses from a total of
your thoughts
35 universities and colleges in the United States and

Canada that were retrieved and included in the synthesis review. The major concepts of the model were
used to organize the presentation of the review of
this extensive use of the Roy Adaptation Model in
nursing research. Although studies focused on more
than one model concept, it was possible to group
the studies by their major topic, as follows: multiple
adaptive modes and processes (n = 36); physiologic
(n = 21), self-concept (n = 18), role function (n =
21), and interdependence (n = 20) modes; stimuli
(n = 19); and intervention (n = 28).
The critical analysis involved evaluating each
study according to predetermined criteria for the
quality of the research and for the linkages of the research to the model. The studies that met the established criteria for adequacy of the quality of the research and links to the model (n = 116 of the total
163) were used to test propositions derived from the
model. They were based on 12 generic propositions
from Roys published work. As the studies were analyzed, the findings were used to state ancillary and
practice propositions. Ancillary propositions are
special instances of the general propositions and
sometimes are stated in terms directly relevant to
practice and thus referred to as practice propositions. Significant research support for the ancillary
propositions lent support to the theoretical statements of the generic propositions. This process is
demonstrated in the exemplar study reported below.
The BBARNS reviewers also examined the application of findings to nursing practice. They used
three categories to assess the potential of research
findings for use in practice: Category 1high potential for implementation based on positive findings
with methodologic adequacy and without risk to pa-
tients; Category 2need further clinical evaluation

before implementation, for example, by teams of
advanced practice nurses in the practice area to evaluate potential effectiveness relative to risk; and Category 3further research warranted before implementation, designation used in cases where findings
were negative or equivocal, or that were promising,
but posed a risk to patients and thus needed replication and clarification before being recommended for
practice. This review showed the breadth and depth
of the use of the Roy model in nursing research in
qualitative and quantitative research, and in instrument development studies, using populations of individuals and groups, of all ages, both in health and
illness, in all areas of nursing practice.
COGNITIVE ADAPTATION
PROCESSING
Two concepts of the modelcognitive adaptation
processing and self-consistencyare discussed in
greater detail as a basis for applying the model in the
research exemplar with the elderly. The Roy Adaptation Model focuses on enhancing the basic life processes of the individual and group. The cognator and
regulator of the individual, and innovator and stabilizer of the group, have basic abilities to promote
adaptation; that is, the process and outcome whereby
thinking and feeling are used in conscious awareness
and choice to create human and environmental integration (Roy & Andrews, 1999). A major concentration of nursing activity is to assist people in using
their cognitive abilities to handle their internal and
external environment effectively. Given the priority
of this notion, Roy focused efforts on further con-
319
ceptual and empirical

work to understand
focuses on enhancing this human ability and
nursing practice based
basic life processes of the on that understandindividual and group. ing. Cognitive adaptation processing is the
specialized term used
for a significant coping strategy that the nurse promotes using the adaptation model.
Conceptual Development
The conceptual basis for cognitive adaptation processing lies in Roys work on understanding the
cognator and regulator as processors of adaptation
(Roy & Andrews, 1999), on the development of a
nursing model for cognitive processing (Roy, 1988a,
1988b), and on understanding of Das and Lurias
model of simultaneous and successive information
processing (Das, 1984; Luria, 1980). Drawing from
knowledge in the neurosciences, her early theory development and research on the model, and observations in neuroscience nursing practice, Roy proposed a nursing model for cognitive processing (Roy,
1988b). Cognitive processes in human adaptation
are described as follows: input processes (arousal
and attention, sensation and perception), central
processes (coding, concept formation, memory, language), output processes (planning and motor responses), and emotion. Through these cognitive processes, adaptive responses occur.
Taylor (1983), in a study of cancer patients, proposed a related theory of cognitive adaptation. According to Taylor, cognitive adaptation is centered on
three themes: a search for a meaning in the experience, an attempt to regain mastery over the event,
and an effort to restore self-esteem through selfenhancing evaluation. Taylors propositions are in
concert with Roys assumptions of cognitive adaptation, in which individuals make cognitive efforts to
understand the purpose of their lives, maintain their
sense of self, and enhance their well-being.
To identify a typology of adaptation strategies, Roy
conducted two qualitative interview studies, content
analysis of nursing process care plans, and clinical research in patient information processing (Roy,
1988a, 1988b), as noted above. The 41 items of inferred coping mechanisms identified in the early
qualitative studies were compared with the later conceptual development of cognitive adaptation processing. In this way, Roy organized and completed
320
the scheme to create a 72-item Cognitive Adaptation

Process Scale (CAPS) (Roy & Kazanowski, 1999).
The number of items was reduced by content experts to a 48-item CAPS for the elderly in a Likertformat scale, and this version of the scale was used
in the research exemplar described in this chapter.
The items retained were inclusive of the inferred
coping mechanisms and the categories of the nursing model for cognitive processing. Content-validity
of the CAPS was based on both the strong theoreticalempirical basis for its development and the review
by content experts. Internal consistency reliability
for the total scale was .85 (Zhan, 1993a). The conceptual clarification of the CAPS was further examined by using a principal component factor extraction with a varimax rotation, resulting in five factors
that accounted for 48% of variances among the
scores (Zhan, 1993b). Roy termed these five factors
(1) cognitive processing of self-perception, (2) clear
focus and method, (3) knowing awareness, (4) sensory regulation, and (5) selective focus. The scores
on this version of the CAPS can range from 48 to 192,
and a total high score represents a greater use of cognitive adaptation strategies.
Cognitive processing of self-perception refers to
self-awareness, self-analysis, emotion, and consciousness (Carver & Scheier, 1991). It serves to signal
needs for cognitive efforts, to help the person to attend, and to interfere with cognition. Examples of
items were keep in touch with emotions, put
things into perspective,rechannel feelings, and be
aware of self-limits. Cognitive processing of clear focus and method refers to programming, attention,
thinking, reasoning, problem solving, concept formation, and cognitive coding. It involves systematic
thinking. The real process of systematic thinking
lacks full understanding. However, it can be viewed
in part as a process in which people classify the
problem, organize information to accomplish some
desired end, and weigh the benefits and risks of their
efforts to their self-structure (Das, 1984; Luria, 1980;
Roy, 1988b). The thinking process requires knowledge of the adaptation encounter, perceptions of
ones thoughts, action tendencies, and bodily
changes. Items included: give self time to grasp situations,be objective about what happened,identify
the situation, and follow directions. Cognitive processing of knowing awareness involves retrieving information from ones mind and recognizing what has
worked for the person in the past. It can be viewed
as a self-regulating process (Carver & Scheier, 1991).
The overall function of such cognitive processing is
to minimize discrepancies between a desirable sense
of self and a present perception of self. It includes
cognitive input processing of receiving, analyzing,

storing, memory, successive processing, and arousalattention (Roy, 1988b). Example items were gather
information, recall past strategies, keep eyes and
ears open,get more resources,learn from others,
feel alert and active, and be creative.
Cognitive processing of sensory regulation involves immediate sensory experience, output processing, motor response, movement, and regulating
tone (Roy & Hanna, 1999). Example of items include
try to maintain balance, change physical activity,
picture actions, and share concerns with others.
Cognitive processing of selective focus refers to
ones cognitive efforts to select attention and focus
in coping with stressful encounters. Some examples
of items were useful to focus, tend not to blame
self, get away by self, and put the events out of
mind.These five cognitive processes form subscales
of the CAPS. Internal consistency reliability of these
five subscales ranged from .56 to .89 (Zhan, 1993).
Further development of the tool continues to improve
the reliability of the subscales (Roy & Kazanowski,
1999).
SELF-CONSISTENCY
Roy (Roy & Andrews, 1999) describes self-concept
as one adaptive mode of the individual within an
adaptive system. The self-concept mode for the individual has two subareas: the physical self and the
personal self. The physical self includes two components: body sensation and body image; and the personal self has three components: self-consistency,
self-ideal, and moral-ethical-spiritual self.
Conceptual Development
Self-consistency was introduced during the development of the Roy Adaptation Model based on the
work of Coombs and Snyggs (1959). These authors
noted that people strive to maintain a consistent selforganization and thus avoid disequilibrium (Coombs
& Snyggs, 1959; Lecky, 1961; Roy & Andrews, 1991).
Lecky (1961) proposed the Theory of Self-Consistency to conceptualize a person as a holistic and consistent structure. Central to Leckys Self-Consistency
Theory is that people are motivated to act in a way
that is congruent with their sense of self and thereby
maintain intactness when facing potentially challenging situations. To maintain self-consistency in the
transaction between the person and the environment (Elliot, 1986, 1988; Lecky, 1961; Rogers, 1961;
Roy & Roberts, 1981), one initiates cognitive and
emotional responses (Roy & Andrews, 1991).
An individuals sense of self may influence the

persons ability to heal and to do what is necessary
to maintain health. In particular, related to the application exemplar in
this chapter, previous The individuals sense of
studies (Atchley, 1988;
Kaufman, 1987; Klar- self may influence the perkowska & Klarkowska, sons ability to heal and to
1987; Zhan, 1994) redo what is necessary to
port that older persons with greater self- maintain health.
consistency had more
positive levels of well-being. Further, they coped better with physical and psychosocial changes in aging
than did those who had less consistency of self-perceptions. Being old does not necessarily mean one
forms a new self-concept. Instead, older people
carry their sense of self and personality with them
into the later stage of their lives and adapt to a given
situation as best as they can (Gove, Ortage, & Style,
1989). Lieberman and Tobin (1988) examined how
older people coped with certain stressful life events
such as the loss of loved ones, relocation, the experience of chronic conditions, and the approach of
death. Their findings suggested that the older people
who had a stability of self-concept coped well in
stressful encounters. Therefore, the critical task for
older people is to maintain self-consistency by transcending internal and external losses in the aging
process. They further assert that central to understanding how well a person can cope with any stressful condition in aging is understanding how one
maintains consistency of self and whether one is able
to achieve that goal.
Based on extensive literature review on theories of
self-concept and self-consistency (Andrews, 1990;
Beck, 1976; Elliot, 1986; Goffman, 1959; Lecky,
1961; Mead, 1934; Rogers, 1961; Rosenberg, 1979;
Roy & Andrews, 1991; Wylie, 1989), Zhan developed
the Self-Consistency Scale (SCS). A measure of selfconsistency is based on the assumption that an individual has the capacity for self-examination and evaluation. Therefore, self-perception and self-evaluation
are consciously available and can be reported by the
individual. Twenty-seven items in the SCS reflect the
concepts of self-esteem, private consciousness, social anxiety, and stability of self-concept.
Self-esteem was measured by a global index containing six items that were originally developed by
Rosenberg (1979, 1989). Elliott (1986, 1988), in examining the relationship between self-esteem and
self-consistency among a sample of 2625 young peo-
321
ple (ages 8 to 19), found that self-esteem was highly

correlated with self-consistency. An example item reflecting the concept of self-esteem in the SCS was I
feel that I am a person of worth, at least on an equal
with others. Private self-consciousness measures
how preoccupied the
The critical task for older individual is with his
or her personal charpeople is to maintain acteristics, or the indiself-consistency by viduals tendency to
be the focus of his
transcending internal or her own attention.
and external losses in the Being excessively focused on ones own
aging process.
characteristics is likely
to lead to negative affect, as the individual becomes increasingly aware
that he or she does not meet those standards of
correctness set for the self (Elliot, 1986). Therefore,
excessive private consciousness leads to less selfconsistency. A sample item in the SCS was: I spend a
lot of time thinking about what I am like.
Stability of self-concept refers to the sameness of
self-concept across time and space (Elliot, 1988). It
measures the continuity of self-concept. A sample
item in the SCS was: I feel I know just who I am. Social anxiety is viewed as ones reaction to social stimuli. It measures ones worry about others appraisals
in social settings. High social anxiety leads to less
self-consistency (Elliot, 1986). A sample item in the
SCS was: I think about how others are looking at
me when I am talking to someone. Private selfconsciousness and social anxiety could be viewed as
mediating factors in self-consistency.
Each item of the SCS was scored on an ordinal
scale from 1 to 4, with 1 indicating never and 4 indicating always.Positive and negative items were ordered in a way to reduce the responsive set. For
analysis, all negative items were reverse scored, so
that a higher score would indicate a greater self-consistency. An example of a reverse-scored item was: I
feel mixed up about what I am really like. The SCS
was administered to a sample of 130 older people.
Psychometric evaluations of the SCS revealed an internal consistency reliability of .89, with a score
range from 51 to 104, a mean total score of 85.10,
and standard deviations of 11.04 (Zhan & Shen,
1994). Content validity was supported by extensive
and concurrent literature research in the field of selfconsistency and self-theory, and an expert panel consisting of four university faculty members who validated each item in the SCS. Convergent validity was
supported by a significantly positive correlation between a Visual Analog Scale, A Sense of Self, and the
322
SCS, r = .60, p < .01. Divergent validity was supported by a significantly negative correlation between the SCS and the Geriatric Depression Scale
(GDS), r = .57, p < .01. Using the GDS was based
on the theoretical proposition that a lack of self-consistency leads to certain affective disorders, including depression (Beck, 1976; Lecky, 1961; Rosenberg,
1979, 1989). Therefore, the effects of its absence can
perhaps best assess the strength of self-consistency.
APPLICATION OF THE MODEL

(RESEARCH EXEMPLAR):
ELDERLY PATIENTS WITH
HEARING IMPAIRMENT
It has been noted that the Roy Adaptation Model is
useful in all areas of nursing practice and has been
the basis of research questions to develop basic and
clinical nursing science for people of all ages in
health and illness (Roy & Andrews, 1999). Several authors have noted the models particular relevance to
assessment and intervention during the changes that
occur across the life span. Particular changes within
human development are the physical changes experienced in aging. Thus, research with elderly adults
who are adapting to physical changes can provide an
exemplar of use of the Roy Adaptation Model in nursing research.
Problem and Significance

Hearing impairment, a common but neglected physical change in old age, affects approximately 24 million older Americans (National Institute of Aging,
1990). The degree and types of hearing loss in older
persons vary, ranging from decreased sensitivity to
high frequency tones, to peripheral loss, sensorineural loss, presbycusis, or tinnitus (Maguire, 1985; Ritter, 1991). Older persons with presbycusis, for example, have more difficulty filtering out background
noises (Von Wedel, Von Wedel, & Streppel, 1990).
Tinnitus, a common hearing problem, is characterized by the symptoms of ringing, buzzing, hissing,
whistling, or swishing sounds arising in the ear, and
it affects nearly 11% of the elderly population (Information about Tinnitus, 1996).
Hearing serves as a sensory input necessary for
ones interaction with the changing environment and
for a number of critical adaptive functions. It provides the individual with cues of oncoming threats
that can be heard only. The sense of hearing augments visual cues for orienting individuals in space
and for locating other people and objects. Loss of
hearing can have profound psychological effects on
your thoughts
ones life, including feeling insecure, rejected, and

depressed; family stress; social isolation; and a decline in ones overall self-concept (Chen, 1994; Salomon, 1986; Whitbourne, 1985; Zhan, 1993b). One
elderly man described that the greatest annoyance
of hearing loss is in the subtle aspect of daily living
with a partner who also has a hearing loss. You have
to constantly repeat what you said; you have to raise
your voice since your partner cannot hear well; after
all, you are in your own silent world (Zhan, 1992).
The core problem of hearing loss lies in communication failures and relationship stress, which in turn
affects ones self-concept and well-being. Older people with hearing loss therefore face a major task that
involves coping with and adapting to hearing impairment so as to maintain their senses of self. Roy
(1991) indicates that either sensory deprivation or
overload can initiate ones cognitive efforts or cognator subsystem. It is through cognitive efforts that
effective adaptation takes place. One effective adaptive response, as described by Roy, is the maintenance of self-consistency. Roys basic theoretical
premises are that individuals are rarely passive in the
face of what happens to them. They are adaptive,
self-protective, and functional in the face of setbacks,
and seek higher levels of adaptation by enhancing
person and environment interactions. People seek to
change things if they can, and when they cannot,
they may use cognitive adaptation processes to
change the meaning of the situation in order to protect themselves and enhance their selves and their
world (Lazarus, 1991; Roy & Andrews, 1999; Taylor,
1983). To empirically validate Roys generic theoretical proposition relating the cognator processes to
adaptation, the author conducted a quantitative
study to examine the relationship between cognitive
adaptation processes and the maintenance of selfconsistency in older persons with impaired hearing.
Study Design
Based on Roys Adaptation Modelspecifically, on
the cognator subsystem of the individualhearing
loss in this study was viewed as a focal stimulus. In
the elderly person, hearing loss during aging initiates
cognitive coping efforts to bring about the effective
adaptation: the maintenance of self-consistency. Personal characteristics and social, cultural, and environmental factors influence maintenance of selfconsistency through cognitive adaptation processes.
Research Hypotheses
The usefulness of a model for research depends on
the ability of the model to generate testable hypotheses. Within a larger study, the following hypothesis
was tested: There will be a positive correlation between cognitive adaptation processes and self-consistency in older persons with hearing impairment.
Sample
The nonprobability sample consisted of 130 subjects
who were age 64 or older, manifested hearing loss
(defined for this study as an elevated threshold equal
to or larger than 26 dB in the speech frequencies of
1000, 2000, and 3000 Hertz), with the onset at age
40 or older, had no cognitive impairment, and
resided in the northeastern part of the United States.
Subjects were drawn from two nonprofit organizations for hard-of-hearing people, and from several
community senior centers. Informed consents were
obtained and the study was approved by the appropriate institutional review board. The mean age of
this sample was 74, with a range from 64 to 94.
323
Forty-five percent of the sample were men, and 55

percent were women.
knowing awareness are related to the maintenance

of self-consistency.
Major Variables
Cognitive adaptation processes referred to cognitive
and emotional efforts made by individuals to cope
with hearing loss. These efforts were operationalized
by the Cognitive Adaptation Processing Scale (form
for elders) (Roy & Kazanowski, 1999). Self-consistency was defined as an organized set of congruent
self-perceptions, including stability of self-concept,
self-esteem, private consciousness, and social anxiety. It was operationalized by the Self-Consistency
Scale (Zhan & Shen, 1994).
Data Collection and Analysis

Data were collected through mailed and handdelivered survey questionnaires, and for the entire
study, included the Cognitive Adaptation Processing
Scale (CAPS) (Roy & Kazanowski, 1999); Self-Consistency Scale (SCS), Geriatric Depression Scale (Sheikh
& Yesavage, 1986), Visual Analog Scale, Demographic
Profile, and Health Status Questionnaire (SF36) (Interstudy Outcome Management System, 1991). The
research hypothesis of interest here was analyzed via
a Pearson product moment correlation.
Findings
The research hypothesis examined whether a positive relationship existed between cognitive adaptation processes and self-consistency. This relationship
was tested via Pearsons product moment correlation
on the total scores of the CAPS and the SCS, resulting
in a positive, moderately strong correlation of .65,
p < .01. The research hypothesis was supported. To
describe the effect of cognitive adaptation processes
on self-consistency, a liner regression equation using
the least square criterion was performed. The result
of R2 = .48 indicated that cognitive adaptation processes accounted for 48 percent of the variance in
self-consistency, suggesting that the cognitive adaptation processing be a significant predictor for selfconsistency.
Empirical evidence of this study supports the
generic proposition of the Roy Adaptation Model that
the adequacy of cognator and regulator processes affects adaptive responses (Roy & Andrews, 1999,
p. 547). Further, the following ancillary proposition
is derived: Patterns of unique cognator processing
identified in a given patient group are related to effective adaptation. In particular, a practice proposition derived for elderly persons with hearing impairment states that the cognitive adaptation processes
of self-perception, clear focus and method, and
324
NURSING PRACTICE
IMPLICATIONS OF THE RESEARCH
Because in this sample, cognitive adaptation processes explained 48 percent of the variances in selfconsistency, it is suggested that cognitive adaptation
processes play an active role in keeping ones self
system in balance in the face of physical changes
such as hearing loss. Further, cognitive processing of
clear focus and method, knowing awareness, and
self-perception contributed most to the maintenance
of self-consistency in this sample. Understanding
these cognitive processes can help nurses to promote individuals coping and adaptation in the context of health and illness, particularly with elderly
patients.
Cognitive processing of clear focus and method
has to do with the internal restructuring of the person
in challenging encounters. It involves mental construction of concept formation (Roy, 1988a, 1988b).
Concepts allow the person to organize information
into manageable units or related data. For example, an
understanding of the relationships among the concepts of hearing loss, aging, and self guides the persons behavior in a given situation. In the situation of
hearing loss, the person may modify or change the
meaning of the term hearing loss, which may in turn
reduce the threat to the person and his or her sense of
self. Realistic concept formation results in effective
coping. Therefore, to promote this adaptive process,
nursing interventions need to identify how the person
represents the problem, what meaning and concepts
are attached to the persons experience, and what
strategies can be used for effective adaptation.
Cognitive processing of knowing awareness involves individuals efforts in searching for coping
resources and strategies, retrieving information, recognizing workable methods or experience in the Understanding cognitive
past, and learning from
or comparing with oth- processes can help the
ers who have experi- nurse promote coping and
enced similar or different encounters. Taylor adaptation in health and
(1983) viewed down- illness, particularly with
ward and upward social
comparison as one ef- elderly patients.
fort of cognitive adaptation. In using an upward comparison, the person
may select a physically disadvantaged person who
adapts effectively as a role model for the purpose of

self-enhancement. Cognitively, a person may use
downward comparison to compare his or her hearing problem to the more serious problems of other
individuals, so as to reduce the threat of hearing loss
and to enhance a sense of self. Such cognitive comparisons may serve the purpose of preventing discrepancies between a desired sense of self and the
current self-perception. Another source of the knowing-awareness dimension of cognitive adaptation processing in older persons is how they address and integrate their historical self into their current life. This
cognitive strategy provides a source of pride for
older persons. Nurses can facilitate older peoples
adaptation to chronic conditions by encouraging
them to review the course of their lives in
perspective, to draw on sources of positive life experiences, and to identify relevant information that promotes effective coping.
Cognitive processing of self-perception refers to
self-awareness, self-analysis, emotion, and consciousness (Zhan, 1993a). This cognitive processing serves
three functions in adaptation. First, self-awareness
signals the need for adaptive efforts. A case in point
is the inability to discriminate pain. In such cases, in
order to survive, the person must be trained to recognize and react to strong stimuli, such as the danger of handling sharp objects. Maintenance of selfconsistency involves efforts of self-adjustment as the
person interacts with the environment. If a discrepancy is sensed, cognitive processes of self-awareness,
analysis, and emotions are activated to reduce that
discrepancy.
Second, self-analysis and emotions interrupt ongoing behavior patterns, so that the person can attend to a more salient danger in order to deal with it.
For example, keeping in touch with emotion directs
the persons attention and efforts toward goals imperative and important for the person in a given situation. In a study of coping strategies, Folkman and
Lazarus (1988) found that stressful health events
elicited greater use of emotion-focused coping responses than use of problem-focused coping strategies. Keeping in touch with emotions creates a sense
of the emergency, without which adaptive reactions
would be too pallid.
Third, self-consciousness and self-analysis involve a persons efforts to restore a sense of self
through self-enhancing evaluation (Taylor, 1983).
Self-enhancing evaluation may involve how an individual perceives the encounter. If older people view
hearing loss as a challenge rather than as a threat, the
anxiety associated with hearing loss may be minimized. Emotionally, older people with hearing loss
may be less overwhelmed, and their self-structure

hence would be protected. However, the relationship between perceiving the encounter as a threat or
as a challenge can shift as an encounter unfolds
(Lazarus & Folkman, 1984). The individuals coping
resources and personality may influence how he or
she views the encounter. Therefore, nursing intervention needs first to assess how the person affected
perceives the stressful encounter and then to develop strategies that encourage perceptions of being
challenged rather than being threatened. It is critical
to keep in mind that the relationship between the
threat and challenge is recursive, in part depending
on the individuals interaction with the external environment. As the environment is altered, cognitive
perception may be changed. For example, as a supportive environment is given and a person searches
for more resources, the perceived encounter can be
changed from negative to positive.
APPLICATION OF EXEMPLAR
This empirical study provided support for the Roy
Adaptation Model and the theoretical proposition
that cognitive processing brings about adaptive responses such as the maintenance of self-consistency.
Cognitive adaptation theory asserts that cognitive
processing is an essential feature of a complete analysis of human responses to stressful conditions of life
(Lazarus, 1991; Roy & Andrews, 1999; Taylor, 1983).
Cognitive adaptation processing is not just information processing per se, although it partakes of such a
process. Rather, it is largely evaluative, focusing on
meaning and significance attached to each individuals lived experience. Further, cognitive adaptation
processing takes place continuously in the transaction between the person and the environment.
Cognitive adaptation processing is dynamic,
evolving, and complex. Cognitive processes that
were effective in this sample of older adults may not
necessarily work in other populations and situations.
In addition, cognitive processing of selective focus
and sensory regulation did not contribute significantly to the maintenance of self-consistency in this
sample; however, it may serve effective coping purposes in different situations. Equally important is the
fact that there are potentially both effective and ineffective cognitive adaptation processes. It may be
adaptive for a person to be cognitively selective in a
stressful situation in order to preserve his or her selfregard. However, this cognitive effort may alter reality and result in improbable hopes. This is a real challenge for nurses in research and in practice, because
the conditions under which a particular method of
325
cognitive adaptation processing is beneficial or deleterious have yet to be elaborated. Self-concept is

cognitive presentation of self. Cognitive efforts are
necessary to protect ones positive self-image and
maintain self-consistency. Understanding cognitive
adaptation processing helps nurses assess how individuals perceive themselves in a stressful situation;
that is, what their levels of self-awareness are, what
kinds of emotional responses they manifest, and
what meanings and significance they attach to their
experience in the context of health and illness.
This study, though limited by the sample size and
representation, provided knowledge related to the
cognator conceptualization of the Roy Adaptation
Model. Maintenance of self-consistency is a task that
engages older persons. It can be achieved through
cognitive processes and influenced by multiple factors. It can be viewed as a health indicator of how
well a person copes with stress in the aging process.
Self-consistency is a complex multidimensional construct. Maintenance of self-consistency is not necessarily a rigid, never-changing self-concept. Modifications of the self-concept are expected. Maturation
and social learning provide the instance of a naturally
changing self-concept. However, these changes need
not imply inconsistency of self (Elliot, 1986, 1988;
Roy & Andrews, 1999).
To further understand the complex human phenomenoncognitive adaptation processing and selfconsistencyfuture studies are needed with larger
and diverse samples within and across populations.
Because the relationship between cognitive adaptation processing and self-consistency is embedded in
human experiences that are shaped by history, culture, politics, and social structure, a grounded theory approach may help to illuminate the meaning attached by each individual and identify multiple
functions in cognitive adaptation processing. A longitudinal study may be necessary to identify patterns of
cognitive adaptation processing in human coping
with health-related problems and to examine dynamic changes that take place in individuals and
groups over time.
The Roy Adaptation Model provides a useful
framework for research inquiry. The theoretical and
empirical study of cognitive adaptation processing is
still in the early stages. The processes used to maintain self-consistency may be highly variable. Specific
cognitive processes may be functionally overlapping.
Understanding cognitive adaptation processes, though
often challenging, can help nurses in their efforts to
restore hope for patients in sometimes hopeless situations, and to help them find new meaning in their
326
lives, to empower themselves, and to promote their

well-being.
Summary
This chapter focused on the Roy Adaptation Model as
a basis for developing knowledge for clinical practice. There is an extensive literature on both the theoretical development of the model and the use of the
model in research. A brief review of the model
focused on recent developments in theory and research. Two major concepts of the model were elaborated: cognitive adaptation processing and self-consistency. The introduction on the model and two key
concepts provided the basis for an application of the
model in a research exemplar with elderly patients.
The exemplar research project served to demonstrate support for a generic theoretical proposition
based on the model. Further, the study illustrates
how a hypothesis based on the model, with adequate
conceptual and empirical development of the variables, can be used to derive clinical knowledge for a
given patient population.
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Lange.
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functional status in patients with closed head injury. 11th Annual ENRS scientific sessions. New
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V., Frederickson, K., Barone, S., & Carson, M.
(1999). The Roy Adaptation Model-based research:
Twenty-five years of contributions to nursing science. Indianapolis: Sigma Theta Tau International.
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327
Chapter 19
Betty Neuman
The Neuman Systems Model
and Global Applications
Global Applications of the Model
Projections for Use of the Model in the Twenty-first Century
Summary
References
Patricia Deal Aylward

Betty Neuman developed the Neuman Systems
Model in 1970 to provide unity, or a focal point, for
student learning at the School of Nursing, University
of California, in Los Angeles (Neuman, 1995, p. 674).
Neuman recognized the need for educators and practitioners to have a framework to view nursing comprehensively within various contexts. She developed
the model strictly as a teaching aid. The model is
now highly recognized and used globally as a conceptual model for nursing. Dr. Neuman has been a
pioneer in several areas within and outside of nursing. One example of her pioneer work is that she
was one of the first nurses licensed as a marriage,
family, and child counselor in the state of California,
in 1970. She is an author, lecturer, and independent
nursing curriculum consultant. Neuman has published numerous books and journal articles in response to requests for support in applying the model
to education, practice, research, and administration.
Dr. Neuman received two honorary doctoratesone
in science in 1998 from Grand Valley State University
in Allendale, Michigan, and the other in letters in
1992 from Neuman College in Aston, Pennsylvania.
In 1993, Dr. Neuman became an honorary member
of the Fellowship of the American Academy of Nursing.
as a system absorbs energy to increase its organization, complexity, and development when it moves
toward a steady or wellness state. An open system
of energy exchange is
never at rest. The open
Neuman described system
system tends to move
cyclically toward differ- as a pervasive order that
entiation and elaboraholds together its parts.
tion for further growth
and survival of the organism. With the dynamic energy exchange, the system also can move away from stability. Energy can
move toward extinction (entropy) by gradual disorganization, increasing randomness, and energy dissipation.
The Neuman Systems Model illustrates a clientclient system and presents nursing as a field primarily concerned with defining appropriate nursing actions in stressor-related situations or in possible
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 disruptive 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 interventions (Neuman, 1995).
THE NEUMAN SYSTEMS MODEL

The Neuman Systems Model provides a comprehensive, flexible, holistic, and systems-based perspective
for nursing. This conceptual model of nursing
focuses attention on the response of the client system to actual or potential environmental stressors,
and the use of primary, secondary, and tertiary
nursing prevention interventions for retention, attainment, and maintenance of optimal client system wellness.
Betty Neuman (1996)
As its name suggests, the Neuman Systems Model is

classified as a systems model or a systems 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 complete
whole structure is maintained by interrelationships
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 either toward or away from stability. Energy moves toward negentropy or evolution
330
Propositions
Neuman has identified 10 propositions inherent
within her model. Fawcett (1995a, p. 2) defined
propositions as statements that describe or link concepts. She provided additional clarity to the term
proposition by adding that some propositions are
general descriptions or definitions of the conceptual
model concepts, whereas other propositions state
the relationships between conceptual model concepts in a general manner. In Fawcetts analysis of
the Neuman Systems Model, she acknowledged that
Neumans propositions that link person, environment, health, and nursing leave no gaps between
these concepts. Fawcett believes that Neumans primary, secondary, and tertiary preventions provide
the required linkages among the concepts of the
model (1995a). The following propositions describe,
define, and connect concepts essential to understanding the conceptual model that is presented in
the next section of this chapter.
1. Although each individual client or group as a
client system is unique, each system is a composite of common known factors or innate char-
2.
3.
4.
5.
acteristics within a normal, given range of response contained within a basic structure.
Many known, unknown, and universal environmental stressors exist. Each differs in its potential for disturbing a clients usual stability level
or normal line of defense. The particular interrelationships of client variablesphysiological,
psychological, sociocultural, developmental,
and spiritualat any point in time can affect the
degree to which a client is protected by the flexible line of defense against possible reaction to a
single stressor or a combination of stressors.
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.
When the cushioning, accordionlike effect 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 interrelationships
of variablesphysiological, psychological, sociocultural, developmental, and spiritualdetermine the nature and degree of system reaction or
possible reaction to the stressor.
The client, whether in a state of wellness or illness, is a dynamic composite of the interrelationships of variablesphysiological, psychological, sociocultural, developmental, and
spiritual. Wellness is on a continuum of available
energy to support the system in an optimal state
of system stability.
6. Implicit within each client system are internal

resistance factors know 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 following an environmental stressor
reaction.
7. Primary prevention relates to general knowledge
that is applied in client assessment and intervention in identification and reduction or mitigation
of possible or actual risk factors associated with
environmental stressors to prevent possible reaction. The goal of health promotion is included
in primary prevention.
8. Secondary prevention relates to symptomatology following a reaction to stressors, appropriate ranking of intervention priorities, and treatment to reduce their noxious effects.
9. 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.
10. The client as a system is in a dynamic, constant
energy exchange with the environment. (Neuman, 1995, pp. 2021, with permission)
The Conceptual Model

Neumans original diagram of her model is illustrated
in Figure 191. The conceptual model was developed to explain the client-client system as an individual person for the discipline of nursing. Neuman
chose the terms client or client system instead of
human to show respect for collaborative relationships that exist between the client and caregiver in
Neumans model. Neuman now believes the model
can be equally well applied to a group, larger com-
your thoughts
Chapter 19 Betty Neuman The Neuman Systems Model and Global Applications
331
332
fense, lines of resistance, and the basic structure energy resources (shown at the core of the concentreic
circles in Figure 19-2). Five client variablesphysiological, psychological, sociocultural, developmental,
and spiritualoccur and are considered simultaneously in each concentric circle that makes up the
client-client system (Neuman, 1995).
Flexible Line of Defense
Stressors must penetrate the flexible line of defense

before they are capable of penetrating the rest of the
client system. Neuman described this line of defense
as an accordionlike mechanism that acts like a protective buffer system to help prevent stressor invasion of the client system. The flexible line of defense
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 reduced by single or
multiple stressors. The flexible line of defense can be
rapidly altered over a relatively short time period.
States of emergency, or short-term conditions such
as loss of sleep, poor nutrition, or dehydration, are
examples of what the client is like in the temporary
state that is represented by the flexible line of defense (Neuman, 1995). Consider the latter examples.
What are the effects of short-term loss of sleep, poor
nutrition, or dehydration, on a clients 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 upon the accordionlike
mechanism described above, along with the other
components of the client system.
Normal Line of Defense
munity, or social issue, and is appropriate for nursing

and other health disciplines (Neuman, 1995).
The Neuman Systems Model provides a way of
looking at the domain of nursing: humans, environment, health, and nursing. Figures 192, 193, and
194 are included to help focus on the client-client
system, environment, and nursing aspects of the
nursing domain.
Client-Client System
The structure of the client-client system is illustrated
in Figure 192. The client-client system consists of
the flexible line of defense, the normal line of de-
The normal line of defense represents what the

client has become over time, or the usual state of
wellness. The nurse should determine the clients
usual level of wellness in order to recognize a change
in the level of wellness. The normal line of defense is
considered dynamic by Neuman, because it can expand or contract over time. She demonstrated this
dynamic state by giving an example in which the
usual wellness level or system stability decreases, remains the same, or improves following treatment of
a stressor reaction. Neuman also considers the normal line of defense dynamic because of its ability to
become and remain stabilized with life stresses over
time. The basic structure and system integrity are
protected (Neuman, 1995).
333
334
Lines of Resistance
Neuman identified the series of concentric circles
that surround the basic structure as lines of resistance for the client. When the normal line of defense
is penetrated by stressors, a degree of reaction, or
signs and/or symptoms,
The normal line of defense will occur. Lines of resistance are activated folrepresents the dynamic
lowing invasion of the
state of wellness that the normal line of defense
by environmental stresclient has developed over
sors. Each line of resistime. tance contains known
and unknown internal
and external resource factors. These factors support
the clients 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 bodys 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
stressors, when the lines of resistance are effective.
The system reconstitutes itself or system stability is
returned. The level of wellness may be higher or
lower than it was prior to the stressor penetration.
When the lines of resistance are ineffective, energy
depletion and death occur (Neuman, 1995).
Basic Structure
The basic structure or central core structure consists
of basic factors that are common to all organisms.
Neuman offered the following examples of basic survival factors: normal temperature range, genetic
structure, response pattern, organ strength or weak-
ness, ego structure, and knowns or commonalities

(Neuman, 1995).
Five Client Variables

Neuman has identified five variables that are contained in all client systems: physiological, psychological, sociocultural, developmental, and spiritual.
These variables are present in varying degrees of development, and a wide range of interactive styles and
potential. Neuman offers the following definitions
for each variable:
Physiologicalrefers to bodily structure and function.
Psychologicalrefers to mental processes and relationships.
Socioculturalrefers to combined social and cultural functions.
Developmentalrefers to life developmental processes.
Spiritualrefers to spiritual belief influence. (Neuman, 1995, p. 28)
Neuman elaborated on the spiritual variable in order to assist readers in understanding the variable by
presenting that variable as an innate component of
the basic structure. This variable may or may not be
acknowledged 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. The client-client system
can have a complete unawareness of the spiritual
variables presence and potential, deny its presence,
or have a conscious and highly developed spiritual
understanding that supports the clients optimal
wellness.
your thoughts
335
Neuman explained that the spirit controls the

mind, and the mind consciously or unconsciously
controls the body. The spiritual variable affects or is
affected by a condition, and interacts with other variables in a positive or negative way. She gave the example of grief or loss (psychological state), which
may inactivate, decrease, initiate, or increase spirituality. There can be movement in either direction of a
continuum (Neuman, 1995). Neuman believes that
spiritual variable considerations are necessary for a
truly holistic perspective and truly caring concern
for the client-client system.
Fulton (1995) has studied the spiritual variable in
depth. She elaborated on research studies that extend our understanding of the following aspects of
spirituality: spiritual well-being, spiritual 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 forgiving, trusting relationships with self,
others, and God, or a deity, or a guiding philosophy.
Environment
The second concept identified by Neuman is the
environment. Figure 193 illustrates this. Neuman
defined environment broadly as all internal and external factors or influences surrounding the identified client or client system (Neuman, 1995, p. 30).
Neuman has identified and defined the following environmental typology or classification of types for
her model:
Internal environmentintrapersonal in nature.
External environmentinter- and extrapersonal in
nature.
Created environmentintra-, inter-, and extrapersonal in nature. (Neuman, 1995, p. 31)
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 variabledegree of mobility, range of
body function.
Psychological and sociocultural variablesattitudes, values, expectations, behavior patterns,
coping patterns.
Developmental variableage, degree of normalcy,
factors related to the present situation.
Spiritual variablehope, sustaining forces. (Neuman, 1995)
The external environment consists of all forces or
interactive influences existing outside the client-
336
client system. Interpersonal factors in the environment are forces between people or client systems.
These factors include the relationships and resources
of family, friends, or caregivers. Extrapersonal factors include education, finances, employment, and
other resources (Neuman, 1995).
Neuman (1995) has identified a third environment as the created environment. The client unconsciously mobilizes all system variables including the
basic structure energy factors toward system integration, stability, and integrity to create a safe environment. This safe, created environment offers a protective coping shield that helps the client to function. A
major objective of the created environment is to
stimulate the clients health. Neuman pointed out
that what was originally created to safeguard the
health of the system may have a negative outcome effect because of the binding of available energy. This
environment represents an open system exchanging
energy with the internal and external environments.
The created environment supersedes or goes beyond
the internal and external environments, while encompassing both. The created environment provides
an insulating effect to change the response or possible response of the client to environmental stressors.
Neuman (1995) gave the following examples of responses: use of denial or envy (psychological), physical rigidity or muscle constraint (physiological), life
cycle continuation of survival patterns (developmental), required social space range (sociocultural), and
sustaining hope (spiritual).
Neuman believes the caregiver, through assessment, will need to determine (1) what has been created (nature of the created environment), (2) the
outcome of the created environment (extent of its
use and client value), and (3) the ideal that has yet to
be created (the protection that is needed or possible,
to a lesser or greater degree). This assessment is necessary to best understand and support the clients
created environment (Neuman, 1995). Neuman suggested that nursing may wish to pursue and develop
further an understanding of the clients awareness of
the created environment and its relationship to
health. Neuman 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).
Health
Health is the third concept in Neumans model. Neuman believes that wellness and illness are on opposite ends of the continuum. Health is the best possible wellness at any given time. Wellness exists when
more energy is built and stored than expended,

whereas death occurs when more energy is needed
than is available to support life. Neuman views
health as a manifestaNursings major concern is tion of living energy
available to preserve
to keep the client system and enhance system instable through nursing tegrity. Health is seen
as varying levels within
actions, or prevention by
a normal range, rising
intervention. and falling throughout
the life span. These
changes are in response to basic structure factors,
and reflect satisfactory and unsatisfactory adjustment by the client system to environmental stressors
(Neuman, 1995).
Nursing
Nursing is the fourth concept in Neumans model
and is depicted in Figure 194. Nursings major concern is to keep the client system stable by (1) accurately assessing the effects and possible effects of
environmental stressors and (2) assisting client adjustments required for optimal wellness. Neuman defined optimal as the best possible health state
achievable at a given point in time. Nursing actions,
which she labels as prevention by intervention, are
initiated to keep the system stable. Neuman has created a typology for her prevention by intervention
nursing actions. They include primary prevention by
intervention, secondary prevention by intervention,
and tertiary prevention by intervention. All of these
actions are initiated to best retain, attain, and maintain optimal client health or wellness. Neuman
(1995) believes the nurse creates a linkage among
the client, the environment, health, and nursing in
the process of keeping the system stable.
Prevention as Intervention
Primary prevention as intervention involves the
nurses use of interventions that promote client wellness by stressor prevention and reduction of risk factors. These interventions can begin at any point a
stressor is suspected or identified, before a reaction
has occurred. They protect the normal line of defense and strengthen the flexible lines of defense.
Health promotion is a significant intervention. The
goal of these interventions is to retain optimal stability or wellness. The nurse should consider primary
prevention along with secondary and tertiary preventions as interventions. Once a reaction occurs
from a stressor, the nurse can use secondary prevention as intervention to protect the basic structure by
strengthening the internal lines of resistance. The
goal of these interventions is to attain optimal

client-system stability, or wellness, and energy conservation. The nurse should use as much of the
clients existing internal and external resources to
stabilize the system by strengthening the internal
lines of resistance and reducing the degree of reaction to the stressors. Neuman suggested the nurse
should collaborate with the client to establish relevant goals. The goals are derived only after synthesizing comprehensive client data and relevant theory in
order to determine an appropriate nursing diagnostic statement. With the nursing diagnostic statement
and goals in mind, appropriate interventions can be
planned and implemented (Neuman, 1995).
Reconstitution represents the return and maintenance of system stability following 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).
Tertiary prevention as intervention can begin at
any point in the clients reconstitution. These actions
are designed to maintain an optimal wellness level
by supporting 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 for nursing action with possible synergistic
benefits (Neuman, 1995).
Nursing Tools for Model Implementation

Neuman has designed the Neuman Nursing Process
format and the Format for Prevention as Intervention
to facilitate implementation of the Neuman model.
These formats are presented in the third edition of
Neumans book (1995, pp. 1820). The format
demonstrates a process that guides information processing and goal-directed activities. Neuman used
the nursing process within three categories: nursing
diagnosis, nursing goals, and nursing outcomes.
Comprehensive data are collected prior to formulating a nursing diagnosis. This process is facilitated using guides such as the Assessment and Intervention
Tool mentioned in Neumans book (1995). Nursing
goals are determined mutually with the caregiver
client-client system, along with mutally agreed upon
prevention as intervention strategies. Nursing outcomes are determined by the accomplishment of the
interventions and evaluation of goals following intervention. The Neuman Nursing Process format was
validated in 1982 by doctoral students. The formats
337
validity and social utility have been proven in a wide

variety of nursing education and practice areas. Using the Neuman Systems Model, the nurse acquires
significant and comprehensive client data to determine the impact or possible impact of environmental
stressors upon the client system. Selected information is prioritized and related to relevant social science and nursing theories. Neuman suggested that
the Neuman Nursing Process format has a unique
component. This specific uniqueness is that the
client and caregiver perceptions are determined for
relevant goal-setting. The nurse and the client mutually determine the client intervention goals. Neuman
pointed out that mutually agreed-upon goals and interventions are consistent with current mandates
within the health-care system for client rights in
health- care issues.
Neuman designed the Format for Prevention as Intervention to convey appropriate nursing actions
with each typology of prevention. Primary, secondary, and tertiary prevention nursing actions are
listed in a table format in Neumans book (1995, p.
20), to assist with model implementation. The nature
of stressors and their threat to the client-client system are first determined for each type of prevention
before any other nursing actions are initiated.
GLOBAL APPLICATIONS
OF THE MODEL
Because the model is flexible and adaptable to a
wide range of groups and situations, people have
used the model globally, and for more than two
decades. Neumans 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. Neuman
published two additional editions of the book, with
the third edition published in 1995 in response to expanded use of the model globally. The third edition
includes applications of the Neuman Systems Model
to nursing education, practice, administration, and
research. This edition is used as a primary resource
for global applications highlighted in this chapter
(Neuman, 1995).
Application of the Neuman Systems

Model to Nursing Education
Lowry, Walker, and Mirenda (1995) pointed out that
in the 1980s exploration and use of the model greatly
accelerated in education at all levels of practice in
varied settings. These settings include the United
338
States and locations such as Canada, Europe, Australia, and the Far East.
There are many schools of nursing in the United
States that have chosen to use the Neuman Systems
Model as a curriculum framework or for selected
courses. Most schools surveyed indicated reasons
they chose the Neuman model. Generally, the reason
for choosing the model was consistency with the
school in one or more of the following areas: the
schools beliefs; philosophy; and concepts of humans, health, nursing, and environment. Associate
degree nursing programs that have used the model
include Athens Area Technical Institute, Athens,
Georgia; Cecil Community College, North East,
Maryland; Central Florida Community College,
Ocala, Florida; Los Angeles County Medical Center
School of Nursing, Los Angeles Valley College, Van
Nuys, California; Santa Fe Community College,
Gainesville, Florida; and Yakima Valley Community
College, Yakima, Washington. Baccalaureate nursing
programs that have used the model include California State University, Fresno; Indiana University; Indianapolis; Purdue University, Fort Wayne, Indiana;
University of Tennessee; and the University of
Texas, Tyler. Gustavus Adolphus College, and St. Peter and St. Olaf College, Northfield, Minnesota, also
have used the model. (Glazebrook, 1995; Hilton &
Grafton, 1995; Klotz, 1995; Lowry & Newsome,
1995; Stittich, Flores, & Nuttall, 1995; StricklandSeng, 1995).
Educational programs in the United States reported benefits with using the model. The model (1)
facilitated cultural considerations in the curriculum
related to the populations the schools and graduates
served (Stittich, Flores, & Nuttall, 1995), (2) provided a nursing focus as opposed to medical focus
(Lowry & Newsome, 1995), (3) included the concept of clients as holistic beings (Lowry & Newsome,
1995), (4) allowed flexibility in arrangement of content and conceptualization of program needs (Lowry
& Newsome, 1995), (5) was comprehensive and facilitated seeing the person as composites of the five
variables, (6) provided a framework to study individual illness and reaction to stressors, (7) was broad
enough to allow educational programs to consider
family as the context within which individuals live or
as the unit of care, and (8) considered the created environment.
Education programs have developed evaluation
instruments to determine the effects of using the
model as a framework for nursing knowledge. The
primary instrument that is cited in the nursing literature is the Lowry-Jopp Neuman Model Evaluation Instrument. This instrument was developed and used
your thoughts
to evaluate the efficacy of using the model at Cecil

Community College (Lowry & Newsome, 1995). The
results of a five-year longitudinal study showed that
the graduates used the model most of the time when
fulfilling roles of care provider and teacher. All
classes in the study claimed colleagues rarely knew,
accepted, or encouraged model use. Therefore, colleagues in work settings tended to have a negative effect on the use of models.
The model is also being used internationally.
Craig (1995b) reported on the experiences of 10 educational institutions in Canada that represent six
Canadian provinces. These institutions include the
University of Saskatchewan, University of Prince Edward Island, University of Calgary, Brandon University of New Brunswick, Universit de Moncton, University of Western Ontario, University of Windsor,
Okanagan College, University of Toronto, and University of Ottawa. Model strengths were reported by
educational institutions in Canada. The holistic approach that addressed levels of prevention guided
the student to focus on the client in his or her own
environment. The model also assisted the student to
carry out in-depth assessments, to categorize comprehensive data, and to plan specific interventions
with the client. The students did report some difficulty in understanding the complexity of the model,
and the developmental and spiritual variables. The
students reported that it was not always easy to differentiate between the lines of defense and resistance, or to assess the degree of stressor penetration.
The Neuman Model is also being used in educational institutions in South Australia, the United Kingdom, and Sweden (Engberg, 1995; McCulloch, 1995;
Vaughan & Gough, 1995). McCulloch (1995) reported that a survey of all Australian university pro-
grams showed that four undergraduate programs

used the model as the major organizational curriculum framework, and another 16 programs introduced
undergraduate and postgraduate students to the Neuman Model as one of several models. Vaughan and
Gough (1995) found that many nursing and midwifery students chose to use the model in their own
practice in the United Kingdom. They also reported
that Avon and Gloucestershire College of Health used
the model as the guiding principle behind curriculum development for child care. Engberg (1995) reported that most colleges throughout Sweden use
the Neuman Systems Model as the theoretical framework in the module of primary health in nursing education.
Application of the Neuman Systems

Model to Nursing Practice
The Neuman Systems Model is being used in diverse
practice settings. In the United States, the model is
used to guide practice with clients with cognitive impairment, meeting family needs of clients in critical
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 traumas.
The model is used in psychiatric nursing, gerontological nursing, perinatal nursing, and occupational
health nursing (Bueno & Sengin, 1995; Chiverton
& Flannery, 1995; McGee, 1995; Peirce & Fulmer,
1995; Russell, Hileman, & Grant, 1995; Stuart &
Wright, 1995; Trepanier, Dunn, & Sprague, 1995;
Ware & Shannahan, 1995).
Internationally, the model is being used in
Canada, the United Kingdom, Sweden, the Nether-
339
lands, New Zealand, Australia, Jordan, Israel, Slovenia, and several East Asian countries (e.g., Japan, Korea, and Taiwan). Practice areas include community/
public health care (Betty Neuman, personal communication, January 10, 1999; Beddome, 1995; Beynon,
1995; Craig, 1995a; Damant, 1995; Davis & Proctor,
1995; Engberg, Bjalming, & Bertilson, 1995; Felix,
Hinds, Wolfe, & Martin, 1995; Vaughan & Gough,
1995; Verberk, 1995).
Nursing Administration and

the Neuman Systems Model
The Neuman Systems Model has been used in diverse
nursing administration settings in the United States.
These settings include a community nursing center,
psychiatric hospital, a continuing care retirement
community, and Oklahoma State Public Health Nursing (Frioux, Roberts, & Butler, 1995; Rodriguez,
1995; Scicchitani, Cox, Heyduk, Maglicco, & Sargent, 1995; Walker, 1995a).
Poole and Flowers (1995) demonstrated how the
model is used in case management of pregnant substance abusers. Kelley and Sanders (1995) presented
an assessment tool that intertwines the management
process, the Neuman Systems Model, and environmental dimensions. Walker (1995b) demonstrated
how the model and total quality management are
used to prepare health-care administrators for the
future.
Nursing Research and

the Neuman Systems Model
Gigliotti (1997) acknowledged that the Neuman
Models use as a guide in directing nursing education
and clinical practice has received much national and
international attention. However, the models use as
a guide to nursing research and the generation of
nursing theory based on the research is in the early
stages of development, although growing. In order
to facilitate the use of nursing research with the Neuman Systems Model, Meleis (1995) has elaborated on
principles and approaches that may be used to develop a futuristic agenda to validate the Neuman Systems Theory.
Fawcett (1995c) has offered guidelines for constructing Neuman Systems Modelbased studies.
Neuman revisited these guidelines in her 1996 article
in Nursing Science Quarterly. She acknowledged
that the Neuman model has guided a range of study
designs, from qualitative descriptions of relevant
phenomena to quantitative experiments that tested
the effects of prevention interventions on a variety of
client-system outcomes. She provided numerous ex-
340
amples of descriptive studies, correlational research,

and experimental and quasiexperimental studies.
Neuman elaborated on how to construct Neuman
Modelbased research.
Smith and Edgil (1995) have proposed a plan for
testing middle-range theories with the model. Their
plan involved the creation of an Institute for the
Study of the Model to formulate and test theories
through collaboration, including interdisciplinary as
well as multisite efforts. They suggested directions
for the work to be done, an organizing structure, and
a task analysis of what and who would be appropriate to participate in task completion. Breckenridge
(1995) has actually used the Neuman model to develop a middle-range theory based on nephrology
practice. Gigliotti (1997) has identified conceptual
and empirical concerns imposed upon her when she
operationalized Neumans lines of defense and resistance in her research. She concluded that the Neuman Model offers an excellent and comprehensive
framework from which to view the metaconcepts
relevant to the discipline of nursing: person, environment, health, and nursing. Gigliotti says it is time
to institute the comprehensive research program
proposed by Smith and Edgil (1995).
PROJECTIONS FOR USE

OF THE MODEL IN THE
TWENTY-FIRST CENTURY
Neuman believes her model is both concept and
process relevant as a directive toward nursing and
other health care activities in the challenging 21st
Century (Betty Neuman, personal communication,
January 10, 1999). This model has been used to make
projections about the future of nursing and health
care. Procter and Cheek (1995) and Tomlinson and
Anderson (1995) provided two examples of this use.
Procter and Cheek used the model to project the role
of the nurse in world catastrophic events, and Tomlinson and Anderson used the model to project family
health as a system. Procter and Cheek studied experiences of Serbian Australians at the time of the civil
war in the former Yugoslavia using the Neuman Systems Model to understand the experiences. As a result of the study, the researchers came up with implications for the role of nursing in world catastrophic
events. The researchers suggested the goal of nursing
in such worldwide events should be to assist individuals and communities to retain maximum wellness
and system stability as they strive for a sense of inner
peace and contentment against impossible odds.
Tomlinson and Anderson (1995) recognized that

there is an increasing focus on the family system as a
health entity. They acknowledged, however, that
there is not a universally accepted definition of family health as a systems phenomenon. Tomlinson and
Anderson proposed that the nurse who uses the
broad concepts of the Neuman Model along with a
shared family health systems perspective, in which
the whole family is the client in the health promotion enterprise, will be well prepared to meet future
nursing challenges.
Summary
The Neuman Systems Model has been used for over
2 decades; first as a teaching tool and later as a conceptual model to observe and interpret the phenomena of nursing and health care globally. Dr. Neuman
(1997, p. 20) wrote: [T]he future of the Neuman
Systems Model looks bright. She believes her model
can readily accommodate future changes in health
care delivery. The reader has been introduced to the
model and some of the global applications of the
model. The reader is also referred to additional citations compiled by Dr. Jacqueline Fawcett (1995a;
1995b).
References
Beddome, G. (1995). Community-as-client assessment.
A Neuman-based guide for education and practice.
In Neuman, B., The Neuman Systems Model (3rd
ed., pp. 567579). Norwalk, CT: Appleton & Lange.
Beynon, C. E. (1995). Neuman-based experiences of
the Middlesex-London Health Unit. In Neuman, B.,
The Neuman Systems Model (3rd ed., pp.
537547). Norwalk, CT: Appleton & Lange.
Breckenridge, D. M. (1995). Nephrology practice and
directions for nursing research. In Neuman, B., The
Neuman Systems Model (3rd ed., pp. 499507).
Bueno, M. M., & Sengin, K. K. (1995). The Neuman
Systems Model for critical care nursing. A framework
for practice. In Neuman, B., The Neuman Systems
Model (3rd ed., pp. 275291). Norwalk, CT: Appleton & Lange.
Chiverton, P., & Flannery J. C. (1995). Cognitive impairment. Use of the Neuman Systems Model. In Neuman, B., The Neuman Systems Model (3rd ed., pp.
Craig, D. M. (1995a). Community/public health nursing
in Canada. Use of the Neuman Systems Model in a
new paradigm. In Neuman, B., The Neuman Systems Model (3rd ed., pp. 529535). Norwalk, CT:
Appleton & Lange.
Craig, D. M. (1995b). The Neuman Systems Model. Examples of its use in Canadian educational programs.
Damant, M. (1995). Community nursing in the United
Kingdom. A case for reconciliation using the Neuman Systems Model. In Neuman, B., The Neuman
Systems Model (3rd ed., pp. 607620). Norwalk,
Davies, P., & Proctor, H. (1995). In Wales: Using the
model in community mental health. In Neuman, B.,
Engberg, I. B. (1995). Brief abstracts. Use of the Neuman Systems Model in Sweden. In Neuman, B., The
Engberg, I. B., Bjalming, E., & Bertilson, B. (1995). A
structure for documenting primary health care in
Sweden using the Neuman Systems Model. In Neuman, B., The Neuman Systems Model (3rd ed., pp.
Fawcett, J. (1995a). Analysis and evaluation of conceptual models of nursing. Philadelphia: F. A. Davis.
Fawcett, J. (1995b). Bibliography. Citations compiled
by Jacqueline Fawcett. In Neuman, B., The Neuman
Fawcett, J. (1995c). Constructing conceptual-theoretical-empirical structures for research. Future implications for use of the Neuman Systems Model. In Neuman, B., The Neuman Systems Model (3rd ed., pp.
Felix, M., Hinds, C., Wolfe, C., & Martin, A. (1995). The
Neuman Systems Model in a chronic care facility: A
Canadian experience. In Neuman, B., The Neuman
Frioux, T. D., Roberts, A. G., & Butler, S. J. (1995). Oklahoma State public health nursing. In Neuman, B.,
Fulton, R. A. (1995). The spiritual variable. In Neuman,
B., The Neuman Systems Model (3rd ed., pp.
Glazebrook, R. S. (1995). The Neuman Systems Model
in cooperative baccalaureate nursing education: The
Minnesota Intercollegiate Nursing Consortium Experience. In Neuman, B., The Neuman Systems Model
(3rd ed., pp. 227230). Norwalk, CT: Appleton &
Lange.
Gigliotti, E. (1997). Use of Neumans lines of defense
and resistance in nursing research: Conceptual and
empirical considerations. Nursing Science Quarterly, 10, 136143.
Hilton, S. A., & Grafton, M. D. (1995). Curriculum transition based on the Neuman Systems Model. Los Angeles County Medical Center School of Nursing. In
Neuman, B., The Neuman Systems Model (3rd ed.,
pp. 163174). Norwalk, CT: Appleton & Lange.
Kelley, J. A., & Sanders, N. F. (1995). A systems approach to the health of nursing and health care organizations. In Neuman, B., The Neuman Systems
341
Klotz, L. C. (1995). Integration of the Neuman Systems

Model into the BSN curriculum at the University of
Texas at Tyler. In Neuman, B., The Neuman Systems
Lowry, L. W., & Newsome, G. G. (1995). Neuman-based
associate degree programs: Past, present, and future. In Neuman, B., The Neuman Systems Model
(3rd ed., pp. 197214). Norwalk, CT: Appleton &
Lange.
Lowry, L. W., Walker, P. H, & Mirenda, R. (1995).
Through the looking glass: Back to the future. In
McCulloch, S. J. (1995). Utilization of the Neuman Systems Model: University of South Australia. In Neuman, B., The Neuman Systems Model (3rd ed., pp.
McGee, M. (1995). Implications for use of the Neuman
Systems Model in occupational health nursing. In
Meleis, A. I. (1995). Theory testing and theory support:
Principles, challenges, and a sojourn into the future.
ed., pp. 447457). Norwalk, CT: Appleton &
Lange.
Neuman, B. (1982). The Neuman Systems Model:Application to nursing education and practice. Norwalk, CT: Appleton-Century-Crofts.
Neuman, B. (1995). The Neuman Systems Model (3rd
ed.). Norwalk, CT: Appleton & Lange.
Neuman, B. (1996). The Neuman Systems Model in research and practice. Nursing Science Quarterly, 9,
6770.
Neuman, B. (1997). The Neuman Systems Model: Reflections and projections. Nursing Science Quarterly, 10, 1821.
Peirce, A. G., & Fulmer, T. T. (1995). Application of the
Neuman Systems Model to gerontological nursing.
Poole, V. L., & Flowers, J. S. (1995). Care management
of pregnant substance abusers using the Neuman
Systems Model. In Neuman, B., The Neuman Systems Model (3rd ed., pp. 377386). Norwalk, CT:
Appleton & Lange.
Procter, N. G., & Cheek, J. (1995). Nurses role in world
catastrophic events: War dislocation effects on Serbian Australians. In Neuman, B., The Neuman Systems Model (3rd ed., pp. 119131). Norwalk, CT:
Appleton & Lange.
Rodriguez, M. L. (1995). The Neuman Systems Model
adapted to a continuing care retirement community.
342
Russell, J., Hileman, J. W., & Grant, J. S. (1995). Assessing and meeting the needs of home caregivers using
the Neuman Systems Model. In Neuman, B., The
Scicchitani, B., Cox, J. G., Heyduk, L. J., Maglicco, P. A.,
& Sargent, N. A. (1995). Implementing the Neuman
Model in a psychiatric hospital. In Neuman, B., The
Smith, M. C., & Edgil, A. E. (1995). Future directions
for research with the Neuman Systems Model. In
Stittich, E. M, Flores, F. C., & Nuttall, P. (1995). Cultural
considerations in a Neuman-based curriculum. In
Strickland-Seng, V. (1995). The Neuman Systems Model
in clinical evaluation of students. In Neuman, B.,
Stuart, G. W., & Wright, L. K. (1995). Applying the Neuman Systems Model to psychiatric nursing practice.
Tomlinson, P. S., & Anderson, K. H. (1995). Family
health and the Neuman Systems Model. In Neuman,
B., The Neuman Systems Model (3rd ed., pp.
Trepanier, M., Dunn, S. I., & Sprague, A. E. (1995). Application of the Neuman Systems Model to perinatal
nursing. In Neuman, B., The Neuman Systems
Vaughan, B., & Gough, P. (1995). Use of the Neuman
Systems Model in England. In Neuman, B., The Neuman Systems Model (3rd ed., pp. 599605). Norwalk, CT: Appleton & Lange.
Verberk, F. (1995). In Holland: Application of the Neuman Model in psychiatric nursing. In Neuman, B.,
Walker, P. H. (1995a). Neuman-based education, practice, and research in a community nursing center. In
Walker, P. H. (1995b). TQM and the Neuman Systems
Model: Education for health care administration. In
Ware, L. A., & Shannahan, M. K. (1995). Using Neuman
for a stable parent support group in neonatal intensive care. In Neuman, B., The Neuman Systems
Chapter 20
Jean Watson
Theory of Human Caring
Theory of Human Caring
Overview of the Theory
Original and Evolving 10 Carative Factors
Transpersonal Caring Relationship
Caring Moment/Caring Occasion
Caring (Healing) Consciousness
Implications of the Caring Model
Summary
References
Bibliography
Jean Watson
Part 1

Dr. Jean Watson is distinguished professor of nursing
and former dean of the School of Nursing at the University of Colorado. She is the founder of the Center
for Human Caring in Colorado. She is also a member
of the American Academy of Nursing and has served
as president of the National League for Nursing.
Dr. Watson has earned undergraduate and graduate degrees in nursing and psychiatric-mental health
nursing and holds a doctorate in educational psychology and counseling. She is a widely published
author and recipient of several awards and honors,
including an international Kellogg Fellowship in Australia; a Fulbright Research Award in Sweden; and
four honorary doctoral degrees, including an international Honorary Doctor of Science from Goteborg
University in Sweden.
She has been distinguished lecturer and endowed
lecturer at universities throughout the United States
and many foreign countries. Her international nursing experiences have taken her around the globe
several times. While director of the Center for Human
Caring, she established international affiliate relations with colleagues in several countries, including
the United Kingdom, Canada, New Zealand, Australia, Scandinavia, Brazil, Thailand, and Korea,
among others.
Dr. Watsons published works on the philosophy
and theory of human caring and the art and science
of nursing are used by clinical nurses and academic
programs throughout the world. Her caring philosophy is used to guide new models of caring and healing practices in diverse settings and in several different countries. Dr. Watson has been featured in
numerous national videos on nursing theory and the
art of nursing. She was the 1993 recipient of the National League for Nursings Martha E. Rogers Award,
recognizing a nurse scholar who has made significant contributions to nursing knowledge that advances the science of caring in nursing and health
sciences. In 1998, she was recognized as distinguished nurse scholar by New York University.
At the University of Colorado, Dr. Watson holds
the title of distinguished professor of nursing, the
highest honor accorded University of Colorado
faculty for scholarly work. In the 1998 to 1999
school year, she assumed the first endowed chair in
caring science. Her latest book, Postmodern Nursing and Beyond, reflects her most recent work on
caring theory and nursing healing practices (Watson,
1999).
THEORY OF HUMAN CARING

by Jean Watson
The Theory of Human Caring was developed between 1975 and 1979, while I was engaged in teaching at the University of Colorado; it emerged from
my own views of nursing, combined and informed
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 with its own
unique values, knowledge, and practices, with its
own ethic and mission to society. The work was also
influenced by my involvement with an integrated academic nursing curriculum and efforts to find common meaning and order to nursing that transcended
settings, populations, specialty, subspecialty areas,
and so forth.
your thoughts
344
Section III Nursing Theory in Nursing Practice, Education, Research, and Administration,
From my emerging perspective, I tried to make

explicit that nursings values, knowledge, and practices of human caring were geared toward subjective
inner healing processes and the life world of the experiencing person, requiring unique caring-healing
arts and a framework called carative factors, which
complemented 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 orientation of medicine, giving nursing its unique disciplinary, scientific, and professional standing with itself and its
public.
OVERVIEW OF THE THEORY

The major conceptual elements of the original (and
emergent) theory are:
carative factors (evolving toward clinical caritas processes)
transpersonal caring relationship
caring moment/caring occasion
Other dynamic aspects of the theory which have/
are emerging as more explicit components include:
expanded views of self and person (transpersonal
mindbodyspirit unity of being; embodied spirit)
caring-healing consciousness and intentionality to
care and promote healing
caring consciousness as energy within the human environment field of a caring moment
phenomenal field/unitary consciousness: unbroken
wholeness and connectedness of all
advanced caring-healing modalities/nursing arts as
future model for advanced practice of nursing qua
nursing (consciously guided by ones nursing
theoretical-philosophical orientation)
ORIGINAL AND EVOLVING

10 CARATIVE FACTORS
The original (1979) work was organized 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 nursing, providing a structure for the initial
work, the term factor is too stagnant for my sensibilities today; I offer another concept today that is
more in keeping with my own evolution and future
directions for the theory. I offer now the concept of
clinical caritas and caritas processes as consistent
with a more fluid and contemporary movement with
these ideas and my expanding directions.
Chapter 20 Jean Watson Theory of Human Caring
Clinical Caritas and Caritas Processes

Caritas comes from the Greek word meaning to
cherish, to appreciate, to give special attention, if
not loving, attention to; it connotes something that
is very fine, that indeed is precious. Katie Eriksson in
Finland has used the word caritas in her theory of
caring to convey similar meanings.
The word caritas also is closely related to the
original word carative from my 1979 book. At this
time, I now make new connections between carative
and caritas, and without hesitation compare them to
invoke the L word, which caritas conveysthat is,
love. This allows love and caring to come together
for a new form of deep transpersonal caring. This relationship between love and caring 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 evoking both the past and the future.
For example, the future of nursing is ironically tied
to Nightingales sense of calling, guided by a deep
sense of 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 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 transforming self and those we serve, including our institutions and the profession itself. As
we more publicly and professionally assert these
positions for our theories, our ethics, and our practiceseven for our sciencewe also locate ourselves and our profession and discipline It is when we include
within a new, emerging cosmology. Such caring and love in our
thinking calls for a work and our life that we
sense of reverence and
sacredness with re- discover and affirm that
gard to life and all liv- nursing is . . . for a lifetime
ing things. It incorporates both art and of growth and learning.
science, as they are
also being redefined, acknowledging a convergence
between art, science, and spirituality. As we enter
into the transpersonal caring theory and philosophy,
345
your thoughts
we simultaneously are challenged to relocate ourselves in these emerging ideas and question for ourselves how the theory speaks to us, which invites us
into a new relationship with ourselves and our ideas
about life, nursing, and theory. In this framework
each one of us is also asked, if not enticed, to examine
and explore the critical intersection between the personal and the professional; to translate our unique talents, interests, and gifts into the human service of caring and healing, for self and others, and even for the
planet Earth itself.
Original Carative Factors

The original carative factors served as a guide to
what was referred to as the core of nursing, in contrast to nursings trim.Core pointed to those aspects
of nursing that potentiate therapeutic 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 philosophy, science, and even art of caring. Carative is that
deeper and larger dimension of nursing that goes beyond the trim of changing times, setting, procedures, functional tasks, specialized 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, at a given point in
time. Nor can nursings trim define and clarify its
larger professional ethic and mission to societyits
raison dtre 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.
346
The 10 carative factors included in the original

work are the following:
1. Formation of a humanistic-altruistic system of
values.
2. Instillation of faith-hope.
3. Cultivation of sensitivity to ones self and to
others.
4. Development of a helping-trusting, human caring relationship.
5. Promotion and acceptance of the expression 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-phenomenologicalspiritual 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 proposing 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. For example, consider
the following within the context of clinical caritas
and emerging transpersonal caring theory.
From Carative Factors to

Clinical Caritas Processes
As carative factors evolve within an expanding perspective, and as my ideas and values evolve, I now offer the following translation of the original carative
factors into clinical caritas processes, suggesting

more open ways in which they can be considered.
For example:
1. Formation of humanistic-altruistic system of values becomes practice of loving kindness and
equanimity within the context of caring consciousness.
2. Instillation of faith-hope becomes being authentically present, and enabling and sustaining the
deep belief system and subjective life world of
self and one-being-cared-for.
3. Cultivation of sensitivity to ones self and to others becomes cultivation of ones 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 developing and sustaining a helping-trusting, authentic caring relationship.
5. Promotion and acceptance of the expression 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-beingcared-for.
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 artistry of caring-healing
practices.
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 healing environment at all levels (physical as well as 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 alignment
of mindbodyspirit, wholeness, and unity of being in all aspects of care, tending to both embodied spirit and evolving spiritual emergence.
10. Allowance for existential-phenomenologicalspiritual forces becomes opening and attending
to spiritual-mysterious, and existential dimen-
sions of ones own life-death; soul care for self

and the one-being-cared-for.
What differs in the clinical caritas framework is
that a decidedly spiritual dimension and an overt evocation of love and caring are merged for a new paradigm for the new millennium. Such a perspective
ironically places nursing within its most mature
framework, consistent with the Nightingale model of
nursingyet to be actualized, but awaiting its evolution within a caring-healing theory. This direction,
ironically while embedded in theory, goes beyond
theory, but becomes a converging paradigm for nursings future.
Thus, I consider my work more a philosophical,
ethical, intellectual blueprint for nursings evolving
disciplinary/professional matrix, rather than a specific theory per se. Nevertheless, others interact
with the original work at levels of concreteness or
abstractness; the caring theory has been, and is still
being used as a guide for educational curricula, clinical practice models, methods for research and inquiry, and administrative directions for nursing and
health care delivery.
This work posits a values explicit moral foundation and takes a specific position with respect to the
centrality of human caring, caritas and love as now
an ethic and ontology as well as a critical starting
point for nursings existence, broad societal mission,
and the basis for further advancement for caringhealing practices. Nevertheless, its use and evolution
is dependent upon critical, reflective practices that
must be continuously questioned and critiqued in order to remain dynamic, flexible, and endlessly selfrevising and emergent (Watson, 1996, p. 143).
TRANSPERSONAL
CARING RELATIONSHIP
The terms transpersonal and a 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 transpersonal also 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 radiates to spiritual, even cosmic, concerns and connections that
tap into healing possibilities and potentials. 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.
347
Such a transpersonal relation is influenced by the

caring consciousness and intentionality 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 persons condition of being (at the soul, or
spirit level). It implies a focus on the uniqueness of
self and other and the uniqueness of the moment,
wherein the coming together is mutual and reciprocal, each fully embodied in the moment, while paradoxically capable of transcending the moment, open
to new possibilities.
Transpersonal caring calls for an authenticity of
being and becoming, an ability to be present to self
and other in a reflective frame; the transpersonal
nurse has the ability to center consciousness and intentionality on caring, healing, and wholeness, rather
than on disease, illness, and pathology.
Transpersonal caring competencies are related
to ontological development of the nurses human
competencies and ways of being and becoming;
thus, ontological caring competencies become as
critical in this model as technological curing competencies were in the conventional modern, Western
nursing-medicine model, which is now coming 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
others 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 transcendence of
suffering. The person is viewed as whole and complete, regardless of illness or disease (Watson, 1996,
p. 153).
Assumptions of Transpersonal
Caring Relationship
The nurses moral commitment, intentionality, and
caritas consciousness is to protect, enhance, promote, and potentiate human dignity, wholeness, and
healing, wherein a person creates or cocreates his or
her own meaning for existence, healing, wholeness,
and living and dying.
The nurses will and consciousness affirm the subjective-spiritual significance of the person while
seeking to sustain caring in the midst of threat and
despairbiological, institutional, or otherwise. This
honors the I-Thou relationship versus an I-It relationship.
348
The nurse seeks to recognize, accurately detect,

and connect with the inner condition of spirit of
another through genuine presencing and be- Transpersonal caring
ing centered in the caring moment; actions, seeks to connect in
words, behaviors, cogni- the moment.
tion, body language, feelings, intuition, thought,
senses, the energy field, and so on, all contribute to
transpersonal caring connection.
The nurses ability to connect with another at
this transpersonal spirit-to-spirit level is translated
via movements, gestures, facial expressions, procedures, information, touch, sound, verbal expressions, and other scientific, technical, aesthetic, and
human means of communication, into nursing human art/acts or intentional caring-healing modalities.
The caring-healing modalities within the context
of transpersonal caring/caritas consciousness potentiate harmony, wholeness, and unity of being by releasing some of the disharmony, the blocked energy
that interferes with the natural healing processes;
thus the nurse helps another through this process to
access the healer within, in the fullest sense of
Nightingales view of nursing.
Ongoing personal-professional development and
spiritual growth and personal spiritual practice assist
the nurse in entering into this deeper level of professional healing practice, allowing the nurse to awaken
to the transpersonal condition of the world and to actualize more fully ontological competencies necessary for this level of advanced practice of nursing.
Valuable teachers for this work include the nurses
own life history and previous experiences, which
provide opportunities for focused studies, the nurse
having lived through or experienced various human
conditions and having imagined others feelings in
various circumstances. To some degree, the necessary knowledge and consciousness can be gained
through work with other cultures and study of the
humanities (art, drama, literature, personal story,
narratives of illness journeys, etc.), along with an exploration of ones own values, deep beliefs, relationship with self and others, and ones world. Other facilitators are personal growth experiences such as
psychotherapy, transpersonal psychology, meditation, bioenergetics work, and other models for spiritual awakening. Continuous growth is ongoing for
developing and maturing within a transpersonal caring model. The notion of health professionals 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 together in a given moment becomes a focal point in space and time. It
becomes transcendent, 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 history of
each person, as well as part of some larger, more
complex pattern of life (Watson, 1985, p. 59; 1996,
p. 157).
A caring moment involves an action and choice
by both the nurse and other. The moment of coming
together presents the two with the opportunity to
decide how to be in the moment, in the relationshipwhat 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 interaction. For
example:
[W]e learn from one another how to be human
by identifying ourselves with others, finding
their dilemmas in ourselves. What we all learn
from it is self-knowledge. The self we learn
about . . . is every self. IT is universalthe 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.
5960)
CARING (HEALING)
CONSCIOUSNESS
The dynamic of transpersonal caring (healing) within
a caring moment is manifest in a field of consciousness. The transpersonal dimensions of a caring moment are affected by the nurses 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 include
the following points:
The whole caring-healing-loving consciousness
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 the
higher energy of the universe.
The caring-healing-loving consciousness of the
nurse is communicated to the one-being-caredfor.
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.
IMPLICATIONS OF
THE CARING MODEL
The Caring Model or Theory can also be considered a
philosophical and moral/ethical foundation for professional nursing and 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, spirituality, and new dimensions of mindbodyspirit medicine and nursing evolving openly as
central to human phenomena of nursing practice.
I emphasize that it is possible to read, study, learn
about, even teach and research the Caring Theory.
However, to truly get it, one has to experience it
personally; thus, the
model is both an invi- A caring moment involves
tation and an opportuan action and choice by
nity to interact with
the ideas, experiment both the nurse and other.
with and grow within
the philosophy, and to live it out in ones personal/
professional life.
The ideas as originally developed, as well as in the
current evolving phase (see Watson, 1999), provide
us with a chance to assess, critique, and see where
or how, or even if, we may locate ourselves within
the framework or the emerging ideas in relation to
our own theories and philosophies of professional
nursing and/or caring practice.
If one chooses to use the caring perspective 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
349
the given nurse, group, system, organization,

curriculum, population needs, clinical
administrative setting, or other entity that is
considering interacting with the caring model
to transform and/or improve practice?
What is ones 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: 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 ones
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
individual and system 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 interested
in shifting their focus from a modern medical
science-technocure orientation to a true caringhealing-loving model?
This work, in both its original and evolving forms,

seeks to develop caring as an ontolgoical and theoretical-philosophical-ethical framework for the profession and discipline of nursing and to clarify its
mature relationship and distinct 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 Model is
consistently one of the nursing caring theories
used as a guide. Nurses reflective-critical practice
models are increasingly adhering to a caring ethic
and ethos.
Because the nature of the use of the Caring
Theory is fluid, dynamic, and undergoing constant
change in various settings around the world and locally, I am not able to offer updated summaries of activities. Earlier publications seek to provide examples of how the work is used, or has been used, in
specific settings.
350
Summary
Nursings future and nursing in the future will depend on nursing maturing as the distinct health,
healing, and caring profession that it has always represented across time, but has yet to actualize. Nursing thus ironically is now challenged to stand and mature within its own paradigm, while simultaneously
having to transcend it and share with others. The future already reveals that all health-care practitioners
will need to work within a shared framework of caring relationships, mindbodyspirit medicine, embracing healing arts and caring practices and processes
and the spiritual dimensions of care much more completely. Thus, nursing is at its own crossroad of possibilities, between worldviews and paradigms, between centuries and eras, invited and required to
build upon its heritage and latest evolution in science and technology, but to transcend itself for a
postmodern future yet to be known. However, nursings future holds promises of caring and healing
mysteries, and models yet to unfold, as opportunities
for offering compassionate caritas service await, at
individual, system, societal, national, and global levels for self, for profession, and for the broader world
community.
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Watson, J. (1990). The moral failure of the patriarchy.
Watson, J. (1990). Transformation in nursing:
Bringing care back to health care. In Curriculum
revolution: Redefining the student-teacher relationship (pp. 1520). New York: National League for
Nursing.
Watson, J. (1990). Transpersonal caring: A transcendent
view of person, health, and nursing. In Parker, M. E.
(Ed.), Nursing theories in practice (pp. 277288).
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Watson, J. (1992). Response to Caring, virtue theory,

and a foundation for nursing ethics. Scholarly Inquiry for Nursing Practice, 6, 169171.
Watson, J. (1993). Rediscovering caring and healing
arts. Nursing Standard, 9(7), 1819.
Watson, J. (Ed.). (1994). Applying the art and science
of human caring. New York: National League for
Nursing.
Watson, J. (1995). A Fulbright in Sweden: Runes, academics, archetypal motifs, and other things. Image:
Watson, J. (1995). Nursings caring-healing paradigm as
exemplar for alternative medicine? Alternative Therapies in Health and Medicine, 1(3), 6469.
Watson, J. (1996). The wait, the wonder, the watch:
Caring in a transplant unit. Journal of Clinical Nursing, 5, 199200.
Watson, J. (1997). The Theory of Human Caring: Retrospective and prospective. Nursing Science Quarterly, 10, 4952.
Watson, J., & Bevis, E. O. (1990). Nursing education:
Coming of age for a new age. In N. L. Chaska (Ed.),
The nursing profession:Turning points (pp.
100106). St. Louis: Mosby.
Watson, J., & Phillips, S. (1992). A call for educational
reform: Colorado nursing doctorate model as exemplar. Nursing Outlook, 40, 2026.
Watson, J., & Ray, M. A. (1988). The ethics of care and
the ethics of cure: Synthesis in chronicity. New York:
Watson, M. J. (1988). New dimensions of human caring
Watson, J., Burckhardt, C., Brown, L., Bloch, D., & Hester, N. (1979). A model of caring: An alternative
health care model for nursing practice and research.
In American NursesAssociation clinical and scientific sessions (pp. 3244). Kansas City, MO: American NursesAssociation.
Weeks, S. K. (1995). What are the educational needs of
prospective family caregivers of newly disabled
adults? Rehabilitation Nursing, 20, 256260, 272,
298.
Wilson, C. (1994). Care: Superior ideal for nursing?
Nursing Praxis in New Zealand, 9(3), 411.
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M. S. (1994). Dimensions of nurse care. Image:
Chapter 20
Part 2
Caring for the Human Spirit

in the Workplace
Applying Watsons Caring Theory in New Contexts
The Human Being, the Human Spirit, and Human
Relationships
Health/Healing
The Denver Nursing Project in Human Caring
(The Caring Center)
Caring Theory in New Contexts
Summary
References
Ruth M. Neil
APPLYING WATSONS CARING

THEORY IN NEW CONTEXTS
During an era when organizational change is rampantexemplified by reengineering, downsizing,
work redesign, and so onnumerous authors are
writing about the human element in the workplace
(Belanger, 1996; Morris, 1997; Seaward, 1995;
Whyte, 1994). The purpose of this chapter is to demonstrate the relevance of the philosophy and science
of human caring (Watson, 1979/1985) in an exemplary nurse-directed facility serving HIV/AIDS clients,
and, concurrently, to all interpersonal human enterprisenot just to those relationships socially defined
as being for the purpose of supporting health and
healing. Attention will be given to the attributes and
behaviors characteristic of caring leaders.
Providing caring leadership for an organization, a
business, or a work group within a larger entity requires an individual to examine the same questions
that a nurse seeking to provide authentic caring in the
nurse-patient situation needs to ask. These include:
What is the nature of the human being and what
does he or she need to experience fulfillment?
What is the basis for harmonious and productive human relationships?
What is the nature of health/healing?
What is the purpose/mission of this organization or
work team?
Examining these questions is a reflective activity
central to developing not only greater awareness of
others, but deepened understanding of ourselves.
The following discussion addresses these questions
and is presented with the purpose of sharing observations about how they apply, so each one of us can
become an effective, caring leader.
THE HUMAN BEING,

THE HUMAN SPIRIT,
AND HUMAN RELATIONSHIPS
Nursing theories unanimously describe humans as
multidimensional beings and endorse complex,
holistic approaches to understanding health, illness,
and healing. Watsons earliest works (1979) acknowledged strongly the spiritual reality of human experience. The 10th original carative factor reminded
persons using the theory to allow for existential-phenomenological-spiritual forces in their relationships
with clients. In later writings, Watson (1988, 1989,
1997) continued to explicate the relationship between caring and spiritual experience:
356
The process of human-to-human caring illuminates the mystery of humanity and the possibility of a higher power, order, or energy in
the universe that can be activated through the
nurse caring process that can in turn potentiate healing and health and facilitate self-knowledge, self-reverence, self-control, self-care,
and possibly even self-healing . . . Universal
spirit and a central cosmic unity are identified
as essential to human caring. (Watson, 1989,
p. 220)
I have come to believe that the spiritual dimension of
human existence provides the most useful guidance
in understanding human relationships and whether
they are harmonious, productive, and fulfilling. Seaward (1995) asserts that human spirituality is the
very core of wellness (p. 165).
Seaward, in a later work (1997), differentiates the
human spirit from the human soul as follows. He says
the human spirit provides each of us with a connection to the universal. It is a universal energy that
draws us toward our greater potential. Curtin (1997,
p. 7) says, [T]his universal energy is what Camus referred to when he said, When I choose for myself,
I choose for all mankind. It is what the Taoists mean
when they say, If you cut a single blade of grass,
the universe trembles. And it is what Jesus Christ
meant when he said, Whatsoever you do . . . you do
unto me. Curtin was emphasizing that all the
worlds great religious traditions recognize the
wholeness of the universe and the reality of a spiritual energy.
The human soul, on the other hand, is that internal energy that is unique for each individual (Seaward, 1997). The soul evolves and changes over a
lifetime. Seaward states that the evolution of the human soul is the pure essence of spirituality. He goes
on to say that the evolution of the soul is gauged entirely by our capacity to love. Thus, when we talk
about caring for the soul in the workplace, we are
concerned with creating environments where caring
and love can flourish.
Watson (1997, p. 50) emphasized that humans
cannot be treated as objects, cannot be separated
from self, other, nature, and the larger universe.
Transpersonal caring, she continues, leads participants to an alignment of intentionality, consciousness and ones being in action, seeking an authentic
presence, an integration of mindbodyspirit which is
healing (p. 51). In addition to being descriptive of
conditions that support healing, these concepts apply to circumstances desirable for meaningful and
fulfilling lives.
To nurture the soul(s) of those in the workplace

(or any other environment), a caring leader will seek
to honor the need for
Health implies harmony harmony and alignment in his or her own
and balance among the life as well as those of
various dimensions of hu- coworkers and others.
As Watson discusses in
man experience.
the first part of this chapter, in her expanded perspective, the 10th carative factor becomes opening
and attending to spiritual-mysterious, and existential
dimensions of ones own life-death; soul care for self
and the one-being-cared-for.
Watson (1997, p. 51) suggests that nurses or practitioners using caring theory
cultivate a daily practice for self. Practices
such as centering, meditation, breath work,
yoga, prayer, connections with nature and
other forms of daily contemplation are essential to the theorys authenticity and success. In
other words, if one is to work from a caringhealing paradigm, one must live it out in daily
life. Thus, living authentically requires a commitment to self-care at that deep level of personal practice and discipline, which in turn is
honoring ones own embodied spirit, taking
time for soul care.
I believe the above words apply whether the person
practicing on the basis of caring theory is an individual nurse seeking to promote caring-healing with a
client or is a person seeking to provide leadership to
nurture the souls of coworkers.
HEALTH/HEALING
In order to appreciate the relationship between using the philosophy and science of human caring as a
basis for nursing and providing leadership in an organization, it is useful to consider the nature of
health/healing. When the human being is considered
from a holistic perspective, health implies harmony
and balance among the various dimensions of human
experiencephysical, emotional, mental, spiritual,
and so on. Because physical wholeness is not always
achievable, other energies of ones existence (mental, emotional, spiritual, etc.) often grow to compensate and achieve harmony on a different level. Belanger (1996, p. 221) describes her understanding of
healing based on her own experience as a cancer patient: My healing journey has led me to see the pro-
cess as movement toward wholeness. I am convinced that the source of healing lives inside us.
THE DENVER NURSING

PROJECT IN HUMAN CARING
(THE CARING CENTER)
The Denver Nursing Project in Human Caring
(DNPHC) provided continuous service to individuals
with HIV/AIDS from 1988 to 1996 (Astorino, et al.,
1994; Lennerts, Koehler, & Neil, 1996; Neil, 1994).
This nurse-directed health-care facility was founded
on a conscious commitment to Watsons philosophy
and science of human caring. During those years,
the staff developed many insights into how the
theory looks and works in the practice setting.
In reflecting on the DNPHC experience, I now
believe that the most essential characteristic of the
center was its attention to the soul and spirit of all
the people it touched, along with the ability of the
participants in the centers life (including staff,
clients, and volunteers) to express love. The following paragraphs describe some of the values and practices that enabled this process to flourish organizationally.
Hecomovich (see Astorino, et al., 1994, pp. 20
21) wrote: When we first started working together
at the Denver Nursing Project, we did not just sit
down and decide that our ways of working together
were going to be different from other settings we
had known. But over time, the unique combination
of our setting and ourselves has contributed
The Denver Nursing Proto a very special and
satisfying team experi- ject was much more than a
ence. . . . We all value
workplace and a facility.
our spirituality, and
though we may use
different language to describe our belief systems, we
do believe our work has a meaning beyond the concrete here and now.
The Denver Nursing Project was much more than
a workplace for its staff and a facility where the
clients came for a large variety of treatments, services, information, and support. It emerged, over
time, to be a caring community. As expressed in an
essay written by a client, In this little red brick building, all these special people have become an extension to each other as one big family (Neil, 1994,
p. 36). Shared beliefs and values included respect for
the dignity of each person, honor of the right and
responsibility of each person to make informed
choices concerning health, faith that individuals pos-
Chapter 20 Ruth M. Neil Caring for the Human Spirit in the Workplace
357
sess inner resources to support their own growth

and healing, and belief that authentic caring relationships contribute to healing and health (Neil, 1994,
p. 37). We believed that these human characteristics
were common to staff, clients, and others with
whom we had contact during the years of the centers life.
Kerfoot (1997) writes that the role of a leader is to
create a sense of community in the workplace where
people can feel a strong sense of unity and a fellowship of caring. She goes on to say that successful
leaders realize that caring is the basis of any spirit of
community (p. 50). At the Denver Nursing Project,
leadership was definitely a shared function. As we
learned to communicate honestly and openly with
each other and reveal our individual values, hopes,
and fears, we were able to decide together on a
shared mission that took precedence over personal
needs and wants. Most often, clients were partners
with the staff in working toward the centers mission.
Two questions people commonly ask about the
Denver Nursing Project experience are:
1. Was it easier or harder to bring Caring Theory to
life with the HIV/AIDS population than it would
have been with another population?
2. How did the nurses and other staff avoid burnout
with such a high death rate among the client population?
I will respond to each of these questions by offering my observations and opinions, many of which
were shaped by reflective discussion with center
staff, clients, other nurses, students, and visitors.
Question 1. Caring Theory was a perfect fit to
guide how we approached our work with the
HIV/AIDS population.
Leadership was definitely Since there wasnt,
and still isnt, a cure
a shared function. for HIV/AIDS, Caring
Theory and practices,
with their emphasis on spiritual energy, connectedness, and inner healing, were the most realistic and
honest approaches we could offer.
Tronto, in writing about care with an elderly (i.e.,
vulnerable) population, offered these interesting suggestions about the status of caring in Western society.
We are unwilling to acknowledge that we all have
needs for care. She believes, in part, the unwillingness to recognize the role of care in our lives stems
from our inability to comprehend death. No matter
how successfully we care for ourselves or others, human life ends in death (Tronto, 1998, p. 19). Tronto
believes that if we interpret the certitude of death as
358
evidence of vulnerability, we fail to embrace care as

an important part of human life. She states, [R]ecognizing its role in creating interconnections and relationships of receiving and giving over a lifetime . . .
may provide us with a way to rethink some of the
ways in which we now seem unable to cope with human vulnerability (Tronto, 1998, p. 19).
Question 2. The above comments in response to
the first question also provide part of the answer to
the second question. In addition, I offer the following observations.
Staff at the Denver Nursing Project came to recognize and honor the profound experience of sharing
the spiritual journey of clients who accepted that
their diagnosis would lead to physical death, but
who chose to live as fully as possible until that death
occurred. Staff learned not to place distance between themselves and clients with whom they were
in relationship. Staff persons and client shared their
vulnerability, and thus gained from one another
(each was transformed).
Even as project director, I was involved in close
relationships with many clients. I want to share Jasons (not his real name) story here because it illustrates many of the ideas about spiritual growth discussed throughout this chapter. It is one example
among hundreds of authentic caring relationships
that were lived at the center.
Jason was a client at the Caring Center for about 3
years. When we first met him, he was a handsome,
intelligent, successful, and somewhat arrogant man.
His message to us then was, Im going to beat AIDS.
It wont get me. But that wasnt to be.
Jason had unusually bad luck with adverse effects
from one after another of the antiviral drugs that
were introduced (necessitating numerous blood
transfusions), many serious opportunistic infections,
painful and debilitating peripheral neuropathy, and,
finally, severe wasting syndrome. As his health began to deteriorate noticeably, he changed his message to, Maybe I wont beat this, but Ill never let it
progress far enough to make me dependent on others for my basic life needs. We interpreted that as
meaning that Jason planned to take his own life,
and we expected that that would happen. It didnt.
Eventually, Jason had to move into his 76-year-old
mothers home, which was extremely stressful for
them both. Eventually his daily needs were being attended to by his mom and by visiting nurses.
I visited him at home about a week before he
died. I asked him (telling him as I asked, that if the
question was too intrusive, he didnt have to answer)
how it was that, after his earlier pronouncements
about staying in control and beating the disease,
your thoughts
things had come to this. (He was, by then, bedfast

and wholly dependent on others.)
He smiled; he knew the meaning of my question.
He said, First, I began to notice that as I lost one
ability, I would find I had another, which Id never
seen before. . . . Then, during the past few months,
my mom and I have made peace, which is a good
feeling . . . I decided not to commit suicide because I
didnt want to leave Mark [his beloved 4-year-old
nephew] with that memory. . . . And, finally, I began
to feel like an observerwatching my life continue
onand it got to be interesting and I wanted to stay
to see what would happen next.
Jason had spent much time during his last months
at the Caring Center. His mom brought him as long
as he could get out of the house. Often he spent
most of his time just dozing on the dayroom sofa,
but he was thinking and redesigning his life. He accepted his inevitable death. He came to value authentic caring. He died spiritually healthy. He wanted
to stay to see what would happen nextnot with a
desire or need to control, but with a sense of acceptance and peace.
Nurses and staff at DNPHC paid attention to their
own spiritual journeys and respected and supported
each others. A variety of specific strategiesincluding mountain retreats, creative art activities, physical
exercise, journaling, body therapies, and more
were used and shared over the years to encourage
open communication and mutual support.
When I left the Denver Nursing Project in Human
Caring and moved into a totally different kind of role,
I wondered whether and how I would be able to sustain the experience of being part of a caring community in my new position. The next section of this
chapter summarizes how it is going and suggests
new directions and uses for nursing theory in the

future.
CARING THEORY
IN NEW CONTEXTS
In 1996, I assumed the responsibility of being project coordinator for the National Resource Center for
Health and Safety in Child Care. Our mission is to
provide resource and referral information to a diverse audience, including child care administrators,
regulatory agencies, consumers, media personnel,
and others. We provide this service by way of our
World Wide Web site, E-mails, toll-free telephone access, and participation in workshops and conferences across the country. The Resource Center is
sponsored through a collaborative agreement with
the Maternal and Child Health Bureau.
Besides me, our work team consists of a project
director (who is involved in major policy decisions
but not day-to-day operation), a resource librarian,
an administrative assistant, and graduate student research assistants. As was true at the Denver Nursing
Project, an important strategy in creating a fulfilling
work environment is believing in our mission. The
opportunity to contribute to improved practice in
out-of-home child care settings is easy enough to believe in, especially as we recognize that nearly 70% of
children under the age of 6 (in the United States)
spend at least part of their time in child care settings.
Because none of us was experienced in child care
issues prior to joining the project, we all accepted
the responsibility to become as knowledgeable as
possible in a short period of time. An important part
of being truly caring is being competent and worthy
Chapter 20 Ruth M. Neil Caring for the Human Spirit in the Workplace
359
of trust from those being cared forthe constituents

we serve.
We have developed a collaborative model of decision making and value creativity in finding solutions
to specific assignments that have come to us during
the life of the project. (For instance, we currently are
coordinating the review and update of a major publication that has more than 100 contributors from
across the country. Developing systems for managing all the relevant communication and documenting
decision making has provided exciting challenges for
us all and given us ways to grow in respect for one
anothers contributions.) We have become more than
coworkers; we have become people who care about
one another.
Having had the opportunity to live Watsons
theory at the Denver Nursing Project with clients facing profound life transitions, I came to know and respect its truth and
The opportunity we have as value on a deep, personal
level.
The
nurses is to share the nurs- strength of the human
ing/caring model with other spirit and evolution of
the human soul durdisciplines as well as with ing times of crisis are
the public in general. inspirational lessons
in the common human quest for wholeness and health. Once one has experienced the
beauty and growth that occur during those transpersonal caring moments, one continues to strive for
reciprocity, respect, and mutuality in other human
relationships.
Summary
The purpose of this chapter has been to share reflections about applying Watsons Caring Theory in a
unique practice setting and to suggest applications of
the theory as a basis for leadership in organizations
or work groups. The concept of caring community is
especially relevant in both instances.
The opportunity that we have as nurses, I believe,
is to share the nursing/caring model with individuals
from other disciplines as well as with the public in
general. Although our own application of caring
360
knowledge is often during times of a major life transition or extreme health challenge, we recognize that
the quality of human interaction in all settings is improved by caring beliefs and actions. It is encouraging to note the trends in the leadership literature that
place a new focus on the need to care for the human
spirit in the workplace. Let us hope that appreciation of this truth will become evident in the lives of
increasing numbers of people in all settings.
References
Astorino, G., et al. (1994). The Denver nursing project
in human caring. In Watson, J. (Ed.), Applying the
art and science of human caring. (pp. 1937).
Belanger, T. W. (1996). Leadership in a healing environment. Seminars for Nurse Managers, 4(4),
218223.
Curtin, L. L. (1997). [Editorial]. Whatsoever you do . . .
Nursing Management, 28(6), 78.
Kerfoot, K. (1997). LeadershipThe courage to care.
Nursing Economics, 15(1), 5051.
Lennerts, M. H., Koehler, J. A., & Neil, R. M. (1996).
Nursing care models increase care quality while reducing costs. Journal of the Association of Nursing
in AIDS Care 7(4), 3746.
Morris, T. (1997). If Aristotle ran General Motors:The
new soul of business. New York: Henry Holt & Co.
Neil, R. M. (1994). Authentic caring: The sensible answer for clients and staff dealing with HIV/AIDS.
Nursing Administration Quarterly,18(2), 3640.
Seaward, B. L. (1995). Reflections on human spirituality for the worksite. American Journal of Health
Promotion, 9(3), 165168.
Seaward, B. L. (1997). Stand like a mountain, flow
like water: Reflections on stress and human spirituality. Deerfield Beach, FL: Health Communications, Inc.
Tronto, J. C. (1998). An ethic of care. Generations,
22(3), 1520.
Watson, J. (1979). Nursing: Philosophy and science of
human care. Norwalk, CT: Appleton-Century-Crofts.
Watson, J. (1988). New dimensions of human caring
theory. Nursing Science Quarterly, 1(4), 175181.
Watson, J. (1989). Watsons philosophy and theory of
human caring in nursing. In Riehl-Sisca, J. (Ed.),
Conceptual models for nursing practice, (3rd ed.,
Watson, J. (1997). The theory of human caring: Retrospective and prospective. Nursing Science Quarterly, 10(1), 4952.
Whyte, D. (1994). The heart aroused: Poetry and the
preservation of the soul in corporate America. New
York: Doubleday.
Chapter 21
Part 1
Theory of Culture Care Diversity
and Universality
Culture Care Diversity and Universality:
A Worldwide Nursing Theory
Rationale for Transcultural Nursing: Signs and Need
Major Theoretical Tenets
Sunrise Model: A Conceptual Guide to Knowledge
Discovery
Current Status of the Theory
Future of the Culture Care Theory
Summary
References

Madeleine Leininger is the founder and leader of the
field of transcultural nursing, focusing on comparative human care theory and research, and is founder
of the worldwide Transcultural Nursing Society. Dr.
Leiningers initial nursing education was at St. Anthony School of Nursing in Denver, Colorado. Her
undergraduate degree is from Mt. St. Scholastic College in Atchison, Kansas, and her masters degree
was earned at the Catholic University of America in
Washington, D.C. She completed her Ph.D. in social
and cultural anthropology at the University of Washington. Dr. Leininger was dean and professor of nursing at the Universities of Washington and Utah and
helped initiate and direct doctoral programs in nursing at the Universities of Utah and Washington, and
at Wayne State University. She facilitated the development of similar programs in other American and
overseas institutions.
Dr. Leininger is a felCaring for people of many
low and distinguished
different cultures seemed living legend of the
inevitable, and yet nurses American Academy of
Nursing. She is profesand other health professor emeritus of the
sionals were not prepared College of Nursing at
Wayne State Univerto meet this challenge. sity (in Detroit, Michigan) and adjunct professor at the University of Nebraska, College of
Nursing (in Omaha, Nebraska). She continues to be
active as an internationally known theorist, educator,
author, administrator, distinguished lecturer, researcher, and consultant in transcultural nursing
from her home in Omaha, Nebraska.
Dr. Leininger is the author and/or editor of 27
books, has published over 200 articles, and has given
more than 1100 public lectures throughout the
United States and abroad. Some of her well-known
books include Basic Psychiatric 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), Care: Ethical and Moral Dimensions of Care (1990), and Culture Care Diversity and Universality: A Theory of
Nursing (1991). Some of her books were the first in
that area of nursing to be published. Nursing and
Anthropology: Two Worlds to Blend (1970) was the
first to bring together nursing and anthropology,
Transcultural Nursing: Concepts, Theories, and
Practices (1978) was the first in transcultural nursing, and Qualitative Research Methods in Nursing
362
(1985) was the first qualitative research book in nursing.

Her published works reflect four decades of cumulative transcultural work with many cultures
throughout the world. In 1989, Dr. Leininger initiated the Journal of Transcultural Nursing, which
was the first transcultural nursing journal.
Dr. Leininger conducted a pioneering field study
of the Gadsup of the eastern highlands of New
Guinea in the early 1960s, and has subsequently
studied many other Western and non-Western cultures. During her 50 years in nursing, Dr. Leininger
has been instrumental in several breakthroughs in
nursing, including focusing on human care as the
essence of nursing, new domains of inquiry, transcultural nursing, comparative care, and the qualitative ethnonursing research method; she also provided new ways to provide culturally competent
health care. She was the first nurse and anthropologist to promote the idea of culture-specific and culturally congruent care. She also initiated the concept
of generic (folk, lay, or complementary) health care
to be contrasted with professional health services. In
1987, she initiated the idea of worldwide certification in transcultural nursing to protect and respect
the needs and lifeways of people of diverse cultures.
This futuristic idea is only now being considered
along with other globally sound modes of transcultural education, practice, and certification.
As a pioneering nurse educator, leader, theorist,
and administrator, Dr. Leininger has been a risk taker,
futurist, and innovator, never afraid to bring forth
new directions in education and service. Her persistent leadership has made transcultural nursing and
human care central to nursing and respected as formal areas of study and practice. She has been called
the Margaret Mead of the health field. Dr. Leiningers genuine interest and enthusiasm for whatever
she pursues is contagious, inspiring, and challenging. She continues to be viewed as a transcultural
leader who is ahead of her time. Dr. Leininger encourages others to be compassionate and caring in
order to help people live peaceful and healthy lives
in our complex and diverse world.
CULTURE CARE DIVERSITY AND

UNIVERSALITY: A WORLDWIDE
NURSING THEORY
by Madeleine M. Leininger
Culturally based care can significantly contribute to
human health and well-being, and transcultural nurs-
ing care can provide such meaningful and therapeutic outcomes. One of the most significant trends in
the twentieth century has been the development of
transcultural nursing concepts, principles, theories,
and research-based knowledge to guide, challenge,
and explain nursing practices. The use of transcultural nursing theories
Care is the essence and has been a critical
means to open the door
central domain of nursing; to advance new scienit is the unique and domi- tific and humanistic dimensions of caring for
nant attribute of nursing. people of diverse and
similar cultures. It has
been the use of transcultural theories and researchbased knowledge in teaching and clinical practices
that has greatly expanded our ways of thinking and
helping people in diverse cultures.
Transcultural nursing was first conceived of in the
mid-1950s and began to be developed in the United
States. The Theory of Culture Care Diversity and Universality also began to be developed in order to establish a knowledge base to guide nurses in transcultural nursing practices. It was at this time that I
foresaw that nurses would need transcultural knowledge and practices to function by the year 2000
(Leininger, 1970, 1978). This was the postWorld
War II period, when many new immigrants and
refugeespeople from many placescame to America, and also migrated to other countries. Caring for
people of many different cultures seemed inevitable,
yet nurses and other health professionals were not
prepared to meet this challenge. Instead, nursing
and medicine were focused on using new technologies and on studying biomedical diseases and symptoms. Shifting to a transcultural perspective in order
to understand and care for people of many different cultures was not seen as a critical need. Thus,
a whole new world of knowledge discovery and
practice related to transcultural nursing and health
had yet to be developed, valued, and put into practice.
In this chapter, an overview of the Theory of Culture Care Diversity and Universality will be presented, along with the purpose, goal, assumptions,
theoretical hunches, and related general features of
the theory, as well as future uses. In addition, theory
terms will be defined and the Sunrise Model will be
explained. The reader is encouraged to explore other
articles on the theory and to use definitive primary
literature to gain accurate knowledge of the theorists perspectives on this important subject (Leininger, 1970, 1981, 1989a, 1989b, 1990a, 1990b, 1991,
1995).
FACTORS LEADING TO THE THEORY

A frequent question often posed to me is, What led
you to develop your theory? This is an important
question for any theorist to answer. What inspires
and motivates most theorists is generally related to
the desire to discover the unknown or limitedly
known. Initially, the idea for the Theory of Culture
Care came to me while I was functioning as a clinical
child nurse specialist in a child guidance home in a
large midwestern city. From my focused observations and daily nursing experiences, I became aware
that the children in the guidance home were from
many different cultures. These children were different in their nursing care needs, responses, and expectations. The children were Anglo-Caucasian,
African, and Jewish, representing Appalachian and
many other cultures. The ways in which these childrens parents responded to the children, and the
parents expectations of care and treatment modes
were different. This was in the early 1950s. I had not
been prepared to care for people of diverse cultures,
nor were other nurses, physicians, social workers,
and health professionals in the health services prepared to respond therapeutically in a knowing and
competent way with clients from different cultures
and cultural backgrounds (Leininger, 1970, 1978,
1991, 1995). I experienced cultural shock and felt
helpless to care for both children and adults of diverse cultures. It soon became evident to me that I
needed cultural knowledge with my psychiatric and
general nursing care insights and experiences. To
remedy this major knowledge deficit, I decided to
pursue doctoral studies in anthropology. While in the
anthropology program, I discovered a wealth of potentially valuable knowledge that could be most
helpful if used within a nursing perspective. The
challenge before me was to link or interface anthropological insights with nursing knowledge and to go
beyond the physical and emotional needs of clients.
At this time, I was questioning what made nursing
a distinct and legitimate profession. I also wondered
about medicine and other disciplines about their
unique knowledge and skill focus to help serve people. Surely not all disciplines were the same. Nurses
had not addressed the cultural care focus with theory
and research. I therefore declared in the mid-1950s
that care is (or should be) the essence and central domain of nursing. However, most nurses resisted this
idea, because they thought care was not important
and was too feminine, too soft and vague and could
never explain nursing (Leininger, 1970, 1977, 1981,
1984). Nonetheless, I firmly held to the claim and began to teach, study, and write about care as the
Chapter 21 Madeleine M. Leininger Theory of Culture Care Diversity and Universality
363
essence of nursing, its unique and dominant attribute (Leininger, 1970, 1977, 1981, 1984). From an
anthropological and nursing perspective I held that
care and caring is a basic and essential need for human growth, development, and survival (Leininger,
1977, 1981). I argued that what humans need most
to survive from birth to old age, or when ill or well,
is human caring. But caring phenomena needed to
be explicated, and had to fit the cultural needs of human beings in order to be scientific and useful.
Clients had often said it was nursing care that helped
them (the acutely or chronically ill) to recover and
be healed.
My next step in the theory was to conceptualize
selected cultural perspectives derived from anthropology and evolving care perspectives as nursing
statements or assumptions related to culture care in
order to establish a new knowledge base for transcultural nursing. Synthesizing or interfacing culture and
care was the real challenge to establishing the new
Theory of Culture Care Diversity and Universality
(Leininger, 1976, 1978, 1990a, 1990b, 1991). Formulating such knowledge was essential to support
the discipline of transcultural nursing and to use this
knowledge to care for
people of different
Transcultural nursing uses
cultures. Because culresearch-based knowledge ture care knowledge
to provide safe, responsible, had not been explicated and linked tomeaningful care to people gether as an integral
of different cultures, sup- part of nursing education, research, and
porting their health needs practice in the midand dealing with illness, 1950s, much work
still lay ahead. It was
disabilities, or death. this new and promising paradigm to serve
clients of diverse cultures. Indeed, care or caring had
largely been the invisible and unknown phenomenon in nursing even though nurses frequently use
words or phrases such as I gave care to X,My nursing care was appreciated by the family, and I coordinated nursing care on this unit. These statements
and similar linguistic uses of the word care were
taken largely for granted or assumed to be understood by nurses, clients, and the public (Leininger,
1981, 1984). Moreover, the meaning of care from
the perspective of different cultures was unknown.
In the 1950s 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 (Leininger, 1981, 1990a,
1991, 1995). Theoretical and practice meanings of
364
care in relation to specific cultures had not been

studied, especially from a comparative cultural perspective. I became excited as I envisioned a whole
new body of essential knowledge related to transcultural nursing care that was awaiting our discovery
and which could be used in nursing. This was exciting to me, yet very troublesome, as nurses needed to
shift their thinking and attitudes from largely medical
symptoms and treatments to that of knowing and
valuing culturally based care. To refocus nursing to a
new theory and mode of practice would be difficult.
The culture care theory, which looks for universals
(or commonalties) along with differences (diversities), was viewed as too idealistic and impossible
for many nurses. But by the mid-1980s the theoretical and clinical ideas became known, used, and valued by many nurses.
RATIONALE FOR TRANSCULTURAL

NURSING: SIGNS AND NEED
Despite the above challenges, the need for transcultural nursing with a theoretical and research knowledge base was tenaciously pursued as essential to
providing quality-based care to people of diverse cultures both now and in the future (Leininger, 1978,
1989a, 1990b). Signs of critical needs became evident by the 1970s to support this position for the
future survival of nursing education and practice.
Several of these factors are briefly stated below
(Leininger, 1970, 1978, 1984, 1989a, 1990a, 1995):
1. There were signs of increased numbers of global
migrations of people from virtually every place in
the world due to modern electronics, transportation, and communication.
2. There were signs of cultural stresses and cultural
conflicts as nurses tried to care for strangers from
many Western and non-Western cultures.
3. There were cultural indications of consumer fears
and resistance to health personnel as they used
new technologies and treatment modes without
cultural knowledge or understanding of the people being served.
4. There were signs that clients from different cultures were angry, frustrated, and misunderstood
by health personnel due to cultural ignorance of
the clients beliefs, values, and expectations
along with the misdiagnosis and mistreatment of
clients from unknown cultures.
5. There were signs of nurses, physicians, and other
professional health personnel becoming quite
frustrated and upset when clients failed to cooperate or respond quickly to them in treatment
6.
7.
8.
9.
regimes. Culture care factors were seldom recognized or understood by professional staff until
nearly the late 1980s.
There were signs that consumers of different cultures, whether in the home, hospital, or clinic,
were being treated in ways that did not satisfy
them and their recovery was thwarted or unsuccessful.
There were many indications of intercultural conflicts and cultural pain of clients when nurses,
physicians, and staff failed to respect important
cultural taboos and values of clients.
There were evidences of culturally unrepresented
(minority) cultures of clients and staff in health
settings.
Last but not least, there were signs that nurses
working in foreign countries in the military and
as missionaries were having great difficulty in understanding and caring for clients of diverse cultures, due largely to a lack of knowledge about
the people and their cultural beliefs and lifewayssome even encountered threats to their
lives.
For these reasons and many others, it was evident

in the 1960s and beyond that nurses and other health
professionals urgently needed transcultural knowledge and skills to work with people of diverse cultures. Nursing and other health-care professionals
were clearly not understanding and serving people
of different cultures in therapeutic ways. Cultural ignorance and the unintentional mistreatment of immigrants and others had potential for major legal suits
and for unfavorable client recovery processes, or
even threats to the clients lives.
It is interesting that while anthropologists are

clearly experts about cultures, many were not 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 physical and cultural anthropology. So, as the first graduate (masters prepared) professional nurse anthropologist, I held that nurses and
nursing needed to understand cultures and caring in
order to provide culturally safe and congruent care
practices with beneficial and therapeutic outcomes.
I encouraged many nurses to take cultural and physical anthropology courses in order to obtain background supporting knowledge until transcultural
nursing courses and programs were established. Unfortunately, some nurses who heeded this advice
never returned to nursing and remained wed to anthropology, as they had no transcultural nursing
framework to use the knowledge gained. Gradually
transcultural nursing undergraduate and graduate
courses and programs were initiated and became
available to nurses by the 1970s. This was essential to
prepare and help nurses remain in the transcultural
nursing field (Leininger, 1970, 1978, 1989a, 1989b,
1995).
Most importantly, nurses were the largest and
most direct health-care providers, so great opportunities existed for them to change health care for culturally congruent care practicesthis was the ultimate goal of transcultural nursing. Nurses and those
in other health-care disciplines urgently needed to
become transculturally prepared to meet a growing
multicultural world by the year 2000, as an essential
requirement for human services worldwide to func-
your thoughts
365
tion with many different people in the world. This

predictive need has already occurred today as nurses
try to function as practitioners, consultants, teachers, and researchers in diverse cultures, often without transcultural knowledge and skills. This has led
to many problems and frustrations that often cause
people to leave nursing, or cause dissatisfaction with
current health-care systems.
As more courses and programs in transcultural
nursing were offered to educate nurses in its basic
concepts, principles, and practices, the interest of
nurses grew to learn about the Theory of Culture
Care Diversity and Universality. Transcultural nursing became meaningful, and was defined as a formal
area of study (education and research) and practice
focused on the cultural care (caring) values, beliefs,
and practices of individuals or groups from a particular culture in order to provide culture-specific and
congruent care to people of diverse cultures (Leininger, 1978, 1984,
Forms, expressions, 1995). The central
purpose of transculpatterns, and processes of tural nursing is to use
human care vary among all research-based knowledge to help nurses
cultures of the world. give safe, responsible,
and meaningful care
to people of different cultures to meet their care
needs and to deal with illnesses, disabilities, or dying. Today the culture care theory with researchbased knowledge has become recognized as essential to help guide nurses in the care of clients,
families, and communities of different cultures or
subcultures.
MAJOR THEORETICAL TENETS

In developing the Theory of Culture Care Diversity
and Universality, there were major predictive tenets
or premises that were essential for nurses and others
using the theory to consider. One of the principal
tenets was that cultural care diversities and similarities (or commonalities) exist within and between
cultures worldwide (Leininger, 1991). Nurse researchers needed to discover this knowledge to
guide nurses thinking, judgements, and decisions in
order to provide therapeutic outcomes. It was predicted that such knowledge could be a gold mine to
help nurses assess, plan, and provide care to people
of different cultures. Providing culture-specific care
that fit the beliefs, values, and lifeways of cultures
would be a major new approach to nursing, as this
was a major missing dimension of traditional nursing.
Human beings are born, live, and die with their spe-
366
cific cultural values and beliefs, as well as with their

historical and environmental context, which includes language considerations. Transcultural nursing knowledge needed to be shared with other
nurses as the substantive and essential knowledge for
all nursing decisions and actions. It was predicted
that discovering which elements of care were culturally universal and which were different would drastically revolutionize nursing and ultimately transform
the health-care systems and practices (Leininger,
1978, 1990a, 1990b, 1991).
Another predictive tenet of the theory was that
the worldview and social structure factorsincluding religion (and spirituality), political and economic
considerations, kinship (family ties), education,
technology, language expressions, the environmental context, and cultural historyare essential to
understand and are powerful influences on care outcomes (Leininger, 1991). This broad holistic perspective, which included specific knowledge, was imperative if one was to grasp the world of the client and
family and help them. Such research-based knowledge was predicted to influence the health, wellbeing, sickness, and disability or dying patterns of
clients from different cultures. Social structure and
other influences on human care from specific cultures had not been systematically studied by nurses
or used explicitly in their teaching, learning, and
clinical practices. These important factors, along
with ethnohistorical, language, and environmental
factors, had to be discovered in order to create the
theory and to bring about beneficial outcomes. Such
factors would not only influence the clients recovery and healing process, but would also disclose
ways to help clients remain well. This holistic cultural knowledge needed to be documented and understood in order to guide nurses decisions in arriving at culturally congruent carewhich was the goal
of the theory.
To discover such holistic yet specific knowledge,
nurses needed a theory and research methods to explicate these cultural influences on the care of human beings. No longer could nurses rely only on bits
and pieces of partial or fragmented medical and psychological knowledge, as these were only small
glimpses of the clients cultural world. Nurses needed
to be aware of social structure knowledge, cultural
history, and environmental factors in order to understand these factors when using the theory. Thus,
transcultural nursing courses and programs provided
instruction and mentoring experiences in these areas
to appreciate and use the theory fully.
One major and predicted tenet of the theory was
that there are both care differences and similarities
with regard to professional and generic (traditional

or indigenous folk) care knowledge and practices
(Leininger, 1991). These differences were also predicted to influence the health and well-being of
clients. In fact, it was predicted that there would be
significant differences between generic care and that
of professionally learned nursing knowledge. Again,
these findings would influence the recovery (healing), health, and well-being of clients from other cultures, and had to be considered. Marked unresolved
cultural conflict differences between generic and
professional care providers were predicted to lead to
serious client-nurse conflicts, potential illnesses, and
even death (Leininger, 1978, 1991).
Finally, I theorized that if three new modalities of
care were used, they would lead to culturally congruent care if based on data obtained from the culture.
The three modalities postulated were (1) culture
care preservation or maintenance, (2) culture care
accommodation or negotiation, and (3) culture care
restructuring or repatterning (Leininger, 1991,
1995). These three modes were very different from
traditional nursing actions, processes, or interventions, as they were focused on ways to facilitate congruent care to fit clients particular cultural needs. To
use these modalities and arrive at culturally appropriate care, the nurse has to draw upon culture care
emic knowledge discovered from the people along
with the use of appropriate professional scientific
and humanistic knowledge that fits with the clients
needs. Using nursing interventions would not be appropriate, as they lead to cultural imposition and cultural tensions and conflicts. These three modalities
were entirely new breakthroughs in nursing, as was
the idea of providing culturally congruent care.
Nurses had to shift from focusing mainly on treating
diseases and symptom management from their etic

views to those of a holistic culture and care based on
a client emic perspective. Although some learned
nursing and medical knowledge might be appropriate, such knowledge was often inappropriate or did
not fit the clients needs (Leininger, 1991, 1995).
With the theory, the primary focus remained on
caring for people within a cultural care context or
environment. Discovering environmental and cultural beliefs and values of humans was much broader,
yet it was a specific approach that was unique to
transcultural nursing practices. As new kinds of
transcultural nursing knowledge were forthcoming,
culturally based care was evident to prevent illness,
maintain health, and to live in reasonably peaceful relationships with others. A life-cycle perspective and
historical patterns related to care were predicted to
be valuable in helping nurses to arrive at meaningful
and therapeutic nursing care outcomes. This theory
was the new postNightingale and postWorld War II
paradigm for new nursing practices worldwide to
value and use as professional nurses.
Theoretical Assumptions: Purpose,

Goal, and Definitions of the Theory
The purpose of the theory was, therefore, to discover, document, analyze, and interpret cultural and
caring factors influencing human beings in health,
sickness, or dying, in order to advance and improve
nursing practices. The theory was developed with
much thought to incorporate ideas related to the
above tenets or predictive premises of the theorist.
Discovery of the largely unknown, covert, and missing cultural care factors related to transcultural nursing was the primary focus and a critical need to pro-
your thoughts
367
vide safe, meaningful, and congruent care to clients

or to work effectively with families and in institutional settings.
The goal of the theory was to use research-based
knowledge in order to provide culturally congruent,
safe, and beneficial care to people of diverse or similar cultures for their health and well-being or for
meaningful dying experiences. This goal of arriving
at culturally congruent care was predicted to promote the health and well-being of clients, or to help
clients face disability or death in culturally meaningful and satisfying ways. Thus, the ultimate and primary goal of the theory was to provide culturally
congruent care that fit or was tailor-made for the lifeways and values of people (Leininger, 1991, 1995).
2.
3.
4.
Assumptions of the Theory

Several assumptions served as the basic beliefs related
to the theoretical tenets and predictive hunches of
the culture care theory. They are as follows (Leininger, 1970, 1977, 1981, 1984, 1991, 1997a):
1. Care is essential for human growth, development,
and survival, and when facing death.
2. Care is essential to curing and healing; there can
be no curing without caring.
3. Forms, expressions, patterns, and processes of
human care vary among all cultures of the world.
4. Every culture has generic (lay, folk, or naturalistic) care, and usually professional care practices.
5. Culture care values and beliefs are embedded in
religious, kinship, social, political, cultural, economic, and historical dimensions of the social
structure and in language and environmental
contexts.
6. Therapeutic nursing care can only occur when
client culture care values, expressions, and/or
practices are known and used explicitly to provide human care.
7. Differences between caregiver and care receiver
expectations need to be understood in order to
provide beneficial, satisfying, and congruent
care.
8. Culturally congruent, specific, or universal care
modes are essential to the health or well-being of
people whom nurses serve worldwide.
9. Nursing is a transcultural care profession and discipline.
Orientational Theory Definitions

1. Culture Care Diversity: Refers to variability
and/or differences in meanings, patterns, values, lifeways, or symbols of care within or between collectivities that are related to assistive,
368
5.
6.
7.
8.
9.
supportive, or enabling human care expressions

(Leininger, 1991, p. 47).
Culture Care Universality: Refers to the common, similar, or dominant uniform care meanings, patterns, values, lifeways, or symbols that
are manifest among many cultures and reflect assistive, supportive, facilitative, or enabling ways
to help people (Leininger, 1991, p. 47).
Care: Refers to abstract and concrete phenomena related to assisting, supporting, or enabling
experiences or behaviors toward or for others
with evident or anticipated needs to ameliorate
or improve a human condition or lifeway. Caring refers to care actions and activities
(Leininger, 1991, p. 46).
Culture: Refers to the learned, shared, and transmitted values, beliefs, norms, and lifeways of a
particular group that guides their thinking, decisions, and actions in patterned ways (Leininger,
1991, p. 47).
Culture Care: Refers to the subjectively and objectively learned and transmitted values, beliefs,
and patterned lifeways that assist, support, facilitate, or enable another individual or group to
maintain their well-being and health, to improve
their human condition and lifeway, or to deal
with illness, handicaps, or death (Leininger,
1991, p. 47).
Professional Care: Refers to formally taught,
learned, and transmitted professional care,
health, illness, wellness, and related knowledge
skills that prevail in professional institutions usually with multidisciplinary personnel to serve
consumers (largely etic or outsiders views)
(Leininger, 1995, p. 106).
Generic (Folk and Lay) Care: Refers to culturally learned and transmitted indigenous (or traditional, folk, lay, or home-based) knowledge or
skills used to provide assistive, supportive, enabling, or facilitative acts toward or for another
individual or group, or in an institution (largely
emic or insiders views) (Leininger, 1995, p.
106).
Health: Refers to a state of well-being that is culturally defined, valued, and practiced, and reflects the ability of individuals (or groups) to
perform their daily role activities in culturally
expressed, beneficial, and patterned ways
(Leininger, 1995, p. 106).
Culture Care Preservation or Maintenance:
Refers to those assistive, supporting, facilitative,
or enabling professional actions and decisions
that help people of a particular culture to retain
and/or preserve relevant care values so that they
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
can maintain their well-being, recover from illness, or face handicaps and/or death (Leininger,
1991, p. 48).
Culture Care Accommodation or Negotiation:
or enabling creative professional actions and decisions that help people of a designated culture
to adapt to, or to negotiate with others for, a
beneficial or satisfying health outcome with professional care providers (Leininger, 1991, p. 48).
Culture Care Repatterning or Restructuring:
or enabling professional actions and decisions
that help clients reorder, change, or greatly
modify their own lifeways for new, different,
and beneficial health-care patterns while respecting the client(s) cultural values and beliefs
and providing more beneficial and healthy lifeways than those that existed before the changes
were coestablished with the clients (Leininger,
1991, p. 49).
Ethnohistory: Refers to those past facts, events,
instances, and experiences of individuals,
groups, cultures, and institutions that are primarily people-(ethno)centered and describe, explain, and interpret human lifeways within particular cultural contexts and over short or long
periods of time (Leininger, 1991, p. 48).
Environmental Context: Refers to the totality of
an event, situation, or particular experience that
gives meaning to human expressions, interpretations, and social interactions in particular physical, ecological, sociopolitical, and/or cultural
settings (Leininger, 1991, p. 48).
Worldview: Refers to the way in which people
tend to look out on the world or their universe
to form a picture or value stance about their life
or world around them (Leininger, 1991, p. 47).
Kinship and Social Factors: Refers to family intergenerational linkages and social interactions
based on cultural beliefs, values, and recurrent
lifeways over time.
Religion and Spiritual Factors: Refers to the supernatural and natural beliefs and practices that
guide individual and group thoughts and actions
toward the good or to improve ones lifeways.
Political Factors: Refers to authority and power
over others that regulates or influences anothers actions, decisions, or behavior.
Technological Factors: Refers to the use of electrical, mechanical, or physical (nonhuman) objects used in the service of humans.
Education Factors: Refers to formal and informal modes of learning or acquiring knowledge
about specific and diverse subject matter domains.

20. Economic Factors: Refers to the production, distribution, and use of negotiable material or consumable productions held valuable to humans or
in need by humans.
21. Environmental Factors: Refers to the totality of
ones living context within a geographic or ecological area.
22. Culturally Congruent Care: Refers to the use of
culturally based care knowledge and action
modes with individuals or groups in beneficial
and meaningful ways for the clients health and
well-being, or in order to face illness, disabilities, or death.
These definitions are referred to as orientational
rather than operational, as they permit the researcher to discover generally and naturally the informants local or emic (insiders) cultural perspectives
rather than focusing on the researchers etic (outsiders) specific variables and particular views. Orientational terms are congruent with the qualitative
ethnonursing discovery method, which is focused
on how people know and experience their world
with their cultural knowledge and lifeways
(Leininger 1985, 1991).
SUNRISE MODEL:
A CONCEPTUAL GUIDE TO
KNOWLEDGE DISCOVERY
The Sunrise Model (Figure 211) was developed to
give a holistic and comprehensive conceptual picture of the major factors held as important to the
(Leininger, 1995, 1997a). The model is a conceptual
visual guide depicting multiple factors predicted to
influence culturally congruent care with people of
different cultures. The model essentially serves as a
cognitive guide for the researcher to visualize and reflect on different factors predicted to influence culturally based care in the discovery process. The Sunrise Model has also been used as a valuable guide
for doing culturalogical health-care assessment of
clients health needs. As the researcher uses the
model, the different factors depicted in the model
are kept in mind in relation to discovering culture
care phenomena. Gender and sexual orientation,
race, class factors, biomedical condition, and the extent of acculturation are all an integral part of the
model and theory. The factors tend to be embedded
in social structure, worldview, and other dimensions
identified in the Sunrise Model and are usually not
369
quickly identifiable. Hence, they are not isolated

variables but are lodged in their natural and meaningful cultural context, yet are important discovery
areas within the theory.
According to the researchers interests and skills,
one can begin the discovery at any place in the
model except with the three modes of action and decisions, which are studied last or after drawing upon
370
data collected in the upper part of the model. All factors in the model need to be studied to obtain comprehensive or holistic data in order to arrive at an
accurate picture of culturally based care. Some researchers may want to start with generic and professional care, whereas others may begin with the
worldview and social structure dimensions. There is
flexibility in the discovery process to fit the infor-
mants interest and level of comfort as well as the researchers goals, domains of inquiry, and research
skills.
Because three modes of action and decision (in
the lower part of the model) are studied and formulated with informants
The Sunrise Model is a after the researcher has
obtained data in the upvaluable guide for cultur- per part of the model,
alogical care assessment the nursing actions or
decisions become eviof clients health needs. dent. The researcher involves informants in the
discussion to arrive at appropriate actions, decisions,
or plans. Throughout this discovery process, the researcher holds his or her own etic views, presuppositions, and biases in abeyance, so that the informants cultural ideas will come forth, because they,
rather than the researchers views, are important and
are the reason for the study. Transcultural nurses are
taught, guided, and mentored in ways to withhold
and deal with their biases and prejudices through formal courses and clinical experiences in transcultural
nursing.
As the researcher carefully documents the different factors influencing care, he or she focuses on a
specific and explicit domain of inquiry. For example,
the researcher may focus on a domain of inquiry
(DOI) such as culture care of Mexican-American
mothers caring for their children in their home.
Every word in the domain statement is important to
study, using the Sunrise Model and theory tenets.
The researcher may have hunches about the domain,
but holds them back until all data have been studied
with the theory tenets. Full documentation of the informants viewpoints, experiences, and actions is
pursued. Generally, informants select what they first

want to talk about with the researcher and then the
researcher moves with informants to cover all aspects of the model and theory tenets. During the indepth study of the domain of inquiry, all areas of the
model are covered and discussed and confirmed
with the informants. The informants remain active
participants throughout the discovery process and in
a manner that they feel is their unique and rich contribution.
The meanings, beliefs, values, and practices related to culture and care are studied in-depth and
with respect to differences and similarities among
key and general informants being studied. Both the
differences and similarities are important to document the theory predictions. Such differences are often noted and observed with the historical, environmental, and social structure factors (i.e., religion,
family, and economic, political, legal, or other factors) that influence human caring. The nurse researcher always reflects on professionally learned
nursing knowledge, but always remains focused on
the informants views and their stories and experiences. Most important, the researcher is careful not
to impose his or her own ideas on the informant or
on the findings. Sometimes informants ask about the
researcher and his or her views, which must be carefully and sparsely shared. The researcher keeps in
mind the fact that some informants may want to
please the researcher by talking about their professional medicines and treatments in order to get help
or satisfy the researcher. Professional ideas, however,
generally often cloud or mask the clients real interests and views. If this occurs, the researcher must be
alert to such tendencies and keep the focus on the informants and the domain of inquiry. The informants
your thoughts
371
knowledge must always be kept central to the discovery process about culture care, health, and wellbeing. Factors that are unfamiliar to the researcher,
such as kinship, economics, and political and other
considerations depicted in the model and with the
theory, may be difficult to discuss unless the nurse is
prepared and understands these areas. In general, it
is the informants emic (insiders) views, beliefs, and
practices that are central to studying the theory, and
the researchers views are put on a back burner in order to arrive at appropriate modes of action or decisions (Leininger, 1985, 1991, 1995, 1997a).
Throughout the study and use of the theory, the
meanings, expressions, and patterns of culturally
based care are important ideas to keep in mind. The
researcher listens attentively to informants accounts
or stories, which include how they live, what they
believe, and how they practice care or caring in their
culture. Learning and documenting ideas from the informants emic viewpoint is critical to arrive at accurate culturally based care. Unknown care meanings,
such as the concepts of protection, respect, and
love, and many other care constraints need to be
teased out and explored in depth as informants share
their ideas and experiences. These care areas of
knowledge are essentially new in nursing when
linked to culture. Moreover, these care meanings and
expressions are often found to be lodged in religion,
kinship (family), cultural values and beliefs, environment, and historical practices over time and are not
always readily known. Sometimes informants are reluctant to share social structure and other ideas with
nurses as they feel they are only interested in medical
facts, techniques, and services and not in their religion, kinship ties, and other factors. Informants may
also fear their cultural ideas will not be accepted or
will be misunderstood by health personnel if they
are partially known. But the cultural care ideas usually found hidden in generic (folk or indigenous)
knowledge has to be teased out from the informant
by showing a genuine interest in whatever they
share. Such generic care must be appropriately integrated into professional knowledge and practices for
quality-based health-care services (Leininger, 1981,
1984, 1990c, 1991). Generic and professional care
complement each other for therapeutic nursing practices.
In identifying culturally based care knowledge
with the three modalities, one will discover which of
the three modes (or all) fit with the informants care
for therapeutic outcomes such as discussed in the
second part of this chapter and from other transcultural nursing research reports. Informants actively
participate to discover which care modes are needed
372
to be maintained (or preserved), accommodated,

structured, or repatterned to arrive at meaningful
transcultural nursing care practices. Sometimes several care modes may be tailor-made to fit different
cultural needs of individuals and groups. Professional
knowledge may or may not be relevant or appropriate to use with some cultures.
The Sunrise Model was developed with the idea
of letting the sun enter the researchers mind and
discovering generally unknown care factors for
nurses related to the cultural values and care needs
of cultures. The model depicts letting the sun rise
and shine to get fresh and new insights. A wealth of
new and unexpected nursing knowledge can be discovered with the model that has never been known
and used in traditional nursing for present-day nursing and medical services.
The ethnonursing qualitative research method
was specifically designed for the theory to facilitate
the discovery of complex culture care phenomena.
It is the only nursing research method that specifically teases out culturally based care as related to the
theory (Leininger, 1985, 1990c, 1991, 1995, 1997a,
1997b). The ethnonursing method focuses primarily
on discovering the peoples care knowledge and lifeways rather than those of the researchers. This
method will be discussed in the second part of this
chapter, where Marilyn McFarland will show how
the ethnonursing method is used in relation to the
theory with a specific domain of inquiry, research
questions, and special enablers to tease out the informants data. Thus, the ethnonursing method is a
method that was tailor-made to fit the theory
(Leininger, 1990c, 1991, 1997a, 1997b). The reader
is encouraged to read more on the theory and findings from use of the theory and ethnonursing
method over the past four decades, and to discover
the wealth of new transcultural care knowledge
available to him or her for nursing practice (Leininger, 1991, 1995, 1997a, 1997b).
CURRENT STATUS OF THE THEORY

Currently, the Theory of Culture Care Diversity and
Universality is being used in many schools of nursing
and several clinical practice sites worldwide. The
theory has grown in recognition and value for several
reasons. First, the theory is the only nursing theory
that focuses explicitly and in depth on discovering
the meaning, uses, and patterns of culture care
within and between specific cultures. Second, the
theory looks for comparative culture care differences
and similarities among and within cultures in order
to expand nurses knowledge about care in diverse
cultures as essential to new nursing knowledge and

practices. Third, the theory has a built-in and tailormade ethnonursing nursing research method that
was uniquely designed for the theory; it is different
than ethnography and other research methods. The
ethnonursing method remains unique and valuable
to tease out largely covert, complex, and generally
hidden care knowledge in cultures or subcultures. It
was the first specific research method in nursing to
fit a theory rather than the other way around; previously, nurse researchers typically used other borrowed and often inadequate research methods to
study nursing phenomena.
Fourth, the theory of culture care is the only
theory that searches for comprehensive and holistic
social structure and worldview factors related to culture and caring to predict the health and well-being
of people. The theory focuses on the totality of lifeways of individuals, families, groups, communities,
and/or institutions related to culture and care phenomena to grasp a more comprehensive picture of
humans in their real lifeworld. In the past, the culture of nursing has often focused on limited variables
or medical symptoms and phenomena, which led to
fragmented ideas about human living, beliefs, and
values about maintaining wellness and preventing illnesses. Discovering the totality of living with a caring ethos in a culture has provided a wealth of new
knowledge about the clients lifeworld.
Fifth, the theory has both abstract and practical
dimensions, which helps nurse researchers to discover what exists, or has the potential to be known
and used for human caring and health practices.
New theories are providing data of what exists and
does not exist, and what has the potential for future
discoveries. Moreover, some theories deal only with
abstract phenomena, but this theory has both abstract and practical realities for nurses.
Sixth, the theory of culture care with the ethnonursing method and enablers has already provided
a wealth of many new insights, knowledge areas, and
valuable ways to work with people of diverse cultures in therapeutic or different ways than in the
past. These transcultural nursing research findings
are the new knowledge holdings that need to be incorporated into nursing, medicine, and other areas.
They are the gold nuggets to change or transform in
beneficial ways the current practices with clients of
diverse cultures. Studies reported in the Journal of
Transcultural Nursing and other transcultural nursing books and journals are valuable and support
these claims (Leininger, 1991, 1995, 1997a, 1997b).
Seventh, the theory and its research findings have
stimulated nursing faculty and clinicians to try differ-
ent teaching and research approaches. Transcultural

nursing findings are slowly beginning to be used in
several schools of nursing to teach transcultural nursing and change outdated unicultural practices. Nursing administrators in service and academia have also
been encouraged to use transcultural nursing findings and approaches with students, faculty, clients,
and colleagues of different cultures and with faculty
of other institutional disciplines and cultures. Nurse
consultants are finding the theory is highly relevant
for effective consultation services in different countries. They often use the theory for culturalogical
assessments in different consultation situations to
get to the problems. Transcultural nursing concepts,
findings, and policies are being used with many
worldwide health consultants in different disciplines.
Many interdisciplinary health personnel are finding
the theory and transcultural nursing research findings of great help in their work and are seeking workshops to learn more about the theory and its uses.
Eighth, and most important, informants of diverse
cultures are often very pleased with the use of the
theory and the ethnonursing method because it explicitly focuses on entering their world and learning
from them about their culture, their health, and their
care. Informants generally like having the opportunity to tell their story and to guide the research
from what they personally believe is important for
health and for their significant others. Informants
speak of being more comfortable with this research
and theory approach than the impersonal, nonculturally focused, and narrowly focused studies on
numbers, variables, and short instant responses. Reflective thinking with the theory and multiple dimensions are valued. The theory encourages the
researcher or clinician to learn from cultural informants and to let them be in control of ideas, a fact
that is usually valued by informants. Many nurses
who have been prepared in transcultural nursing and
have used the theory and method say, I love it and
do not want to use traditional nursing research methods and theories that have failed to search for the
holistic lifeways of people and their meanings.
Ninth, nurses who have used the theory and findings over time often speak of how much they have
learned about cultures and caring. They realize that
ethnocentric professional biases and prejudices influence quality of care to people of different cultures. Ethnocentrism and racial biases and prejudices
have been reduced with transcultural nurses with
the use of the theory and research method and findings. Searching for differences and similarities among
cultures has expanded nurses worldviews and deepened their appreciation of human beings and diverse
373
cultures. The use of the theory has encouraged nursing students, staff, and faculty to become immersed
in transcultural nursing, to grow intellectually, and to
appreciate compassionate perspectives of past and
current historical changes among cultures over time
in accessing and receiving health care.
Finally, the strength of the theory is that it can be
used in any culture and at any time and with most disciplines if modified slightly to fit the major and unique
interest and goals of a specific discipline besides nursing. This fact makes the theory valuable and a major
model and contribution from transcultural nursing
and the nursing profession to other disciplines. Several disciplines, including dentistry, medicine, social
work, and pharmacy, are now focusing on culturally
congruent care in education and practice. Most encouraging is the fact that the concept of culturally
congruent care (a term that I coined in the early
1960s) has become a major goal for United States government and accrediting groups in recent years. The
concept is growing in use and is becoming imperative
in the United States and overseas.
In general, the theory of culture care (launched in
the mid-1950s) has today become well known in the
past three decades and is now being used by many
nurses and other health disciplines worldwide (Leininger, 1995, 1997a, 1997b). It is a theory of global interest and significance as we continue to understand
cultures and their care needs and practices worldwide. As transcultural nursing concepts, principles,
theory, and findings became fully incorporated into
all health professional areas of teaching, practice,
consultation, and research, one can anticipate many
encouraging new and different health-care services
from the past practices. Unquestionably, the theory
will continue to grow in relevance and use as our
world continues to become more intensely multicultural, especially in the twenty-first century. Indeed,
nurses and other health professionals are expected in
the future to function competently to meet the
health-care needs of people from many diverse and
similar cultures, to avoid racially destructive practices and prejudices, and to function in beneficially
or therapeutic ways within and between cultures
and with professional staff and students.
FUTURE OF THE CULTURE

CARE THEORY
In looking to the future, one can predict that the
will be in increasing demand and highly relevant as
world conflicts and tensions increase and the world
374
becomes increasingly multicultural. Religious, business, education, and other occupations and institutions will need transcultural knowledge and practices. Already, global, transcultural, international,
and culturally diverse linguistic terms and practices
are common in communication and popular media.
More and more, we are realizing that we are truly living in one global world with many diverse cultures
and subcultures. Accordingly, worldview, social
structure, and historical lifeways will be essential to
assess as one works with people of different cultural
lifeways in virtually every place in the world. Healthcare, business, and government entrepreneurs worldwide will increasingly promote, sell, and function
with transcultural or global worldwide products
and interests in the twenty-first century. Many transcultural research findings and the theory will be
found useful in marketing and explaining outcomes.
After the launching transcultural nursing in the
mid-1950s, the concept of cultural awareness has finally taken hold in nursing education and practice.
The concept of culturally congruent care has
gained recognition and continues to grow in use in
health education and practices. It was, indeed, fortuitous and futuristic to have launched the field of
transcultural nursing four decades ago and to lay the
foundation for transculturalism in nursing and other
fields. The full meaning and values of transcultural
nursing, however, will become more evident in education, research, consultation, and practice in the
third millennium, and our world will become intensely globally oriented in all spheres of birth, living, and dying.
It is reasonable to predict that the theory of culture care will become more relevant to nurses and
other health-care providers as they move into working in foreign cultures and market nursing worldwide with diversities and universalities. Discovering
differences and similarities worldwide in nursing is
still a goal to be reached. The theory and ethnonursing method will be of great help toward attaining this
goal. Indeed, the ethnonursing research method will
become important so nurses can grasp how multicultural groups of immigrants and others live together,
maintain health, and become ill. The theory will be
important in helping to prevent community-based intercultural conflicts, violence, and crime, because
the sources of these tension areas can be identified
with the help of the theory. One can predict a major
shift in the twenty-first century from the present
dominance of the biomedical and psychology foci to
culturalogical models and factors to prevent illnesses
and maintain health in different environments and
ecological niches. The culture care theory, along
with diverse qualitative research methods, will be extremely helpful for this new future thrust in healthcare, business, and educational settings. Computer
models will rely on holistic data for an accurate and
complete picture of culturalogical and environmental factors.
Summary
In summary, there are several major reasons why the
and research-based findings will be in demand and
used worldwide. They are summarized below:
1. Global migration and movement of people
worldwide will be rapidly increasing due to
modern transportation, communication, and
electronic media.
2. Use of electronic data and other communication
modes will markedly increase, bringing more
cultures closer together in Western and nonWestern worlds almost instantly.
3. There will be a marked increase in demand for
transcultural health-care services in education
and practice by consumers worldwide.
4. Transcultural research findings in health-care
services will be imperative to support, justify,
and respond to meaningful health-care services.
5. There will be a marked increase in the use of human life experiences, religious ideas, spiritual
beliefs, and historical data and environmental
knowledge for food and well-being.
6. Transcultural ethical and moral issues will
markedly increase as nurses, physicians, ethicists, and other disciplines struggle with justice,
human rights, birth, death, and many genetic
engineering issues.
7. Transcultural health education, consultation,
and clinical practices will necessitate becoming
a reality due to demands from diverse cultures.
8. Transcultural health-care and treatment policies
will be essential to attract and retain consumers
in using future health-care services.
9. As hospital services decrease by the year 2015
and new community services increase, transcultural control and regulation by cultural consumers will be evident.
10. Transworld corporations will become active in
marketing transcultural health services and
other products by the year 2010.
11. Many underrepresented (or minority) cultures
today will become majority cultures in the
decades to come, which will necessitate
major changes in education, research, and practice.

12. Transcultural distance in learning, consultation,
and educational policies will significantly increase within countries but also across countries
to remote places in the world. While electronic
communication modes will be important, one
will find that many cultures will want to promote peace and have fewer intercultural wars.
13. Theory development will change from a
present-day reliance on a few variables to multiple holistic theories. Mini- and middle-range theories will decrease as they will be viewed as too
limited to deal with complex and holistic data.
Qualitative paradigmatic research will increase
in value and uses with computer models to handle large amounts of rich transcultural findings.
References
Leininger, M. (1970). Nursing and anthropology:Two
worlds to blend. New York: John Wiley and Sons.
Leininger, M. (1976). Transcultural nursing presents an
exciting challenge. The American Nurse, 5(5), 69.
Leininger, M. (1977). Caring: The essence and central
focus of nursing. Nursing Research Foundation Report, 12(1), 214.
Leininger, M. (1978). Transcultural nursing: Concepts,
theories, and practices. New York: John Wiley and
Sons.
Leininger, M. (1981). Caring:An essential human
need. Thorofare, NJ: Slack.
Leininger, M. (1984). Care:The essence of nursing and
health. Thorofare, NJ: Slack.
Leininger, M. (1985). Qualitative research methods in
nursing (pp. 3373). Orlando, FL: Grune & Stratton
Co.
Leininger, M. (1988). Care: Discovery and uses in clinical and community nursing. Detroit: Wayne State
University Press.
Leininger, M. (1989a). Transcultural nursing: Quo vadis
(where goeth the field)? Journal of Transcultural
Nursing, 1(1), 3345.
Leininger, M. (1989b). Transcultural nurse specialists
and generalists: New practitioners in nursing. Journal of Transcultural Nursing, 1(1), 416.
Leininger, M. (1990a). Transcultural nursing: A worldwide necessity to advance nursing knowledge and
practices. In McCloskey, J. & Grace, H. (Eds.), Current issues in nursing. St. Louis: Mosby.
Leininger, M. (1990b). Culture: The conspicuous missing link to understand ethical and moral dimensions
of human care. In Leininger, M. (Ed.), Ethical and
moral dimensions of care. Detroit: Wayne State University Press.
Leininger, M. (1990c). Ethnomethods: The philosophic
and epistemic basis to explicate transcultural nursing knowledge. Journal of Transcultural Nursing,
1(2), 4051.
Leininger, M. (1990d). Care: Ethical and moral dimensions of care. Detroit: Wayne State University Press.
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Leininger, M. (1991). Culture care diversity and universality:A theory of nursing. New York: National
Leininger, M. (1995). Transcultural nursing: Concepts,
theories, research, and practice. Columbus, OH:
McGraw Hill College Custom Series.
Leininger, M. (1997a). Overview of the theory of
culture care with the ethnonursing research
376
method. Journal of Transcultural Nursing, 8(2),

3253.
Leininger, M. (1997b). Transcultural nursing research to
transform nursing education and practice: 40 years.
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Leininger, M., & Hofling, C. (1960). Basic psychiatric
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Chapter 21
Part 2
The Ethnonursing Research

Method and the Culture
Care Theory: Implications for
Clinical Nursing Practice
The Ethnonursing Research Method
Culture Care Theory and Nursing Practice
Summary
References
Marilyn R. McFarland
The purpose of the second part of Chapter 21 is

twofold. The first part will include an overview of
the ethnonursing research method, which was designed to study the Theory of Culture Care Diversity
and Universality. The second part will present a discussion of the implications of the culture care theory
and related ethnonursing research findings for clinical nursing practice. Many nursing theories are
rather abstract and do not focus on how practicing
nurses might use the research findings related to a
theory. However, with the culture care theory, along
with the ethnonursing method, there is a purposeful
built-in action means to discover and confirm data
with informants in order to make nursing actions and
decisions meaningful and culturally congruent (Leininger, 1991a).
THE ETHNONURSING
RESEARCH METHOD
The ethnonursing research method was specifically
designed by Leininger (1985, 1991b) to study the
culture care theory. This was the first research
method designed to study a nursing theory and related nursing phenomena. The method facilitates the
discovery of people care knowledge and culturally
based care related to the theory. Leininger (1991b,
p. 79) has defined the ethnonursing research
method as a qualitative research method using naturalistic, open discovery, and largely inductively derived emic modes and processes with diverse strategies, techniques, and enabling tools to document,
describe, understand, and interpret the peoples
meanings, experience, symbols, and other related
aspects bearing on actual or potential nursing phenomena.
Qualitative Paradigm
and Quantitative Paradigm
In order to grasp an understanding of the qualitative
ethnonursing research method, it is important to understand the major philosophical differences between the qualitative and quantitative paradigms.
Leininger has described qualitative paradigmatic
research as characterized by naturalistic and open
inquiry methods and techniques focused on systematically documenting, analyzing, and interpreting attributes, patterns, characteristics, and meanings of
specific domains and gestaltic (or holistic) features of
phenomena under study within designated environmental or living contexts (Leininger, 1997). She has
described quantitative research as characterized by
a focus on an empirical and objective analysis of dis-
378
crete and preselected variables that have been derived a priori and as theoretical statements or hypotheses in order to determine causal and measurable relationships among the variables being tested
(Leininger, 1997, p. 43). In qualitative research there
is no control of informant ideas or manipulation of
data or variables by the researcher; only open inquiry prevails to obtain data directly and naturally
from informants in their own homes, communities,
or other natural environmental contexts. In contrast,
in quantitative research precise measurements are
obtained and specific causal relationships among
variables are sought. Leininger has stated that the
quantitative and qualitative paradigms should The ethnonursing method is a
not be mixed as they
violate the philosophy, unique qualitative method to
purposes, and integrity study caring and healing
of each paradigm. The
practices and beliefs in
ethnonursing method is
a unique and essential diverse cultural contexts.
qualitative method to
It is designed specifically for
study caring and healing
practices, beliefs, and the culture care theory.
values in diverse cultural and environmental contexts and is a major
holistic method specifically designed to fit the culture care theory.
Purpose and Philosophical Features

Leininger developed the ethnonursing research
method from a nursing and cultural care perspective
to discover largely unknown phenomena held essential to practice nursing. She has stated that ethnonursing method is used (1985, 1991b) to systematically document and gain greater understanding
and meaning of the peoples daily life experiences
related to human care, health, and well-being in different or similar environmental contexts (1991b,
p. 78). The central purpose of the ethnonursing research method is to establish a naturalistic and
largely emic open inquiry method to explicate and
study nursing phenomena especially related to the
Theory of Cultural Care Diversity and Universality
(1991b, p. 75). The term ethnonursing was purposefully coined for this method. The prefix ethno
comes from the Greek word ethos and refers to the
people, while the suffix nursing is essential to focus
the research on the phenomena of nursing, particularly human care, well-being, and health in different
environments and cultural contexts (Leininger,
1991b).
The ethnonursing research method has philosophical and research features that fit well with the
culture care theory. Philosophically, the ethnonursing method has been grounded with the people
(Leininger, 1991b) and has supported the discovery
of people truths in human living contexts (Leininger,
1988). This research method was designed to tease
out complex, elusive, and largely unknown nursing
dimensions from the local peoples viewpoints of human care, well-being and health, and environmental
contexts. The terms emic and etic were important
concepts chosen for foci with the ethnonursing
method. Ethnonursing focuses largely on the importance of emic (insiders or local peoples) views but
does not neglect etic (the nonlocal or outsiders)
views to obtain a holistic view. For instance, one ethnonursing researcher gathered emic data from elderly retirement home residents on their ideas and
experiences with care but also gathered etic data focused on the professional perspectives of the nursing staff (McFarland, 1997). The culture care theory
has been developed to be congruent with the ethnonursing method and requires the researcher to
move into familiar and naturalistic people settings to
discover human care and the related nursing phenomena of health (well-being), illness, and other
phenomena within an environmental context (Leininger, 1991b, p. 85).
Domain of Inquiry
A domain of inquiry is the major focus of the ethnonurse researchers interests. A domain of inquiry is
broad and yet focused to obtain specific care and
health outcomes of a culture with a nursing perspective. With the ethnonursing method, problem statements are not used because a researcher does not
know whether there is a people problem or more of
a researchers problem of selected (and possibly biased) views of the people (Leininger, 1997). For example, some domains of inquiry in ethnonursing
studies using the culture care theory have been: (1)
TABLE 21-1
Phases
Description
the care meanings and experiences of Lebanese Muslims living in the United States in a designated urban
context (Luna, 1994), (2) the cultural care of elderly
Anglo- and African-American residents within the environmental context of a long-term care institution
(McFarland, 1997), and (3) the care of MexicanAmerican women during pregnancy (Berry, 1999).
Key and General Informants

Key and general informants are important in the ethnonursing research method. The research using this
method does not have subjects, but works with informants. In an ethnonursing study of the culture
care of Anglo- and African-American elderly residents
of a retirement home (McFarland, 1997), the researcher worked with the elders and nursing staff
members as key and general informants. They told
the researcher about themselves and the cultural
care within the environmental context of a retirement home. Key informants were carefully and purposefully selected (often by the people themselves,
e.g., elderly residents suggested other residents for
the researcher to observe, interview, and study
about care, health, and well-being). These informants were most knowledgeable about the domain
of inquiry and could give details to the nurse researcher. General informants usually are not as fully
knowledgeable about the domain of inquiry as the
key informants. They have general ideas about the
domain, however, and can offer data from their emic
and etic views. For instance, general informants can
reflect on how similar and/or different their ideas are
from those of the key informants when asked by the
researcher.
Enablers
In order to discover the peoples (or informants) innermost world of knowing, Leininger developed sev-
Leiningers Ethnonursing Observation-ParticipationReflection Phases

1
Primary
observation and
active listening
(no active
participation)
Primary
observation
with limited
participation
3
Primary
participation
with continued
observations
4
Primary
reflection and
reconfirmation of
findings with
informants
Source: Leininger, M. (1997). Overview and reflection of the Theory of Culture Care and the Ethnonursing Research
Method. Journal of Transcultural Nursing, 8(2), 3251.
Chapter 21 Marilyn R. McFarland Implications of Ethnonursing Research Method
379
TABLE 21-2
Leiningers Stranger to Trusted Friend Enabler Guide
The purpose of this enabler is to facilitate the researcher (or clinician, who can also use it) to move from a mainly distrusted
stranger to a trusted friend in order to obtain authentic, credible, and dependable data or establish favorable relationships
as a clinician. The user assesses himself or herself by reflecting on the indicators as he or she moves from stranger to
friend.
Indicators of Stranger
(Largely etic or outsiders views)
Date
Noted
Indicators of a Trusted Friend

(Largely emic or insiders views)
Active to protect self and others. They are

gatekeepers and guard against outside
intrusions. Suspicious and questioning.
Less active to protect self. More trusting of

researchers (their gatekeeping is down or less).
Less suspicious and less questioning of
researcher.
Actively watch and are attentive to what

researcher does and says. Limited signs of
trusting the researcher or stranger.
Less watching of the researchers words and

actions. More signs of trusting and accepting a
new friend.
Skeptical about the researchers motives and

work. May question how findings will be used by
the researcher or stranger.
Less questioning of the researchers motives,

work, and behavior. Signs of working with and
helping the researcher as a friend.
Reluctant to share cultural secrets and views as

private knowledge. Protective of local lifeways,
values, and beliefs. Dislikes probing by the
researcher or stranger.
Willing to share cultural secrets and private

world information and experiences. Offers most
local views, values, and interpretations
spontaneously or without probes.
Uncomfortable to become a friend or to confide in

stranger. May come late, be absent, and
withdraw from researcher at times.
Signs of being comfortable and enjoying friends

and a sharing relationship. Gives presence, is on
time, and gives evidence of being a genuine
friend.
Tends to offer inaccurate data. Modifies truths to

protect self, family, community, and cultural
lifeways. Emic values, beliefs, and practices are
not shared spontaneously.
Wants research truths to be accurate regarding

beliefs, people, values, and lifeways. Explains and
interprets emic ideas so researcher has accurate
data.
Date
Noted
Source: Leininger, M. (1991). Culture care diversity and universality: A theory of nursing. New York:
National League for Nursing, p. 82.
eral enablers to tease out data bearing on cultural

care related to specific domains of study. As the word
denotes, enablers help ease out ideas from informants in meaningful and natural ways. Leininger
(1997) specifically makes the point that enablers are
different than tools, scales, or measurement instruments used in quantitative studies, which tend to cut
off natural flow of informant ideas. Some of the enablers that serve as important guides to obtain data
naturalistically and holistically are: (1) Leiningers observation participation reflection enabler (Table
211); (2) the stranger to trusted friend enabler
(Table 212); (3) Leiningers acculturation enabler
(Leininger, 1991b); and (4) specific enablers developed by the researcher to tap ideas of informants related to the specific domain of inquiry (Figure 212).
380
The Sunrise Model (see Part 1 of this chapter by Dr.

Leininger and the discussion under the Three Care
Modes later in this chapter) can also be viewed as
an enabler since it assists and guides the researcher
to tease out culture care and health data within
each dimension of the Sunrise Model to provide
holistic and yet specific cultural findings (Leininger,
1997).
The observation participation reflection enabler
(Table 211) guides the nurse researcher to be an active observer and listener before being a participant
in any research context. Researchers have found it
most helpful to observe informants and their environmental contexts before and after the researcher
becomes an active participant. This is quite different
from the traditional participant observation method
used in anthropology, because the process is reversed (Leininger, 1997). Nurses who are used to doing something actively for or with clients must stop
and observe before actively participating with informants with this method.
The stranger to trusted friend enabler (Table
212) has been extremely helpful as a researcher enters and remains in a strange and unfamiliar environment. The researcher moves from being a stranger to
a trusted friend and can eventually obtain accurate,
honest, credible, and in-depth data from informants.
Several ethnonurse researchers have found that
when informants considered the researcher a trusted
friend, the findings were very different from those
found by a stranger (Berry, 1999; Luna, 1994; McFarland, 1997). Being a trusted friend leads to informants sharing their cultural secrets and their insights
and experiences. For instance, the author used the
stranger friend enabler to assess her relationship
with elderly residents and the staff in a study of cul-
ture care in a retirement home. She used this enabler

to enter the informants world and get close to the
people who were being studied (McFarland, 1997).
Initially the researcher worked with a staff nurse
while observing and interviewing the informants for
the first few weeks she was in the institution. The
staff nurse was friendly and acted as a guide but also
watched the researcher and planned her day in a general way. The researcher knew she had moved from
being a stranger to a trusted friend when the director
of nursing said, You are on your own today; you
know several residents really look forward to your
visits. After the researcher had been at the research
site for several months, an elderly Anglo-American
resident informant said to her, Im really revealing
myself to you today, and then went on to describe
her negative feelings about the increasing numbers
of African-Americans coming to live at the retirement
home. The researcher had moved from a stranger to a
trusted friend; the informant revealed meaningful
381
your thoughts
and sensitive information to her, and the informant

felt safe and trusted the researcher. This enabler is invaluable to gauge ones relationship with informants
as the study progresses.
Leiningers acculturation enabler (Leininger,
1991b) has been used in many ethnonursing studies
to identify traditional and nontraditional beliefs, values, and general lifeways of informants. This enabler
is useful with all informants, but especially with immigrant groups undergoing rapid cultural changes.
The Sunrise Model was also developed as an enabler
to help researchers discover multiple and diverse
holistic lifeways related to culture care experiences
and practices. It is unique as a guide for holistic yet
specific factors influencing care in cultures under
study within an ethnohistory, language, social structure, and environmental context (Leininger, 1991b,
1995, 1997).
In addition to the four enablers just discussed, the
ethnonurse researcher develops a special enabler
that fits with the specific domain of inquiry under
study, such as the care meanings and experiences
of Lebanese Muslims (Luna, 1989), the culture care
of Anglo- and African-American elders (McFarland,
1997), and the culture care of pregnant MexicanAmerican women (Berry, 1996). These enablers
were specifically designed by the researchers to help
tease out in-depth specific details of culture care
phenomena related to the theoretical assumptions
and the domain of inquiry of the study. Examples of
special enablers can be found in the studies mentioned above and in other ethnonursing research
studies listed in the references at the end of this
chapter and in the Journal of Transcultural Nursing
(1989 to 1999). The complete text of an enabler, The
Experience of Mexican Americans Receiving Profes-
382
sional Care: An Open Inquiry Guide, has been published in the Journal of Transcultural Nursing
(Zoucha, 1998, pp. 4244).
Qualitative Criteria to Evaluate

Ethnonursing Studies
Leininger has developed specific criteria to evaluate
qualitative research, including ethnonursing studies.
Because qualitative studies have very different meanings and purposes, goals, and outcomes from quantitative studies, the nurse researcher is required to use
qualitative criteria to evaluate ethnonursing research
studies (Leininger, 1991b, 1995). Leiningers (1997)
succinct definitions of qualitative criteria are as follows:
1. Credibility: Refers to direct evidence from the
people and the environmental context as truths
to the people.
2. Confirmability: Refers to documented verbatim
evidence from the people who can firmly and
knowingly confirm the data or findings.
3. Meaning-in-Context: Refers to meaningful or understandable findings that are known and relevant to the people within their familiar and natural living environmental contexts.
4. Recurrent Patterning: Refers to documented evidence of repeated patterns, themes, and acts
over time reflecting consistency in lifeways or
patterned behaviors.
5. Saturation: Refers to in-depth evidence of taking
in all that can be known or understood about
phenomena or a domain of inquiry under study
by the informants.
6. Transferability: Refers to whether the findings
from the study will have similar (not identical)
TABLE 21-3
Leiningers Phases of Ethnonursing Analysis

for Qualitative Data
Fourth Phase
Major Themes, Research Findings, Theoretical Formulations, and Recommendations
This is the highest phase of data analysis, synthesis, and interpretation. It requires synthesis of thinking, configurations,
analysis, interpreting findings, and creative formulations from data of the previous phases. The researchers task is to
abstract and present major theses, research findings, recommendations, and sometimes theoretical formulations.
Third Phase
Pattern and Contextual Analysis
Data are scrutinized to discover saturation ideas and recurrent patterns of similar or different meanings, expressions,
structural forms, interpretations, or explanations of data related to the domain of inquiry. Data are examined to show
patterning with respect to meanings-in-context and along with further credibility and confirmation of findings.
Second Phase
Identification and Categorization of Descriptors and Components
Data are coded and classified as related to the domain of inquiry and sometimes the questions under study. Emic or etic
descriptors are studied within context and for similarities and differences. Recurrent components are studied for their
meanings.
First Phase
Collecting, Describing, and Documenting Raw Data (Use of Field Journal and Computer)
The researcher collects, describes, records, and begins to analyze data related to the purpose, domain of inquiry, or
questions under study. This phase includes recording interview data from key and general informants; making observations
and having participatory experiences; identifying contextual meanings; making preliminary interpretations; identifying
symbols; and recording data related to the phenomena under study, mainly from an emic focus, but attentive to etic ideas.
Field data from the condensed and full field journal are processed directly into the computer and coded.
Source: Leininger, M. (1991). Culture care diversity and universality: A theory of nursing New York: National
League for Nursing (p. 95).
meanings and relevance in a similar situation or

context (pp. 4445).
Each of these criteria needs to be used thoughtfully and explicitly in a systematic and continuous
process while obtaining data or observing informants over periods of time.
Four Phases of Ethnonursing

Analysis for Qualitative Data
Leininger (1997) has developed the phases of ethnonursing qualitative data analysis (Table 213). The
four phases provide for systematic ongoing data
analysis, which is from the beginning of data collection until the final analysis and completion of the
written report of the research findings. The Leininger
Templin Thompson (LTT) Qualitative Software Data
Program (or a similar one) can be used to process the
qualitative data. The first two phases of data analysis
are focused on obtaining raw data and beginning indicators of the phenomena under study. The third
phase of data analysis requires that the researcher

identify recurrent patterns, and in the fourth phase
the focus is on developing and synthesizing major
themes derived from the previous sequential three
phases. A research mentor skilled in the ethnonursing method can help the researcher to reflect on the
major phases and to meet the qualitative evaluation
criteria. Themes must be clearly stated to provide
guidance to assist nurses in providing culturally congruent and relevant care for people from diverse cultures or subcultures. Themes are the dominant finding from the analysis, and thematic statements
require much critical and analytic thinking to accurately reflect the emic and etic raw data and holistic
findings.
The Steps in the Ethnonursing

Research Process
The general research process of conducting an ethnonursing study is presented as a guide. The process
may be modified to fit with the research setting or
383
your thoughts
context. The research process needs to be flexible so

the researcher can move with the people and be
open to make allowances or change plans in accord
with naturalistic developments. As the researcher
moves from stranger to friend to collect and process
research data, modifications in the research plan often become necessary. The phases of the ethnonursing research method developed by Leininger (1991b,
p. 105) are as follows:
1. Identify the general intent or purpose(s) of your
study with a focus on the domain(s) of inquiry
phenomenon under study, area of inquiry, or research questions being addressed.
2. Identify the potential significance of the study to
advance nursing knowledge and practice.
3. Review available literature on the domain or phenomena being studied.
4. Conceptualize a research plan from the beginning to the end with the following general phases
or sequence of factors in mind:
a. Consider the research site, community, and
people to study the phenomena.
b. Deal with the informed consent expectations.
c. Explore and gradually gain entry (with essential permissions/informed consent) to the community, hospital, or country where the study is
being done.
d. Anticipate potential barriers and facilitators related to getekeepers expectations, language,
political leaders, location, and other factors.
e. Select and appropriately use the ethnonursing
enablers with the research process; for example, Leiningers Stranger-Friend Guide, Observation-Participation-Reflection Guide, and others. The researcher may also develop enablers
as guides for their study.
384
5.
6.
7.
8.
f. Chose key and general informants.

g. Maintain trusting and favorable relationships
with the people conferring with ethnonurse
research experts to prevent unfavorable developments.
h. Collect and confirm data with observations,
interview, participant experiences, and other
data. (This is a continuous process from the
beginning to the end and requires the use of
qualitative research criteria to confirm findings
and credibility factors.)
i. Maintain continuous data processing on computer and with field journals, depicting active
analysis and reflections and discussions with
research mentor(s). Computer processing
with Leininger Templin Thompsons software
is a helpful means of handling large amounts
of qualitative data.
j. Frequently present and reconfirm findings
with the people studied to check credibility
and confirmability of findings.
k. Make plans to leave the field site, community,
and informants in advance.
Do final analysis and writing of research findings
soon after completing the study.
Prepare published findings in appropriate journals.
Help implement the findings with nurses interested in findings.
Plan future studies related to this domain or other
new ones.
Again, there is flexibility with the ethnonursing

data processing, but the above steps help to conceptualize the process to do a systematic investigation
that has credibility and meets other qualitative evaluation criteria.
CULTURE CARE THEORY

AND NURSING PRACTICE
Over the past four decades, the culture care theory,
along with the ethnonursing method, have been
used by nurse researchers to discover knowledge
that can and has been used in nursing practice.
Nurses can use such knowledge not only to care for
individual clients, but also to focus on care practices
for families, groups, communities, cultures, and institutions that are beneficial. Our multicultural world
has made it imperative that nurses understand different cultures to work and care for people who have
diverse and similar values, beliefs, and ideas about
nursing, health, caring, wellness, illness, death, and
disabilities (Leininger, 1991a, 1995). As stated in the
first part of this chapter by Dr. Leininger, the goal of
the Theory of Culture Care Diversity and University is
to improve or maintain health and well-being by providing culturally congruent care to people that is
beneficial and fits with the lifeways of the client,
family, or cultural group. The Sunrise Model serves as
a cognitive map depicting the seven culture and social structure dimensions that influence care, which
in turn influences the health and/or illness of clients.
The culture care theory
The term nursing interven- and the Sunrise Model
include what is similar
tion often implies to clients (universal) and differfrom different cultures that ent (diverse) between
generic (or folk) care
the nurse is imposing his or and professional care
her views, which may not and provides a focus on
both types of care for
be helpful. the provision of culturally congruent care for
clients in diverse nursing practice settings. Leininger
predicted that if culturally congruent care was evident, this would prevent cultural clashes, cultural illnesses, and other unfavorable human conditions under human control (Leininger, 1991a). These general
ideas are kept in mind as one uses findings related to
the theory in clinical practice.
The Three Care Modes

and the Sunrise Model
To provide a different focus from traditional nursing,
Leininger developed the unique three modes of care
to incorporate theory findings (Sunrise Model, Figure 211). To review, the three modes are: (1) culture care preservation or maintenance, (2) culture
care accommodation or negotiation, and (3) culture
care repatterning or restructuring. The theorist predicts that the researcher can use ethnoresearch findings to guide nursing judgements, decisions, and actions related to providing culturally congruent care
(Leininger, 1991a). Leininger prefers not to use the
phrase nursing interventionbecause 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 is used, but always with the clients
helping to arrive at whatever actions or decisions are
implemented. The modes fit with the clients or
peoples lifeways and yet are therapeutic and satisfying for them. The nurse can draw upon scientific
nursing, medical, and other knowledge with each
mode.
Data collected from the upper and lower parts of
the Sunrise Model provide culture care knowledge
for nurse researchers to discover and establish useful
ways to provide quality care practices. Active participatory involvement with clients is essential to arrive
at culturally congruent care with one or all of the
three action modes in order 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 transcultural
and general nursing practice with clients of diverse
cultures.
It is most important (and a shift in nursing) to
carefully focus on the holistic dimensions as depicted in the Sunrise Model to arrive at therapeutic
culture care practices. All the factors in the Sunrise
Model (which include worldview, and technological,
religious, kinship, political/legal, economic, and educational factors, as well as cultural values and lifeways, environmental context, language, ethnohistory,
and generic [folk] and professional care practices)
(Leininger, 1991a) must be considered to arrive at
culturally congruent care. Only when the nurse in
clinical practice (in a community, home, or institutional context) becomes fully aware of and explicitly
uses knowledge generated from the theory and ethnonursing method will care become safe, congruent,
meaningful, and beneficial to clients. The culture
care theory, along with the ethnonursing method,
are a powerful means for new directions and practices in nursing. Incorporating culture-specific care
into clients care is essential today and in the future
to practice professional care and to be licensed as
registered nurses. Culture-specific care is the safe
means to ensure culturally based holistic care to fit
the clients culturea major new challenge for
nurses who practice and provide services in all
health-care settings.
385
The Use of Culture Care

Research Findings
Culture Care of Lebanese

Muslims in the United States
Over the past four decades, Dr. Leininger and other

research colleagues have used the culture care
theory and the ethnonursing method to focus on the
meanings and lived experiences of 87 cultures, and
discovered 187 care constructs in Western and nonWestern cultures (Leininger, 1998), as reported in
the Journal of Transcultural Nursing (1989 to
1999). Leininger listed the 11 most dominant constructs of care in priority ranking, with the most universal or frequently discovered first: (1) respect
for/about (most universal care construct); (2) concern for/about; (3) attention to/with anticipation of;
(4) helping, assisting, and facilitative acts; (5) active
listening; (6) giving presence (being there physically); (7) understanding the cultural beliefs, values,
and lifeways of clients; (8) being connected to/relatedness; (9) protection of/for some gender and kin
differences; (10) touching (how, where, and when
varied); and (11) providing comfort measures. These
care constructs are the most critical and important
universal or common findings to consider in nursing
practice, but care diversities must also be considered. Although many of these dominant care constructs may be found in certain cultures, diversities
will also be found. The ways in which culture care is
applied and used in specific cultures will reflect
both similarities and differences among (and sometimes within) different cultures. Next, three ethnonursing studies will be reviewed with a focus on
the findings, which have implications for nursing
practice.
In the late 1980s, Luna conducted an ethnonursing

study of the culture care of Arab Muslim cultural
groups in a large urban community in the midwestern United States. In 1989, she published the findings relevant to the culture care of Lebanese Muslim
Americans using Leiningers three modes of nursing
decisions and actions to provide culturally congruent
and responsible care. The study focused on the care
for Lebanese Muslims in the hospital, clinic, and
home-community contexts. She stated: [An] understanding [of] the cultural context in which Lebanese
Muslims attempt to adapt, survive, and practice their
faith in America necessitates a look into the community into which they migrate (Luna, 1994, p. 15).
Lunas research findings and the nursing practice implications related to the home and community context in the late 1980s remain important today as
health care shifts from hospital care services to home
or community settings. Luna discovered that attending a clinic in an urban context (in the midwestern
United States) was often a new and different approach to health care for Lebanese Muslim women,
especially during pregnancy and childbirth. Lunas
study revealed that many women relied on the traditional midwife in Lebanon for home deliveries. The
routine of monthly and weekly visits to the prenatal
clinic was incongruent with what the client had experienced in her home country. In the United States,
prenatal care in the clinic context involved long waiting periods with the husband missing work to take
his wife to the clinic. Examination by a male physi-
your thoughts
386
cian was culturally incongruent for the women, so

culture care negotiation and repatterning was essential for culturally congruent care. Luna described
the clinic as culturally decontextualized for clients
and their families because the prenatal care and the
environmental clinic context in which the care was
provided were not congruent with the clients cultural values, beliefs, and practices (Luna, 1989).
Luna discovered the dominant and universal care
constructs for Lebanese Muslim men, which included surveillance, protection, and maintenance of
the family. For Lebanese women, the dominant and
universal care constructs included emphasizing the
positive attributes of educating the children and
maintaining a family caring environment according
to the precepts of Islam. A number of generic or folk
care practices were discovered related to these care
constructs that should be recognized, preserved,
and maintained by nurses to enhance the health and
well-being of clients. For instance, the female network in the Lebanese Muslim culture is very important at the time of birth; Lebanese women come together to care for each other and offer practical and
emotional assistance for new immigrants who are
struggling to survive in a new cultural context such
as the United States. Hence, by recognizing the benefits of this network and by allowing women flexibility in their visiting and presence in the hospital and
clinic contexts, the nurse would use culture care
preservation to maintain these generic care practices
for the health and well-being of clients.
Luna found that female modesty was an important
cultural care value for Lebanese women; this was reflected in requests by female clients to have only
female nurses, physicians, and other caregivers. Culture care accommodation of this generic care practice was accomplished by nurses negotiating for
these women to have female caregivers whenever
possible, which would promote health, well-being,
and client satisfaction with care. Including Lebanese
Muslim men in health teaching and discharge planning was a way Luna discovered to use culture care
preservation that recognized the family as a unit,
rather than focusing on the individual. Luna recognized that the patriarchal organization of the family
should be preserved as a social structure feature,
which acknowledges males for their roles in family
care continuity rather than being narrowly interpreted as males always being in control. Negative
stereotypes about the Arab males reluctance to
participate in the birth process were discovered
often to be a barrier in giving nursing care. To
counter this, Luna suggested the nurse could use cul-
ture care preservation to maintain and support the

generic culture care practices of men, which included surveillance, protection, and maintenance of
the family.
Still another finding from Lunas study was the discovery of the importance of religious rituals to many
Muslim clients as an essential component of providing care within their cultural context (Luna, 1989,
1994). Luna found that some Muslims pray three to
five times a day, and others do not pray at all. During
the culturalogical assessment (in the hospital context), Luna suggested the nurse should ask about the
clients wishes regarding prayer, and could practice
cultural care accommodation by negotiating for time
and a private place for prayer which for many Muslims is an important cultural expression for their
health and well-being. She also suggested that nurses
should practice cultural care accommodation for
clients by negotiating with a social service organization which served Arab clients in order to gather
written and video materials in the Arabic language related to health to be used in the hospital and clinic
settings. Luna (1989) identified culture care repatterning to improve attendance at the prenatal clinic
for Lebanese Muslim women. Nurses should avoid direct confrontation and spend considerable time during the first clinic visit to educate women regarding
the benefits of regular prenatal care, including emphasizing the health and well-being of both the
mother and the baby.
Culture Care of Elderly

Anglo- and African Americans
In the mid-1990s the theory of culture care was used
to guide a study of the culture care of Anglo- and
African-American elders in a long-term care institution (McFarland, 1997). This study revealed care implications for nurses who practice in retirement
homes, nursing homes, apartments for the aged, and
other long-term care settings. Many residents from
both cultural groups participated in the care of their
fellow residents. Residents assisted other residents to
the dining room, checked on others who did not appear for meals in the dining room (care as surveillance of others), and assisted in ambulation of those
who were not able to walk independently. This focus
on other care versus only self-care was a form of cultural congruent care that residents desired in order
to maintain healthy and beneficial lifeways in an institutional setting. Culture care preservation was practiced by nursing staff as these generic care practices
were integrated into professional nursing care.
387
Within the retirement home, both Anglo- and

African-American residents desired spiritual or religious care and had some diverse aspects of such care
rooted in their respective cultures. The findings of
both universality and diversity within the pattern of
religious or spiritual care supported Leiningers
theory, which states that culture care concepts,
meanings, expressions, patterns, processes, and
structural forms of care are different (diversity) and
similar (toward universality) among all cultures of
the world (Leininger, 1991a, p. 45). African-American residents received care from church friends who
ran errands, did banking, paid bills, did laundry, visited, and brought communion to them. Anglo-American residents received a more formal type of care
from their churches, such as a minister coming to
the retirement home to do a worship service or a
church choir traveling to the retirement home to entertain the residents. The nurses at the retirement
home practiced culture care preservation by maintaining the involvement of churches in the daily lives
of both cultural groups to help residents face living
in a retirement home with increasing disabilities related to aging and handicaps, and even with the
prospect of death. With an increase in the numbers
of elderly from both the Anglo- and African-American
cultural groups being admitted to long-term care institutions, the knowledge of culture-specific care for
both Anglo- and African-American elders is important
to nurses who practice in these settings.
The generic care pattern of families helping their
elderly relatives enhanced the health and lifeways of
both Anglo- and African-American elders in the retirement home setting. Anglo-American residents
received help from their spouses and/or adult children. In contrast with the Anglo-American findings,
African-American spouses and children, extended
family members, and nonkin who were considered
family reflected the care pattern of families helping
elderly residents. Grandchildren, great-grandchildren,
nieces, nephews, grandnieces, and grandnephews,
as well as church members or friends who were considered family and referred to as brothers, sisters, or
daughters, were involved in caring for African-American elders. The nursing staff recognized the importance of family involvement in the care of residents
and practiced culture care preservation to maintain
culture-specific family care practices for residents
from each cultural group.
The care pattern of protection was important to
African-American residents but not to Anglo-American residents. Most African-American residents had
left homes that were in unsafe neighborhoods and
had moved in part for that reason. African-American
388
nursing staff recognized the importance of protective care and often accompanied African-American
residents when they wanted to go outside. The nursing staff made efforts to practice culture care accommodation by negotiating to take the residents outside
to sit on the small grass strip around the perimeter of
the parking lot of the home. McFarland (1997) also
discovered that the nursing care and the lifeways of
elderly residents in the nursing home setting were
less satisfying than in the apartment setting within
the retirement home context. Professional nurses
need to be involved in culture care repatterning as
coparticipants with elders to restructure lifeway
practices, care routines, and the environmental context of nursing homes (including room designs and
privacy considerations). Culture care restructuring
of these care-related concerns can only be accomplished by nurses assuming an advocacy role for the
elderly residents and working with governmental
and private agencies that provide the funding and
make the rules and regulations that affect long-term
care. The culture care theory, along with the ethnonursing method, assisted the researcher in this
study to discover action and decision modes that
were culturally specific for Anglo- and African-American elders residing in a long-term care institution.
Culture Care of MexicanAmerican Pregnant Women

In the late 1990s, Berry studied the generic and professional nursing care of pregnant Mexican-American
women in an urban area of southern California. Cultural care values and practices related to religion,
family, respect, and generic care were found to be of
particular importance to the informants (Berry,
1999). Spiritual beliefs and the extended family network were major sources of strength and provided
support for Mexican-American women throughout
pregnancy. There was a universal pattern among
both key and general Mexican-American informants
that revealed a fatalistic worldview in which individuals did not have control over their lives but had faith
that God would protect them. Berry discovered that
assisting in the provision of religious advisors and
providing time for prayer when desired in the hospital context would demonstrate culture care maintenance by preserving the cultural values and practices
related to religion for this cultural group.
Involvement of the Mexican-American family in
care during pregnancy was a universal cultural care
value and practice, which demonstrated the care pattern of concern for pregnant women. Berry discovered that it was important that nurses practice cul-
ture care accommodation by negotiating for family

participation in the care of pregnant women in both
clinic and hospital contexts. Berry found that some
male partners in the Mexican-American culture may
want to be present during the birth process to provide care as protection and support, but may not
want to be actively involved in direct care practices.
Mexican-American women often also desired female
family members such as mothers and sisters to be
present (care as presence), which may be counter to
the usual hospital labor room practice of limiting
participants in the United States. Berry suggested
that nurses could provide culturally congruent care
through the practice of culture care accommodation
by negotiating with family and staff to arrange for
multiple family members to be present in the delivery area as well as on the postpartum units.
Berry discovered that the Spanish language was
an important part of cultural care for Mexican-American women. As a sign of respect, bilingual nurses
could practice culture care accommodation by offering a choice of languages when speaking with clients,
and developing enablers with common phrases in
Spanish and English with pictures could greatly facilitate communication. Health-care institutions with
large Latino populations might consider culture care
accommodation by offering a course on the Spanish
language for the nurses.
There was little need for professional nurses to
use the mode of culture care repatterning or restructuring for childbearing Mexican-American women,
because the majority of generic care practices for
pregnancy in this culture, such as herbal remedies,
activity levels, or the wearing of metal during an
eclipse, were either discovered to be health promoting or not harmful. However, Berry discovered that,
although many Mexican-American foods and eating
patterns are healthy, some, such as the belief that
large food consumption during pregnancy is necessary, could contribute to obesity and medical or obstetrical complications. Nurses could practice culture care restructuring by helping Mexican-American
women to repattern their dietary consumption by
considering culturally congruent alternatives. For example, educational emphasis could be placed on the
Mexican-American cultural belief that one should eat
well for the health of the baby when discussing an
appropriate diet for pregnancy.
Summary
The purpose of the culture care theory has been to
discover culture care (along with the ethnonursing
method) with the goal of using the knowledge to

combine generic and professional care to provide
culturally congruent nursing care (using the three
modes of nursing actions and decisions) that is meaningful, safe, and beneficial to people of similar and
diverse cultures worldwide (Leininger, 1991a, 1995).
The clinical use of the three major care modes (culture care preservation or maintenance, culture care
accommodation or negotiation, and culture care
repatterning or restructuring) by nurses to guide
nursing judgements, decisions, and actions is essential in order to provide culturally congruent care that
is beneficial, satisfying, and meaningful to the people nurses serve. The studies of the four cultures just
reviewed (Lebanese Muslim, Anglo-American, AfricanAmerican, and Mexican-American) substantiate that
the three modes are care-centered and based on the
use of generic care (emic) knowledge along with
professional care (etic) knowledge obtained from research using the culture care theory along with the
ethnonursing method. This chapter has reviewed
only a small selection of the culture care findings
from ethnonursing research studies conducted over
the past four 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 institutional and community contexts around the world. More in-depth culture care findings along with the use of the three
modes can be found in the Journal of Transcultural
Nursing (1989 to 1998) and in the numerous books
and articles by Dr. Madeleine Leininger. Nurses in
clinical practice are advised to consult a list of research studies and doctoral dissertations conceptualized within the culture care theory for additional detailed nursing implications for clients from diverse
cultures (Leininger, 1998, p. 24).
The Theory of Culture Care Diversity and Universality 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 improve care to people. Nursing students and practicing nurses have remained
the strongest advocates of the culture care theory
(Leininger, 1997). The theory focuses on a longneglected area in nursing practicethat of culture
carewhich is most relevant to our multicultural
world now and in the new millennium.
For practicing nurses, the depiction of the Theory
of Culture Care Diversity and Universality, the Sunrise Model, is a rising sun. This metaphor is particularly apt as the future of the culture care theory
shines brightly indeed because it is holistic, comprehensive, and fits discovering care related to different
389
cultures, contexts, and ages of people in familiar and

naturalistic ways. Not only is the theory useful to
nurses and nursing, but also to professionals in other
disciplines, such as medicine and pharmacy. Healthcare 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, 1997).
References
Berry, A. (1996). Culture care expression, meanings,
and experiences of pregnant Mexican American
women within Leiningers culture care theory.
(UMI No. 9628875). Ann Arbor, MI: UMI Microfilm.
Berry, A. (1999). Mexican American womens expressions of the meaning of culturally congruent prenatal care. Journal of Transcultural Nursing 103,
203212.
Leininger, M. (1985). Qualitative research methods in
nursing. Orlando, FL: Grune & Stratton, Inc.
Leininger, M. (1988). Care: Discovery and uses in clinical and community nursing. Detroit: Wayne State
University Press.
Leininger, M. (1991a). The Theory of Culture Care Diversity and Universality. In Leininger, M. (Ed.), Culture care diversity and universality:A theory of
nursing (pp. 568). New York: National League for
Nursing Press.
Leininger, M. (1991b). Ethnonursing: A research
method with enablers to study the theory of culture
390
care. In Leininger, M. (Ed.), Culture care diversity

and universality:A theory of nursing (pp. 73118).
New York: National League for Nursing Press.
Leininger, M. (1995). Transcultural nursing: Concepts
theories, research, and practice. Blacklick, OH:
McGraw-Hill College Custom Series.
Leininger, M. (1997). Overview and reflection of the
theory of culture care and the Ethnonursing Research Method. Journal of Transcultural Nursing,
8(2), 3251.
Leininger, M. (1998). Special research report: Dominant culture care (emic) meanings and practice findings from Leiningers theory. Journal of Transcultural Nursing, 9(2), 4447.
Luna, L. (1989). Care and cultural context of Lebanese
Muslims in an urban U.S. community:An ethnographic and ethnonursing study conceptualized
within Leiningers theory. (UMI No. 9022423). Ann
Arbor, MI: UMI Microfilm.
Luna, L. (1994). Care and cultural context of Lebanese
Muslim immigrants with Leiningers theory. Journal
of Transcultural Nursing, 5(2), 1220.
McFarland, M. (1995). Cultural care of Anglo- and
African American elderly residents within the
environmental context of a long-term care institution. (UMI No. 9530568). Ann Arbor, MI: UMI
Microfilm.
McFarland, M. (1997). Use of culture care theory with
Anglo- and African American elders in a long-term
care setting. Nursing Science Quarterly, 10(4),
186192.
Zoucha, R. (1998). The experiences of Mexican-Americans receiving professional nursing care: An ethnonursing study. Journal of Transcultural Nursing,
9(2), 3343.
Chapter 22
Part 1
Anne Boykin and

Nursing as Caring
Introducing the Theorists
Nursing as Caring: An Overview of
a General Theory of Nursing
Relevance of Nursing as Caring in Various Nursing Roles
Questions Nurses Ask about the Theory of Nursing as Caring
Nursing as Caring: Historical Perspective and Current
Development
References
Anne Boykin and

INTRODUCING THE THEORISTS

Anne Boykin
Anne Boykin is dean and professor of the College of
Nursing at Florida Atlantic University. She is director
of the Christine E. Lynne Center for Caring, which is
housed in the College of Nursing. This center was
created for the purpose of humanizing care through
the integration of teaching, research, and service.
She has demonstrated a long-standing commitment
to the advancement of knowledge in the discipline,
especially regarding the phenomenon of caring.
Positions she has held within the International Association for Human Caring include: president-elect
(1990 to 1993), president (1993 to 1996), and member of the nominating committee (1997 to 1999). As
immediate past president, she served as co-editor of
the journal International 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 co-authored book, Nursing as Caring: A Model for Transforming Practice (1993), and the book Living a Caring-based Program. The latter book illustrates how
caring grounds the development of a nursing program from creating the environment for study
through evaluation. In addition to these books, Dr.
Boykin is co-editor of Power, Politics and Public Policy: A Matter of Caring (1994), and Caring as Healing: Renewal through Hope. She has also authored
numerous book chapters and articles. She serves as a
consultant locally, regionally, nationally, and internationally on the topic of caring.
Dr. Boykin is a graduate of Alverno College in Milwaukee, Wisconsin; she received her masters degree
from Emory University in Atlanta, Georgia and her
doctorate from Vanderbilt University in Nashville,
Tennessee.
Savina Schoenhofer was born the second child and
eldest daughter in a family of nine children, and
spent her formative years on the family cattle ranch
in Kansas. She is named for her maternal grandfather,
who was a classical musician in Kansas City, Missouri. She has a daughter, Carrie, and granddaughter,
Emma. Schoenhofer spent 3 years in the Amazon region of Brazil in the 1960s, working as a volunteer in
community development. Her initial nursing study
was at Wichita State University, where she earned undergraduate and graduate degrees in nursing, psychology, and counseling. She completed a Ph.D. in
educational foundations and administration at Kansas
392
State University in 1983. In 1990, Schoenhofer cofounded Nightingale Songs, an early venue for communicating the beauty of nursing in poetry and
prose. In addition to her work on caring, she has
written on nursing values, primary care, nursing education, 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, Ph.D., a faculty
colleague who mentored her in the idea of nursing as
a discipline, the academic role in higher education,
and the world of nursing theories and theorists; and
Anne Boykin, Ph.D., who introduced her to caring as
a substantive field of nursing study.
NURSING AS CARING:
AN OVERVIEW OF THE
GENERAL NURSING THEORY
by Anne Boykin and
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). This theory
serves as an organizing framework for nursing scholars in the various roles of practitioner, researcher, administrator, teacher, and developer.
Initially, we will present the theory in its most abstract form, addressing assumptions and key themes.
We will then discuss the meaning of the theory in relation to practice and other nursing roles. In the second part of this chapter, Danielle Linden further describes the theory by illustrating its use as a guide to
practice.
Assumptions
Certain fundamental beliefs about what it means to
be human underlie the Theory of Nursing as Caring.
These assumptions, which will be illustrated later, reflect a particular set of values that provide a basis for
understanding and explicating the meaning of nursing, listed as follows:
1. Persons are caring by virtue of their humanness.
2. Persons are whole and complete in the moment.
3. Persons live caring from moment to moment.

4. Personhood is a way of living grounded in caring.
5. Personhood is enhanced through participation in
nurturing relationships with caring others.
6. Nursing is both a discipline and a profession.
ing of the situation and the openness of the situation

as text. Storytelling, poetry, graphic arts, and dance
are effective modes of representing the lived experience and allowing for reflection and creativity in advancing understanding.
Caring
Personhood
Caring is an altruistic, active expression of love, and

is the intentional and embodied recognition 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 primary interest, and the
The focus of nursing . . . is
direct intention of its
person as living in caring practice. The full meanand growing in caring. ing of caring cannot be
restricted to a definition, but is illuminated
in the experience of caring and in reflection on that
experience.
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 understanding of personhood
communicates the paradox of person-as-person and
person-in-communion all at once.
Key Themes
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 what it means to be in the world.
The disciplinary community represents a value system that is expressed in its unique focus on knowledge and practice. The focus of nursing, from the
perspective of the Theory of Nursing as Caring, is
person as living in caring and growing in caring. The
general intention of nursing as a practiced discipline 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 personwith-person caring. The nursing situation involves
particular values, intentions, and actions of two or
more persons choosing to live a nursing relationship.
Nursing situation is understood to mean the shared
lived experience in which caring between nurse and
nursed enhances personhood. Nursing is created in
the caring between.All knowledge of nursing is created and understood within the nursing situation.
Any single nursing situation has the potential to illuminate the depth and complexity of nursing knowledge. Nursing situations are best communicated
through aesthetic media to preserve the lived mean-
Call for Nursing

A call for nursing is a call for acknowledgment and
affirmation of the person living caring in specific
ways in the immediate situation (Boykin & Schoenhofer, 1993, p. 24). Calls for nursing are calls for
nurturance through personal expressions of caring.
Calls for nursing originate within persons as they live
out 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, 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 intentional
and authentic presence of the nurse with another
who is recognized as living [in] caring and growing
in caring (Boykin & Schoenhofer, 1993, p. 25). The
nurse enters the nursing situation with the intentional commitment of knowing the other as a caring
person, and in that knowing, acknowledging, affirming, and celebrating the person as caring. The nursing response is a specific expression of caring nurturance to sustain and enhance the other as he or she
lives caring and grows
in caring in the situaThe caring between is
tion of concern. Nursing responses to calls the source and ground of
for caring evolve as nursing.
nurses clarify their understandings of calls
through presence and dialogue. Nursing responses
are uniquely created for the moment, and cannot be
Chapter 22 Anne Boykin and Savina O. Schoenhofer Nursing as Caring
393
predicted or applied as preplanned protocols. Sensitivity and skill in creating unique and effective ways
of communicating 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 cocreate by living the intention to
care. Without the loving relation of the caring between, unidirectional 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 and
recognizing the other as caring person.
Lived Meaning of Nursing as Caring

Abstract presentations of assumptions and themes
lay the groundwork and provide an orienting 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 nurses expression
of the meaning of nursing, situated in one particular
experience of nursing and linked to a general conception of nursing.
I CARE FOR HIM
My hands are moist,
My heart is quick,
My nerves are taut,
Hes in the next room,
I care for him.
The room is tense,
Its anger-filled,
The air seems thick,
Im 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.
Its time to leave.
Our bond is made,
Unspoken thoughts,
But understood,
I care for him!
J. M. Collins (1993)
Each encountereach nursing experience

brings with it the unknown. In Collinss reflections,
he 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. Initially,
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 him to see
past the anger-filled room and to be with him
your thoughts
394
(Stanza 2). As they connect through their humanness, the beauty and wholeness of other is uncovered and nurtured. By living caring moment to moment, hope emerges and fear subsides. Through this
experience, both nurse and nursed live and grow in
their understanding and expressions of caring.
In the first stanza, the nurse prepares to enter the
nursing relationship with the formed intention of offering caring in authentic presence. Perhaps he has
heard a report 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 authentic presence and caring: Im with him
now,/I care for him. Patterns of knowing are called
into play as the nurse brings together intuitive, personal knowing, empirical knowing, and the ethical
knowing that it is right to offer care, creating the integrated understanding of aesthetic knowing that enables him to act on his nursing intention (Boykin,
Parker, & Schoenhofer, 1994; Carper, 1978). Mayeroffs (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 situation is completed in linear time. But
each one, nurse and nursed, goes forward newly affirmed and celebrated as caring person, and the nursing situation continues to be a source of living caring
and growing in caring.
Assumptions in the Context

of the Nursing Situation
In this 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 com-
plete in the moment permits the nurse to accept

conflicting 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,
Nursing is . . . always
striving to know self
and other as caring in unfolding and guided by
the moment with a
intention.
growing repertoire of
ways of expressing
caring. Personhood, a way of living grounded in caring that can be enhanced in relationship with caring
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 discipline 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.
RELEVANCE OF NURSING
AS CARING IN VARIOUS
NURSING ROLES
Nursing Practice
The commitment of the nurse practicing nursing as
caring is to nurture persons living caring and growing in caring. This implies that the nurse comes to
know the other as caring person in the moment. Difficult to care situations are those that demonstrate
the extent of knowledge and commitment needed to
nurse effectively. 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. In these extreme (though not unusual)
situations, a task-oriented, nondiscipline-based concept of nursing may be adequate to assure the completion of certain treatment and surveillance techniques. Still, in our eyes that is an insufficient
responseit certainly is not the nursing we advocate. The Theory of Nursing as Caring calls upon the
nurse to reach deep within a well-developed knowledge base that has been structured using all available
patterns of knowing, 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
emerging from research; and related knowledge
from a variety of disciplines, ethical beliefs, and
395
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 integrated
into practice in particular nursing situations (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.
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
person 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.
The nurse practicing within the caring context
described here will most often be interfacing with
the health-care system in two ways: first, communicating nursing so that it can be understood; and second, articulating nursing service as a unique contribution within the system in such a way that the
system itself grows to support nursing.
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 nurturing persons as
they live caring and grow in caring. All activities in
the practice of nursing administration are grounded
in a concern for creating, maintaining, and supporting an environment in which calls for nursing are
heard and nurturing responses are given. From this
point of view, the expectation arises that nursing administrators participate in shaping a culture that
evolves from the values articulated within Nursing as
Caring.
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 administrator is to enter the world of the
nursed either directly or indirectly, to understand
special calls when they occur, and to assist in securing the resources needed by each nurse to nurture
persons as they live and grow in caring (Boykin &
Schoenhofer, 1993). All administrative activities
396
should be approached with this goal in mind. Here,

the nurse administrator reflects on the obligations inherent in the role in relation 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 implementation allow for the consideration of unique situations. 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 structures and activities should reflect the fundamental assumption that persons are caring by virtue of their
humanness. Other assumptions 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 enhanced
through participation in nurturing relationships with
caring others; and, finally, affirming nursing as a discipline and profession.
The curriculum, the foundation of the education
program, asserts the focus and domain of nursing as
nurturing persons living caring and growing in caring:
All activities of the program of study are directed toward developing, organizing, and
communicating nursing knowledge, that is,
knowledge of nurturing persons living caring
and growing in caring.
The model for organizational design of
nursing education is analogous to the dancing
circle. . . . Members of the circle include administrators, faculty, colleagues, students,
staff, community, and the nursed. What this
circle represents is the commitment of each
dancer to understand and support the study of
the discipline of nursing. The role of administrator in the circle is more clearly understood
when the origin of the word is reflected upon.
The term administratorderives from the Latin
ad ministrare, to serve (according to Websters, cited in Guralnik, 1976). This definition
connotes the idea of rendering service. Administrators within the circle are by nature of
[their] role obligated to ministering, to securing, and to providing resources needed by faculty, students, and staff to meet program objectives. Faculty, students, and administrators
dance together in the study of nursing. Faculty

support an environment that values the
uniqueness of each person and sustains each
persons unique way of living and growing in
caring. This process requires trust, hope,
courage, and patience. Because the purpose of
nursing education is to study the discipline
and practice of nursing, the nursed must be in
the circle. The community created is that of
persons living caring in the moment and growing in personhood, each person valued as special and unique. (Boykin & Schoenhofer, 1993,
pp. 7374)
In teaching Nursing as Caring, faculty assist students to come to know, appreciate, and celebrate
both 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 illustrated in the book Living a Caring-based
Program (Boykin, 1994).
Nursing Research and Development

The roles of researcher and developer in nursing take
on a particular focus when guided by the Theory of
Nursing as Caring. The assumptions 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 personally (Schoenhofer, Bingham, & Hutchins, 1998) and
in nursing practice (Schoenhofer & Boykin, 1998b).
Dialogue, description, and innovations in interpretative approaches characterize research methods. De-
velopment of systems and structures (e.g., policy

formulation, information management, nursing delivery, 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).
QUESTIONS NURSES ASK

ABOUT THE THEORY OF
NURSING AS CARING
How Does the Nurse Come to Know
Self and Other as Caring Persons?
Nursing practice guided by the Theory of Nursing as
Caring entails living the commitment 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.
Mayeroffs (1971) caring ingredients offer a useful
starting point for the nurse committed to knowing
self and other as caring persons. These ingredients
include knowing, alternating rhythm, honesty,
courage, trust, patience, humility, and hope. Roachs
(1992) five Cscommitment, confidence, conscience, competence, and compassionprovide another conceptual framework that is helpful in providing a language 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.
Learning to let go, to transcendto let go of
problems, difficulties, in order to remember the
interconnectedness that enables us to know self
your thoughts
397
and other as living caring, even in suffering and

in seeking relief from suffering.
Being open and humble enough to experience
and know self to be at home with ones
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 humanness,
for one can only truly understand in another
what one can understand in self.
Finding hope in the moment.
(Schoenhofer & Boykin, 1993, pp. 8586)
Must I Like My Patients to Nurse Them?

The simple answer to this question is yes. In order
to know the other as caring, the nurse must find
some basis for respectful human connection 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 upon to judge the other, only to care for
the other. A concern with judging or censuring anothers actions is a distraction from the real purpose
for nursingthat is, coming to know the other as
caring person, as one with dreams and aspirations of
growing in caring, and responding to calls for caring
in ways that nurture personhood.
What about Nursing a Person for

Whom It Is Difficult to Care?
Related to the previous dilemma, this question presents the crucible within which ones commitment
to the assumptions and themes of Nursing as Caring
is tested to the limit. The underlying question is,
Does the person to be nursed deserve or merit my
care?Again, as before, the simple answer is yes.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 humanness. In discussions of
hypothetical situations 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 judgements. However, when such a person as described above presents 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 situation. This question and the previous one make it clear that caring is
398
much more than sweetness and light; caring effectively in difficult to care situations is the most challenging prospect a nurse can face. It is only with sustained intention, commitment, study, and reflection
that the nurse is able to offer nursing in these situations. Falling short in ones 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 in study and reflection, individually and in
concert with caring others.
Is it Impossible to Nurse Someone

Who Is in an Unconscious or Altered
State of Awareness?
The key point here is the caring between that is the
nursing creation:
When nursing a person who is unconscious,
the nurse lives the commitment to know the
other as caring person. How is that 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
Mayeroffs caring ingredients: 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, patiently trusting in self to understand the others 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 person who lies unconscious
from surgical anesthetic or traumatic injury. In
that vulnerability, the nurse recognizes that
the one nursed is living caring in humility,
hope, and trust. Instead of responding to the
vulnerability, merely taking care of the other,
the nurse practicing Nursing as Caring might
respond by honoring the others humility, by
participating in the others hopefulness, by
steadfast trustworthiness. Creating caring in
the moment in this situation might come from
the nurse resonating with past and present experiences of vulnerability. Connected to this
form of personal knowing might be an ethical
knowing that power as a reciprocal of vulnera-
bility can develop undesirable status differential in the nurse-patient role relationship. As the
nurse sifts through a myriad of 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 person, rather than as helpless object of
anothers 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. 8687).
How Does Nursing Process

Fit with This Theory?
Process, as it is understood in the term nursing process, connotes a systematic and sequential series of
steps resulting in a predetermined, specifiable product. Nursing process, as introduced into nursing by
Orlando (1961), is a linear stepwise decision-making
tool based on rational analysis of empirical data,
known in other disciplines as the problem-solving
process, and is a key structural theme of many nursing theories developed in past decades. Proponents
of the Theory of Nursing as Caring view nursing not
as a process with an endpoint, but as an ongoing process; that is, as dynamic and unfolding, guided by intention although not directed by a preenvisioned
outcome or product. Nursing responses of care arise
in aesthetic knowing, the creative and evolving patterns of appreciation and understanding, in the context of a shared lived experience of caring. Instead of
preselected and quantifiable outcomes, the value of
nursing to the nursed and to others is that which is
experienced as valuable arising in and evolving
through the caring between of the nursing situation. Much of that value is
neither measurable nor empirically verifiable.
That which is measurable and empirically verifiable is relevant in the situation, however, and
may be called upon at any time to contribute
to and through the nurses empirical knowing.
Information which the nurse has available becomes knowledge within the nursing situation. Knowing the person directly is what
guides the selection and patterning of relevant
points of factual information in a nursing situation. That is, any fact or set of facts from nursing research or related bodies of information
can be considered for relevance and drawn
into the supporting knowledge base. This
knowledge base remains open and evolving as

the nurse employs an alternating rhythm of
scanning and considering facts for relevance
while remaining grounded in the nursing situation. (Schoenhofer & Boykin, 1993, pp. 8990)
In addition to empirical knowing, knowing for nursing purposes also requires personal knowing, including intuition and ethical knowing, all converging
in aesthetic knowing within each unique nursing
situation.
How Practical Is This Theory

in the Real World of Nursing?
Nurses are frequently heard to say they have no time
for caring, given the demands of the role. All nursing
roles are lived out in the context of a contemporary
environment. At the beginning of the twenty-first
century the environment for practice, administration, education, and research is fraught with many
challenges. Some of these challenges are:
technological advancement and proliferation
that can promote routinization and
depersonalization on the part of the caregiver
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 configurations
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 reflects the assumption that caring is created from moment to moment and does not
demand idealized patterns of caring. Caring in the
moment (and moment to moment) occurs when the
nurse is living a committed intention to know and
nurture the other as caring person. No predetermined ideal amount of time or form of dialogue is
prescribed. A simple example of living this intention
to care is the nurse who goes to the IV or the monitor through the person, rather than going directly to
the technology, and failing to acknowledge the person. When the nurse goes to the person, it becomes
clear that the use of technology is one way the nurse
expresses caring for the person. In proposing his
model of machine technologies and caring in nursing, Locsin (1995) distinguishes between mere
399
technological competence and technologiwho recognize their care cal competence as an

intentional expression
role are in an excellent of caring in nursing.
position to act on their Simply avowing an intention to care is not
committed intention to pro- sufficient; the commote caring environments. mitted intention to
care is supported by
serious study of caring and ongoing reflection if nurses are to communicate caring effectively from moment to moment. As
Locsin (1995, p. 203) so aptly states:
Nursing practice leaders
[A]s people seriously involved in giving care

know, there are various ways of expressing
caring. Professional nurses will continue to
find meaning in their technological caring
competencies, expressed intentionally and authentically, to know another as a whole person. Through the harmonious coexistence of
machine technology and caring technology
the practice of nursing is transformed into an
experience of caring.
The nurse administrator is subject to challenges
similar to those of the practitioner and often walks a
very precarious tightrope between direct caregivers
and corporate executives. 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 suspected of disassociating from their nursing colleagues, on one hand, and of not being sufficiently
cognizant of the harsh realities of fiscal constraint,
on the other hand. Administrative practice guided by
the assumptions and themes of Nursing as Caring
can enhance eloquence in articulating the connection between 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 negotiations for fiscal, material, and
human resources 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 administrator who understands the caring ingredients (Mayeroff, 1971) recognizes that caring is
neither soft nor fixed in its expression. A developed
400
understanding of the caring ingredients helps the

nurse administrator mobilize the courage to be honest with self and other, to trust patience, and to
value alternating rhythm with true humility while living a hope-filled commitment to knowing self and
other as caring persons.
Nurse educators guided by Nursing as Caring
struggle with similar challenges. Mentoring students
as colearners and creating caring learning environments while concomitantly accepting responsibility
for summative evaluation calls for the integrated
foundation provided by the guiding intention to
know and nurture persons as caring. This intention
helps the nurse to transcend limiting historical practices while creatively inventing ways to inspire. The
humility of unknowing, joined with courage and
hope, helps the nurse educator to guide the study of
nursing as a commitment to knowing and nurturing
persons as caring. Many nurse educators are struck
with the incongruity of instilling a commitment to
nursing as an opportunity to care through means that
seem to view the student as an object and the discipline as a preexisting set of operating rules. Nursing
education practiced from the perspective of Nursing
as Caring opens the way for faculty to truly value the
discipline and the student.
Nurses in research and development roles carry
out their work facing environmental pressures similar to those experienced by the practitioner, the administrator, and the educator. Research and development in nursing require disciplinary-congruent
values and perspective, freely ranging thought,
openness, and creativity. Institutional systems and
structures often seem to favor values and practices
that are incongruent with the values of the discipline
of nursing, patterned thought, rigidity, and conformity. Researchers and developers guided by the assumptions and themes of Nursing as Caring are empowered to create novel methods in the search for
understanding and meaning and to articulate effectively the value, purpose, and relevance of their
work.
NURSING AS CARING:
HISTORICAL PERSPECTIVE
AND CURRENT DEVELOPMENT
The Theory of Nursing as Caring developed as an outgrowth of the curriculum development work in the
College of Nursing at Florida Atlantic University,
where both authors were among the faculty group
revising the caring-based curriculum. When the re-
vised 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
comprehensive expression of the meaning and purpose of nursing as a discipline and a profession. The
point of departure was the acceptance that caring is
the end, rather than the means, of nursing, and 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
assumptions about nursing clarified the idea of the
nursing situation, a shared lived experience in which
the caring between enhances personhood, with
personhood understood as living grounded in caring. The clarified focus and the idea of the nursing
situation 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 profession. 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.
Three bodies of work significantly influenced the
initial development of Nursing as Caring. Roachs
(1987/1992) basic thesis that caring is the human
mode of being was incorporated into the most
basic assumption of the theory. We view Paterson
and Zderads (1988) existential phenomenological
Theory of Humanistic Nursing as the historical antecedent of Nursing as Caring. Seminal ideas such as
the between,call for nursing,nursing response,
and personhood served as substantive and structural bases for our conceptualization of Nursing as
Caring. Mayeroffs (1971) work, On Caring, provided a language that facilitated the recognition and
description of the practical meaning of caring in
nursing situations. In addition to the work of these
thinkers, both authors are long-standing members of
the community of nursing scholars whose study focuses on caring, and who are supported 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 theory conference in 1992 (Boykin & Schoenhofer,
1990, 1991; Schoenhofer & Boykin, 1993), followed
by the work, Nursing as Caring: A Model for Transforming Practice, published in 1993 (Boykin &
Schoenhofer, 1993).
Research and development efforts at this writing

are concentrated on expanding the language of caring by uncovering personal ways of living caring in
everyday life (Schoenhofer, Bingham, & Hutchins,
1998), reconceptualization of nursing outcomes as
value experienced in nursing situations (Boykin &
Schoenhofer, 1997; Schoenhofer & Boykin, 1998a,
1998b), and in consultation with graduate students,
nursing faculties, and health-care agencies who are
using aspects of the theory to ground research,
teaching, and practice.
References
Boykin, A. (Ed.). (1994). Living a caring-based program. New York: National League for Nursing Press.
Boykin, A., Parker, M. E., & Schoenhofer, S. O. (1994).
Aesthetic knowing grounded in an explicit conception of nursing. Nursing Science Quarterly, 7,
158161.
Boykin, A., & Schoenhofer, S. O. (1990). Caring in nursing: Analysis of extant theory. Nursing Science
Quarterly, 3(4), 149155.
Boykin, A., & Schoenhofer, S. O. (1991). Story as link
between nursing practice, ontology, epistemology.
Image, 23, 245248.
Boykin, A., & Schoenhofer, S. O. (1993). Nursing as
caring:A model for transforming practice. New
Boykin, A., & Schoenhofer, S. O. (1997). Reframing outcomes: Enhancing personhood. Advanced Practice
Nursing Quarterly, 3(1), 6065.
Carper, B. A. (1978). Fundamental patterns of knowing
in nursing. Advances in Nursing Science, 1(1),
1324.
Collins, J. M. (1993). I care for him. Nightingale Songs,
2(4), 3.
Gaut, D., & Boykin, A. (Eds.). 1994. Caring as healing:
Renewal through hope. New York: National League
for Nursing Press.
Guralnik, D. (1976). Websers new world dictionary of
the American language. Cleveland: William Collings
& World Publishing Co.
Locsin, R. C. (1995). Machine technologies and caring
in nursing. Image, 27, 201203.
Mayeroff, M. (1971). On caring. New York: Harper &
Row.
Orlando, I. (1961). The dynamic nurse-patientrelationship: Function, process and principles.
New York: G. P. Putnams Sons.
nursing. New York: National League for Nursing
Press.
Roach, S. (1987/1992). The human act of caring.
Ottawa, Canada: Canadian Hospital Association.
Roach, M. S. (1992). The human act of caring:A blueprint for the health professions (rev. ed.). Ottawa,
Canada: Canadian Hospital Association Press.
Schoenhofer, S. O. (1995). Rethinking primary care:
Connections to nursing. Advances in Nursing Science, 17(4), 1221.
401
Schoenhofer, S. O., Bingham, V., & Hutchins, G. C.

(1998). Giving of oneself on anothers behalf: The
phenomenology of everyday caring. International
Journal for Human Caring, 2(1), 2329.
Schoenhofer, S. O., & Boykin, A. (1993). Nursing as caring: An emerging general theory of nursing. In
Parker, M. E. (Ed.), Patterns of nursing theories in
Nursing Press.
402
Schoenhofer, S. O., & Boykin, A. (1998a). The value of

caring experienced in nursing. International Journal for Human Caring, 2(3), 915.
Schoenhofer, S. O., & Boykin, A. (1998b). Discovering
the value of nursing in high-technology environments: Outcomes revisited. Holistic Nursing Practice, 12(4), 3139.
Chapter 22
Part 2
The Lived Experience

of Nursing as Caring
Current Practice as an Advanced Practice Nurse
Application of the Theory
Broad Application for Advanced Practice Nursing
References
Danielle Linden
Anne Boykin and Savina Schoenhofer have developed a theory of nursing that suspends the traditional past and offers nursing a new lens with which
to view otherthe one nursed. This nontraditional
perspective transforms the way one comes to know
other and creates an endless array of new possibilities for nursing.
I have been invited to share the experience of
nursing from the theoretical perspective of the book
Nursing as Caring: A Model for Transforming Practice. The application of Nursing as Caring in my
practice has been fulfilling both professionally and
personally. Professionally, every day poses a new
challenge. Nursing as
Nursing as Caring guides Caring requires the
nurse to use many difthe nursing situation, serv- ferent ways of knowing as a framework in my ing to come to know
other in the fullness
patient encounters.
of ones existence.
Each domain contains
a vast amount of knowledge. The nurse must be
knowledgeable of each and artfully apply this knowledge in an effort to transcend the physical boundaries of the human body to come to know others
complex existence. Personally, this effort is rewarded by enhancing who I am as a person. I grow
with each encounter.
CURRENT PRACTICE
AS AN ADVANCED
PRACTICE NURSE
The application of the theory of Nursing as Caring is
a unique practice perspective. Nursing as Caring
guides the use of knowledge generated from within
and borrowed from other disciplines. The theory embodies all of the knowledge that is brought into the
nursing situation and all that is generated therein. It
is through this theory that I have come to know new
possibilities for nursing practice.
As an Advanced Registered Nurse Practitioner
(ARNP) in family practice, I see patients in a primary
care setting. Grounded in Nursing as Caring, I borrow knowledge from other disciplines, such as
pathophysiology, microbiology, pharmacology, and
philosophy, and use this knowledge to come to
know other in each moment of our visit. Some patients have acute needs that need to be addressed immediately. Some of them have chronic problems that
require maintenance therapy. All of them need to be
recognized as holistic and complex human beings
with a unique existence in this world, living in car-
404
ing and growing in caring. I am a facilitator of

this process and risk entering into anothers world
with the intent of living caring in that nursing situation.
I enjoy my role as a primary care provider. In
practice, I emphasize wellness and prevention. Nursing as Caring guides the nursing situation, serving as
a framework in my patient encounters. I walk in the
room with the intent of coming to know other as a
holistic being with a body, mind, and spirit. The call
for nursing then begins to unfold and reveals itself to
me. My presence with other is authentic and there
exists a genuine responsiveness to come to know
other.Authentic presence allows one to know that
which is not spoken. A
person can speak ones
mind. A physical assess- Authentic presence allows
ment can reveal an ail- one to know that which is
ment. The spirit, hownot spoken.
ever, must be attended
to as well. Everything is
revealed in ones spirit. When you are in authentic
presence with other, the call for nursing unfolds before you. These are the profound encounters that
never leave you.
Then there are the more frequent encounters
where reflection becomes a useful tool to uncover
the deeper meaning behind these chance nursing situations. Sometimes the patients call for nursing is
physical. I recognize it and treat accordingly. Reflection allows me to answer these questions: Was I nursing? What did I do differently from another healthcare provider? My answer is the perspective from
which I practice. I walked into the room with the
willingness to come to know other, whatever may
have been revealed in that moment. It was the way I
touched the patient, my tone of voice, my unhurried
pace, and my smileall the tools I use to convey to
other that I am here for you and I care about you.
The goal is to enhance other as he or she live and
grow in caring. Boykin and Schoenhofers theory
puts forth a framework for reflection: Reflection, in
their view, serves as a form of personal theorizing
about caring experiences, trusting that each person
will examine the content of those experiences as a
sequence of more or less meaningful eventsmeaningful both in themselves and in the patterns of their
occurrence (Boykin & Schoenhofer, 1993, p. xxiii).
I take time regularly to reflect upon the profound
and not so profound nursing situations in my life. Reflection uncovers those hidden meanings that are
not readily apparent in the moment. It is also a time
for self-growth and validationa process of coming
to know self and others as caring persons.
your thoughts
APPLICATION OF THE THEORY

Another form of reflection is the sharing of nursing
situations with others. There are many different ways
one can present a nursing situation, such as case presentations, poems, projects, and various other art
forms. When one shares a nursing situation with others, new possibilities for knowing other unfold exponentially. Each practitioner brings the wealth of
his or her education and experiences. New revelations come to life.
I would like to share with you a nursing situation
presented in the traditional medical model of case
presentation and then in the form of a story from a
nursing perspective grounded in the Nursing as Caring theory. It is my intent that through comparison,
the lived experience of both of these models will
make clearer the difference between practice perspectives.
Nursing Situation:
As a Case Presentation
The following is a case presentation of a person I had
the privilege of caring for.
E. S. was a 76-year-old white female patient who
came to the office with the complaint of a lump in
her abdomen. By her own admission, she remarked
that she did not like going to the doctor and had neglected to have any checkups in quite a few years. A
comprehensive history and physical exam was unremarkable with the exception of her abdomen, which
revealed a small, palpable, nontender mass in the
right lower quadrant.
I ordered blood tests, all of which were unremarkable with the exception of the Ca125, which was
625, well above normal parameters. My suspicion for

ovarian cancer was confirmed.
Three days after our initial visit, I asked her to return to the office so we could discuss the results. She
did so, and with her, she brought a gift. She said I
had done so much for her in our visit, she wanted to
share with me a precious gift the Lord had given
herher voice. There, in the office, I sat with her
labs in my lap as she serenaded me with a song. I
dont remember the name of the song, but the verse
told me Jesus was calling her home and she was not
afraid.
When she was done, we discussed the findings. I
advised her that although the blood test was not diagnostic, the possibility of cancer did exist and she
needed to see an oncological gynecologist. Tears
were shed and hugs exchanged.
After a month of invasive testing at the familys
prompting, exploratory surgery and biopsies confirmed the diagnosis of ovarian cancer with extensive
metastasis. The patient underwent a total abdominal
hysterectomy and bilateral salapingo-oophorectomy
with debulking, and died shortly thereafter.
There is a lot one can learn from a case presentation such as this one, but it does not reflect the
essence of what occurred between the nurse and
the one nursed. The reader is left wondering what
the nurse did that prompted such a special present in
return.
Nursing Situation: As a Story

I invite you now to relive this nursing situation as I
have chosen the form of a story to illustrate the application of Nursing as Caring to help others understand what it is to nurse from this perspective.
Chapter 22 Danielle Linden The Lived Experience of Nursing as Caring
405
As the morning rolled along I began to dream. I

dreamed I was a tree. My roots entwined deep within
the foundation upon which I stood. I took from the
Earth what I needed to nourish and strengthen me.
My roots drank from the spring of knowledge beneath me. I felt strong. I grew tall. My arms outstretched, reached for the sun, found the sky, and in
it, a gentle breeze that surrounded and calmed me. I
stood in awe of the suns beauty as its rays poured
over me and warmed my spirit. I felt connected. I
felt whole.
I saw a glow on the horizon, unlike the sun and
different from the moon and stars. An ember, the
residual of a fire that has burned through the night,
tirelessly, to provide warmth. I was drawn to it. Unafraid that my branches might catch fire and burn, I
reached for her abdomen. I searched. As my hands
pressed on, I began to feel the Earth slipping from
the sky. I reached upward, grasping for the restoration of harmonious interconnectedness, but in the
sky, there is nothing to grab onto. You may grow into
it, enjoy its beauty, bask in its breezes, and breathe in
its life-giving oxygen, but you cannot hold onto it or
possess it.
My arms grew weary, my leaves were wilted, so I
drank from the spring beneath my foundation. My
roots nourished me with courage, patience, trust,
and humility. She reached for my hand. Her spirit
filled me and strengthened me as she ascended toward the sky. I began to feel stronger and reached toward the sky, hoping to catch one last glimpse of her
ember and saw her reflection in the sun. Her rays
poured over me and warmed my spirit. I felt whole
once again.
This nursing story is a reflection of a nursing situation grounded in caring. It demonstrates the perspective of enhancing other as one lives and grows
in caring, which subsequently results in the enhancement of self as the nurse lives and grows in caring.
I chose this story as the medium with which to
share. Boykin and Schoenhofer encourage nurses
to choose various art
forms as media for
Nursing theory sets apart
sharing and reflecwhat nurse practitioners do tion. This is aesthetic
from any other profession. knowing. It is the artful integration of all
the ways of knowing
to create a meaningful, caring moment that is born in
a nursing situation.
Personal knowing is that which is known intuitively by encountering self and other. Authentic
presence is a key component for my intuitive experi-
406
ences when I just know. The patient trusted me and

humbled herself to ask me to validate her concern
that the mass in her belly was of grave concern. The
patient knew, intuitively, before I laid my hands on
her. There is a lot to be gained by learning to trust
our intuition, and we can know more by engaging
in authentic presence. Authentic presence, for me,
removes all physical boundaries to my coming to
know other. It is a spiritual connectedness that has
no time limits or physical boundaries. It is a feeling
of interconnectedness with the patient that reverberates beyond the room, city, state, country, world,
and galaxy. It brings with it the wisdom of the universe.
The first three basic assumptions inherent in
Nursing as Caring facilitate the lived experience of
authentic presence in this moment. The assumption
that this person is a caring person by virtue of her
humanness, complete in that moment, gave me the
courage to enter into authentic presence to come to
know her as a complete, caring person in that moment. As the moment unfolded, our mutual trust enhanced and supported who we were as we lived and
grew in that caring encounter.
The patients need to share with me a special gift
was validation that she felt it, too. The fifth basic assumption of the theory of Nursing as Caring is personhood, which is enhanced through participation
in nurturing relationships. As the patient demonstrated in the words of her song, she knew that the
end of her physical existence was coming to an end
and she was not afraid. There was a mutual knowingness that was unspoken, even without the lab work
or biopsies. Her lack of fear and her courage allowed
her spirit to soar free in the open sky, giving me a
glimpse of the spiritual existence.
This is not to devalue the importance of empirical
knowledge. It, too, is an important part of coming to
know other. Empirical knowledge is the information that is organized into laws and theories to describe, explain, or predict phenomena. This knowledge is acquired through the senses. Based in the
sciences, it is our understanding of anatomy and
physiology, diagnostic processes, and treatment regimens. For me, it is the concrete form of the foundation upon which my practice is built.
Empirical knowledge is essential to be recognized
as a profession. The sixth assumption of Nursing as
Caring is that nursing is both a discipline and a profession. The scientific evidence that lends theorybased knowledge to our profession gives us the diagnostic reasoning we need to address the physical
needs that people have. In this particular situation,
the laboratory findings confirmed that which we

knew personally. Oftentimes the bereaved loved
ones need a diagnosis to help cope with the grief of
losing a family member.
This brings us to ethical knowingthe patience
and compassion to be with grieving family members
when they are not ready to let go of a loved one who
is ready to die. Ethical knowing is also the recognition that these family members are caring persons as
well, coping in the only way they know how, through
their experiences. Humility has allowed me to come
to know and respect the familys perspective. Patience
is needed to allow other to come to know hope in
the moment a loved one is diagnosed with a terminal
illness. Hope for a spiritual existence beyond this
world was revealed to me in this nursing situation.
Each of these patterns of knowingaesthetic,
personal, empirical, and ethicalis borrowed from
Carper (1978). They serve as conceptual tools to
help us understand and implement the theory of
Nursing as Caring. These tools lend organization to
the theory, helping us to examine ways of knowing
the whole of a nursing situation, with caring as the
central focus.
BROAD APPLICATION FOR

ADVANCED PRACTICE NURSING
Nursing as Caring provides a theoretical perspective
with an organizing framework that guides practice
and allows for the generation of new knowledge. In
addition, it lends a methodologic process to define,
explain, and verify this knowledge. This theory
reaches beyond the received view of traditional science. Nursing as Caring guides the use of nursing
knowledge and information from other disciplines in
ways appropriate to nursing. Through the applica-
tion of this theory, I have come to know new possibilities for nursing practice.
I believe now, more than ever, that, with the advancing roles of nurses, we need to be clear on what
it is that we do that is different from other practitioners. As Advanced Practice Nurses (APNs) and ARNPs,
assume more responsibilities and perform tasks that
were traditionally reserved for those of the medical
profession, the overlapping further blurs the boundaries of our professions. We need to maintain our
nursing perspective. As nurse practitioners continue
to be lumped into categories with other midlevel
practitioners, we need to demonstrate to our patients that our profession was born of a need from society, a need that only nurses can fill. If there is no
call to nursing, our profession will dissolve into the
sea of midlevel practitioners.
Nursing theory sets apart what nurse practitioners do from any other profession. To ensure that our
practice maintains its identity, the practice must
be built upon research-based nursing theory. The
Theory of Nursing as Caring is one such theory. I
hope that by sharing how I live and practice Nursing
as Caring, I will lend understanding to applying
something that can seem abstract.
The call for nursing can be spoken in many different languages. If you use only your ears, you may not
hear it.
References
Boykin, A., & Schoenhofer, S. O. (1993). Nursing as
caring:A model for transforming practice. New
Carper, B. A. (1978). Fundamental patterns of knowing
in nursing. Advances in Nursing Science, 1(1),
1324.
Chapter 22 Danielle Linden The Lived Experience of Nursing as Caring
407
Section IV
Nursing Theory: Illustrating
Processes of Development
Chapter 23
Kristen M. Swanson
A Program of Research
on Caring
Turning Point
Predoctoral Experiences
Doctoral Studies
Postdoctoral Study
The Miscarriage Caring Project
A Literary Meta-analysis of Caring
Summary
References
Kristen M. Swanson
This chapter has turned out to be somewhat autobiographical. In writing it, I have tried to answer the
questions of graduate students who were interested
in learning more about how my research on caring
came to be. I have attempted to situate myself as a
nurse and woman so that the history of my scholarship, particularly as it pertains to caring, may be
chronicled. I consider myself to be a second-generation nursing scholar. I was taught by first-generation
nursing scientists (that is, nurses who received their
doctoral education in fields other than nursing). My
struggle for identity as a woman and as an academician was, like that of other women of my era (the
baby boomers), and continues to be, a reflective process of self-discovery. Third-generation nursing scholars (those taught by nurses whose doctoral preparation is in nursing) may find my yearning somewhat
naive and adolescent given their struggle for identity.
To those who are wont to offer critique about the
egocentricity of my pondering, I offer the defense of
having been brought up during an era in which
nurses dealt with such struggles as, Are we a profession? Have we a unique body of knowledge? Are we
entitled to a space in
the full (i.e., Ph.D.I believe that the key to my
granting) academy?
research is that I have stud- As we enter a new
ied human responses to a century, I fully appreciate that questions of
specific health problem in uniqueness and entia framework that assumed tlement have not completely disappeared.
from the start that a clinical Rather, they have
therapeutic had to be faded as a backdrop
to the weightier condefined. cerns of making a significant contribution
to the health of all, working collaboratively with consumers and other scientists and practitioners, embracing pluralism, and acknowledging the socially
constructed power differentials associated with gender, race, 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. However, my dissertation chairperson, Dr. Jean Watson, had quite a different idea.
Given her devotion to studying caring, I suppose I
should not have been very surprised that when I approached her to chair my committee, she immediately struck a deal that included the need for me to
examine the meaning of caring in the context of mis-
412
carriage. In truth, I said yes because, having been a

student at that point for 20 of my 29 years, I readily
recognized the difference between a negotiable and
a nonnegotiable request. As it turned out, Dr. Watsons advice proved sage, and to this day I am grateful for her firmness and wisdom. I believe that the
key to my 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 between whats wrong and what can be
done about it, whats right and how can it be
strengthened, and whats real to women who miscarry and how might care be customized to that reality. 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. Because the caring theory was developed
empirically and from a clinical perspective, it is my
hope that the theory has merit for guiding practice,
education, and research even beyond the perinatal
contexts from which it was originally derived.
PREDOCTORAL EXPERIENCES
My preparation for studying caring-based therapeutics from a psychosocial perspective began, ironically, 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 University of Massachusetts Medical Center (U. Mass.) in Worcester, Massachusetts. I
was drawn to that institution because of the nursing
administrations clear articulation of how nursing
could and should be. It was so exciting to be there
from day one. We were all essential players in shaping the institutional vision for practice. Within 6
months of opening, the hospital was ready to launch
a cardiac surgery program, and with that I shifted
from the floor to the unit (and I do mean the in
both cases, because we literally had one of each). It
was a phenomenal experience to witness myself and
my friends (nurses, physicians, respiratory therapists, and housekeepers) make a profound difference in the lives of those people 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
upon 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
Section IV Nursing Theory: Illustrating Processes of Development
the heart (and lives) of their partner 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. It warmed my heart to be so privileged
as 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. It also both humbled and filled me with gratitude for all that I was learning.
After a year and a half at U. Mass., I was still a
fairly new nurse and very unclear about what all of
these emotional insights had to do with nursing. I
really saw all of it as more of something about my
spiritual beliefs and me
Caring consisted of five than about my profession. At that point,
basic processes: knowing,
what mattered most to
being with, doing for, me as a nurse was my
emerging technological
enabling, and maintaining
savvy, understanding of
belief. complex pathophysiological processes, and
desire to convey that same information to other
nurses. Hence, I applied to graduate schools with
the intention of focusing on teaching and care of the
acutely ill adult. Approximately 2 years after completing my baccalaureate degree, I enrolled in the
Adult Health and Illness Nursing program at the University of Pennsylvania.
While I was at Penn, I served as the student representative to the graduate curriculum committee and,
as such, was invited to attend a 2-day retreat to revise
the masters program. I distinctly remember when,
having just caught myself daydreaming, I made myself focus on the speaker, Dr. Jacqueline Fawcett. As I
tuned in, I could not believe what I was hearing. She
was talking about such concepts as health, environments, persons, and nursing and claiming that these
four concepts were the stuff that really comprises
nursing. It was like hearing someone give voice to
the inner stirrings I had kept to myself back in Massachusetts. It really impressed me that there were actually 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
post-masters student in Dr. Fawcetts new course on
the conceptual basis of nursing. It proved to be one
of the best decisions I had ever made, primarily because it helped me to figure out an answer to that
constant question, Why doesnt a smart girl like you
enter medicine? I finally knew that it was because
nursing, a discipline that I was now starting to un-
derstand from an experiential and personal as well as

an academic point of view, was more suited to my
beliefs about serving people who were moving
through the transitions of illness and wellness. I suppose it is safe to say that I was beginning to understand that my gifts lie not in the diagnosis and treatment of illness but in the ability to understand and
work with people going 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 person-environment fit. Having been supported
by a National Institute of Mental Health (NIMH)
traineeship, one requirement of our doctoral 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 occurred 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 social policy statement, namely,
Nursing is the diagnosis and treatment of human responses to actual and potential health problems
(1980, p. 9). It was so clear to me that whereas the
physician had talked about the health problem of
spontaneously aborting, the women were living the
Chapter 23 Kristen M. Swanson A Program of Research on Caring
413
human response to miscarrying. Second, being in my

last semester of course work, I was desperately in
need of a dissertation 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 very little
about anything having to do with childbearing. An
additional concern was that during the early 1980s
although there was a very strong emphasis on epistemology, ontology, and the methodologies to support
multiple ways of understanding nursing as a human
science, our methods courses were very traditionally
quantitative. Luckily, two mentors came my way. Dr.
Jody Glittenberg, a nurse anthropologist, agreed to
guide me through a predissertation pilot study of five
womens experiences with 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.
Dissertation: Caring and Miscarriage

Twenty women who had miscarried within 16 weeks
of being interviewed agreed to participate in my phenomenological study of miscarriage and caring. The
results of this inquiry have been published in greater
depth elsewhere (Swanson-Kauffman, 1985, 1986,
1991). Through that investigation, I proposed that
caring consisted of five basic processes: knowing,
being with, doing for, enabling, and 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 peoples caring
and noncaring responses; and finally, (4) I learned
that 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 accomplishing
my agenda to gather detailed accounts of the informants experiences was that women felt, heard,
understood, and attended to in a nonjudgmental
fashion. In later years, this insight would actually become the grist for a caring-based intervention study.
At the completion of the dissertation, and in the
years following, I have often been asked if my re-
414
search was an application of Jean Watsons Theory

of Human Caring (Watson, 1979/1985, 1985/1988).
Neither Dr. Watson nor I have ever seen my research
program as an application 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. Watsons research tradition asserts that caring is (1) a central concept in nursing,
(2) values multiple methodologies for inquiry, and
(3) honors the importance of nurses (and others)
studying caring so that it may be better understood,
consciously claimed, and intentionally acted upon to
promote, maintain, and restore health and healing.
POSTDOCTORAL STUDY
Postdoctoral Study #1:
Providing Care in the NICU
Approximately 9 months after I completed the dissertation, my second son was born. This child had a
difficult start on life and spent a few days in the newborn intensive care unit (NICU). Through this event,
I became aware that in my later 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 Research
Service Award postdoctoral fellowship (19891990),
was inspired. Dr. Kathryn Barnard, at the University
of Washington, agreed to sponsor this investigation
and ended up opening doors for me that still continue to open. With her guidance, 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 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 (specific words having to do with miscarrying were
replaced with more general language).
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 responsibilities (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 misunderstanding the behaviors of others and second-guessing each others motives.
While I was presenting the findings of the NICU
study to a group of neonatologists, I received a very
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 evaluated on and made accountable for the
aspects of his job that dealt with managing responsibilities 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 inside. Unfortunately, it was his experience that those more person-centered aspects of
his role could not be stuffed for too long and that
they oftentimes came hauntingly into his consciousness at about 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 practitioners whose comprehensive
care embraces caring, attaching, managing responsibilities, and avoiding bad outcomes.
Postdoctoral Study #2:

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 masters-prepared public health nurses.
As I did the presentation, I noticed that there was a
lot of head nodding going on. When I finished, the
five of them became quite excited and claimed that
the model I had just described was a good description of what it had been like for them to care for a
group of socially at-risk new mothers. As it turned
out, about 4 years prior to my meeting them, these
five advanced practice nurses had participated in Dr.
Barnards Clinical Nursing Models Project (Barnard et
al., 1988). They had provided care to 68 socially atrisk expectant 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 control of
themselves and 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 (a
group of women with highly transient lifestyles).
They agreed to participate in a study of what it had
been like to receive an intensive long-term advanced
practice nursing intervention. The result of this phenomenological 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 responsibility (Swanson, 1991, p. 162).
Knowing, striving 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
I define caring as a nurthe self of both the
one caring and the one turing way of relating to a
cared for. Being with valued other, toward
means being emotionally present to the whom one feels a personal
other. It includes be- sense of commitment and
ing there, conveying
availability, and shar- responsibility.
ing feelings while not
burdening the one cared for. Doing formeans 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 skillfully, and protecting the other while preserving their dignity.
Enabling means facilitating the others passage
through life transitions and unfamiliar events. It involves focusing on the event, informing, explaining,
supporting, allowing and validating feelings, generating alternatives, thinking things through, and giving
feedback. The last caring category is maintaining belief, which means sustaining faith in the others 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, offering realistic optimism,
helping find meaning, and going the distance or
standing by the one cared for, no matter how his or
415
her situation may unfold (Swanson, 1991, 1993,

1999a, 1999b).
THE MISCARRIAGE
CARING PROJECT
As my postdoctoral studies were coming to an end,
Dr. Barnard suggested that I should apply for a new
investigator award from the National Institutes of
Health. I told her I had been thinking about another
phenomenological study on loss and caring. In her
straightforward fashion, she looked at me and said, I
think youve described caring long enough. Its time
you did something with it! We then proceeded to
talk about the fact that data-gathering interviews
were so 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.
The next thing I knew, I was writing a proposal
for a Solomon four-group randomized experimental
design (Swanson, 1999a,b). It was funded by the National Institute of Nursing Research and the University of Washington Center for Womens Health Research. The primary purpose of the study was to
examine the effects of three 1-hour-long, caringbased counseling sessions on the integration of loss
(miscarriage impact) and womens emotional wellbeing (moods and self-esteem) in the first year subsequent to miscarrying. Additional aims of the study
were to (1) examine the effects of early versus delayed measurement and the passage of time on
womens healing in the first year after loss, and (2)
develop strategies to monitor caring as the intervention/process variable.
An assumption of the caring theory was that the
recipients well-being should be enhanced by receipt
of caring from a provider who is 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 miscarrying into their lives. 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, 1999b; 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 (earlycompletion
of outcome measures immediately, 6 weeks, 4
months, and 1 year post loss; or delayedcompletion of outcome measures at 4 months and 1 year
only). Counseling took place at 1, 5, and 11 weeks
postloss. ANOVA was used to analyze treatment effects. Outcome measures included self-esteem
(Rosenberg, 1965); overall emotional disturbance,
anger, depression, anxiety, and confusion (McNair,
Lorr, & Droppleman, 1981); and overall miscarriage
your thoughts
416
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, 1999a). There were 242
women enrolled, of which 185 completed. Participants were within 5 weeks of loss at enrollment; 89%
were partnered, 77% were employed, 94% Caucasian. Over 1 year, main effects included the following: (1) caring was effective in reducing overall emotional disturbance, anger, and depression; and (2)
with the passage of time, women attributed less personal significance to miscarrying, and realized increased self-esteem and decreased anxiety, depression, anger, and confusion. There were no interactive
effects of treatment and time over that first year. Between 4 months and 1 year, the following main effects were determined: (1) treated women had less
anger; (2) delayed-measured women (those who
completed no outcome measures until 4 months after loss) had higher anger and were less likely to
identify their loss as a baby; and (3) time passing led
to diminished impact of miscarriage and personal significance of loss, increased self-esteem, and decreased overall emotional disturbance, anxiety, depression, anger, and confusion. Between 4 months
and 1 year there were also the following interactive
effects: (1) the healing effect of time on the personal
significance attributed to miscarrying was greater for
treated women; (2) the healing effects of treatment
on the assessment of miscarriage as personally significant and as a devastating event were greater for delayed-measured women; and (3) the healing effects
of time on overall miscarriage impact and assessment
of miscarriage as a devastating event were greater for
women in the delayed-measured groups.
In summary, the Miscarriage Caring Project provided evidence that, although time had a healing effect on women after miscarrying, 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 difference. I believe
that its greatest strength lies in the fact that the intervention was based both on an empirically derived
understanding of what it is like to miscarry and on a
conscientious attempt to enact caring in counseling
women through their loss. Of course, 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 am currently making a concerted effort to
try to rectify this situation and to examine what it is
like for diverse groups of women to experience both
miscarriage and caring.
Monitoring Caring as
an Intervention Variable
Monitoring caring as an intervention variable was the
second specific aim of the Miscarriage Caring Project. The project was an attempt to monitor the intervention variable and document that caring had indeed occurred, as claimed. Three strategies were
employed. First, approximately 10% of the total intervention sessions were transcribed. Analysis was
done by Research Associate Katherine Klaich, RN,
Ph.D. Dr. Klaich, having also been one of the counselors in the study, found she could not approach
analysis of the transcripts naivelythat is, with no
preconceived notions, as would be expected in the
conduct of phenomenologic analysis. Hence, she
employed both deductive and inductive content analytic techniques 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 monitored
was through the completion of paper-and-pencil
measures. Before each session, the counselor completed a Profile of Mood States (McNair, Lorr, &
Droppleman, 1981) in order to document her presession moods (thus enabling examination of the association between counselor presession mood and self
or client postsession ratings of caring). After each
session, women were asked to complete the Caring
Professional Scale (investigator-developed). Women,
having been left alone to complete the measure,
were asked to place the evaluations in a sealed enve-
417
lope. In the meantime, in another room, the counselor 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 five-point Likert-type scale. It was developed through the Miscarriage Caring Project and
was completed by participants 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: Was the health-care
provider that just took care of you understanding, informative, aware of your feelings, centered on you,
etc.? The response set ranged from 1 yes, definitely to 5not at all.The items were derived from
the caring theory. Three negatively worded items
(abrupt, emotionally 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, Chronbach alphas were .80, .95, and .90
(sample sizes for the counselor reliability estimates
were 80, 87, and 76). The lower reliability 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 extremely
high for both counselors indicating that, overall,
the clients were pleased with what they got and,
as claimed, caring was delivered and received.
4. One of the counselors was a psychiatric nurse by

background. She knew very little about miscarriage prior to 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
counselors vulnerabilities came through. This
counselor, having just gone through a divorce,
was probably least able to hide her presession
moods (depression ( p .05) and low vigor, confusion, fatigue, and tension (all at p .01), as
was evident in the significant associations with
her own postsession self-rating. Also, most notably, there was an association between this
counselors presession tension and the clients
caring professional rating ( p .05).
A LITERARY META-ANALYSIS
OF CARING
My most recent study about caring was an in-depth
review of the literature. This literary meta-analysis is
published elsewhere (Swanson, 1999). Approximately
your thoughts
418
130 data-based publications on caring were reviewed

for this state of the science paper. Developed was 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) assumes
the presence of all previous domains (e.g., Levels I
and II). The first domain 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 caring 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 quantitative studies of caring actions was performed. It was
demonstrated that the top five caring behaviors valued by patients were that the nurse helps the patient
to feel confident that adequate care was provided;
knows how to give shots and manage equipment;
gets to know the patient as a person; treats the patient with respect; and puts the patient first, no matter what. By contrast, the top five caring behaviors
valued by nurses were: listens to the patient, allows
expression of feelings, touches when comforting is
needed, is perceptive of the patients needs, and realizes the patient knows himself/herself best. The second part of the caring actions summary was a review
of 67 interpretive studies of how caring is expressed
(the total number of participants was 2314). These
qualitative studies were classified under Swansons
caring processes, thus lending credibility to caring
theory. The last domain was labeled consequences.
These are the intentional and unintentional outcomes 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
Swansons Caring Theory beyond the perinatal contexts from which it was originally derived.
Summary
Much work lies ahead. The profession has a long way
to go to make a case for the education needed to support caring practices; the importance of nurses practicing in a caring manner; the essential contributions
of caring to the well-being of all; and the costs of caring in terms of time, money, and personal energy ex-
pended. The discipline also has much work left to

do. It is essential that nurse investigators frame nursing interventions under the framework of caring in
order to tie together the essential contributions of
the profession to the health of society. Finally, caring, in order to be effective, must be sensitive to
those involved in caring transactions (nurses and
clients), the cultural contexts in which it is performed, and the common responses that individuals,
families, groups, and communities experience when
living with conditions of wellness and illness.
References
American NursesAssociation. (1980). Nursing:A social
policy statement. Kansas City, MO: American
NursesAssociation.
Barnard, K. E., Magyary, D., Sumner, G., Booth, C. L.,
Mitchell, S. K., & Spieker, S. (1988). Prevention of
parenting alterations for women with low social
support. Psychiatry, 51, 248253.
McNair, D. M., Lorr, M., & Droppleman, L. F. (1981).
Profile of mood states: Manual. San Diego: Educational and Industrial Testing Service.
Rosenberg, M. (1965). Society and the adolescent selfimage. Princeton: Princeton University Press.
Swanson, K. M. (1990). Providing care in the NICU:
Sometimes an act of love. Advances in Nursing Science, 13(1), 6073.
Swanson, K. M. (1991). Empirical development of a
middle-range theory of caring. Nursing Research,
40, 161166.
Swanson, K. M. (1993). Nursing as informed caring for
the well-being of others. Image, 25, 352357.
Swanson, K. M. (1999). Whats known about caring in
nursing science: A literary meta-analysis. In Hinshaw, A. S., Feetham, S., & Shaver, J. (Eds)., Handbook of clinical nursing research. Thousand Oaks,
CA: Sage.
Swanson, K. M. (1999a). The effects of caring, measurement, and time on miscarriage impact and womens
well-being in the first year subsequent to loss, Nursing Research, 48, 6, 288298.
Swanson, K. M. (1999b). Research-based practice with
women who miscarry. Image: Journal of Nursing
Scholarship, 31, 4, 339345.
Swanson-Kauffman, K. M. (1983). The unborn one: The
human experience of miscarriage (Doctoral dissertation, University of Colorado Health Sciences Center,
1983). Dissertation Abstracts International, 43,
AAT8404456.
Swanson-Kauffman, K. M. (1985). Miscarriage: A new
understanding of the mothers experience. Proceedings of the 50th anniversary celebration of the
University of Pennsylvania School of Nursing,
6378.
Swanson-Kauffman, K. M. (1986a). A combined qualitative methodology for nursing research. Advances in
Swanson-Kauffman, K. M. (1986b). Caring in the instance of unexpected early pregnancy loss. Topics
in Clinical Nursing, 8(2), 3746.
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Swanson-Kauffman, K. M. (1988). The caring needs of

women who miscarry. In Leininger, M. M. (Ed.),
Care: Discovery and uses in clinical and community nursing. Detroit: Wayne State University Press.
Watson, M. J. (1979/1985). Nursing:The philosophy
and science of caring. Boulder, CO: Colorado Associated Press.
420
Watson, M. J. (1985/1988). Nursing: Human science

and human care. New York: National League for
Nursing.
Chapter 24
Part 1
Marilyn Anne Ray

The Theory of
Bureaucratic Caring
The Theory of Bureaucratic Caring Revisited:
From Grounded Theory to Holographic Theory
Contemporary Nursing Practice
Practice Theory Reviewed: Evolution of Theory
Development
Revisioning the Theory of Bureaucratic Caring as
Holographic Theory
Summary
References
Marilyn Anne Ray

Marilyn A. Ray, RN, PhD, CTN, CNAA, is a professor
at Florida Atlantic University, College of Nursing, in
Boca Raton, Florida. She holds a bachelors of science in nursing and a masters of science from the
University of Colorado in Denver, Colorado, a masters of arts in cultural anthropology from McMaster
University in Hamilton, Canada, and a doctorate
from the University of Utah. She recently retired as a
colonel after 30 years of service with the U.S. Air
Force Reserve Nurse Corps. As a certified transcultural nurse, she has published widely on the subjects
of caring in organizational cultures, caring theory
and inquiry development, transcultural caring, and
transcultural ethics. She is associate editor of the
Journal of Transcultural Nursing. Dr. Rays research
has revolved around technological and economic issues related to caring in complex organizations. Her
current research, which uses both qualitative and
quantitative research methods, relates to the study of
the nurse-patient relationship as an economic resource and how the economics of health and managed care are affecting the practice and administration of nursing. She is active in local and national
political and educational activities. She was recently
elected vice president of Floridians for Health Care,
Inc., and is a charter member of the Nurses Network
for a National Health Care Program.
THE THEORY OF BUREAUCRATIC

CARING REVISITED: FROM
GROUNDED THEORY TO
HOLOGRAPHIC THEORY
by Marilyn Anne Ray
Theory is the intellectual life of nursing (Levine,
1995): Scientific theories in the discipline of nursing
have developed out of the choices and assumptions a
particular theorist believes about nursing, what the
basis of nursings knowledge is, and what nurses do
or how they practice in the real world (Ray, 1998, p.
91). Van Manen (1982) refers to theory as wakefulness of mind or the pure viewing of truth. Truth in
the Greek sense is not the property of consensus
among theorists but the disclosure of the essential
nature or the good of things. In essence, truth refers
to contemplating the good (van Manen, 1982). Collectively, theories in nursing have focused on the
good of nursingwhat nursing is and what it does or
should do. Based on the assumptions of nursing as
serving the good, the locus of the discipline centers
422
on caring for others, caring in the human health experience (Newman, 1992; Newman, Sime, & Corcoran-Perry, 1991). A theory of nursing actually must
edifydirect or enlighten the good. Theories such as
the classical grand theories in nursing demonstrate a
variety of integrated approaches to nursing based on
the worldview of an individual theorist. Ongoing research through testing and evaluation has supported
the validity and reliability of the theories. Grounded
or middle-range theories, however, focus on particular aspects of nursing practice and are commonly
generated from nursing practice. As such, some intellectuals view middle-range theories as more relevant
and useful to nursing than the application of grand
theories (Cody, 1996). Newer approaches to theory,
such as holographic theory/complexity theory (Battista, 1982; Davidson & Ray, 1991; Harmon, 1998;
Wheatley, 1994; Wilbur, 1982), center on the multiple interconnectedness and relational reality of all
things, the interdependence of all human communities, and the concept of choice.
Levine (1995) pointed out that one of nursings
most recent innovations, nursing theory, has already
received its share of criticism and skepticism from
educators and practitioners. Many schools of nursing
pride themselves on taking a theoretical approach
and believe that nursing theory is not a part of nursings consciousness and professional life. This thinking often results from the way in which some nurses
view theoryas abstract, esoteric, or distant from
everyday life. Frequently critics say that after all the
research, theory has contributed little to guide nursings practical tasks and responsibilities. The criticism persists, especially because of the strength of
the varying worldviews or paradigms of organizational social systems, such as the power of the current economic system, which impact nursings professional practice. Given the interpretive nature of
consciousness or wakefulness, this author holds the
position that nurses do operate within a theory or
theories by integrating their knowledge and experience. These theories, whether positive or negative,
are established by the way in which nurses interpret
their world and in the context where nursing is
played out. Theories in this sense are philosophies or
ideologies that serve a practical purpose. The Theory
of Bureaucratic Caring illuminated in this chapter is a
theory with a practical purpose that emerged from
the worldviews of health professionals and clients
in practice (Ray, 1989). This chapter will present a
discussion of contemporary nursing culture, share
theoretical views related to the authors developmental theoretical vision of nursing, and discuss the
Theory of Bureaucratic Caring as grounded theory.
After revisiting the

theory in the contemtheory, such as holographic porary age, the author
will elucidate bureautheory, center on multiple cratic caring theory as a
interconnectedness and re- holographic theory to
further the good of
lational reality of all things. nursing by illustrating
the significance of spiritual and ethical caring in relation to the structural dimensions of complex organizations and societal cultures.
Newer approaches to
CONTEMPORARY
NURSING PRACTICE
The Current Context: Organizational
Cultures as Bureaucracies
The practice of nursing occurs in organizations that
are generally bureaucratic or systematic in nature.
Organizational culture has a rich heritage and has
been studied both formally and informally since the
1930s in the United States (Smircich, 1985). Informal
organization or the integration of codes of conduct
encompassing commitment, identity, character, coherence, and a sense of community was considered
essential to the successful functioning or the administering of power and authority in the formal organization. Political, economic, legal, and technical
systems comprise the formal organization. What distinguishes organizations as culture from other paradigms, such as organizations as machines, brains, or
other images (Morgan, 1997) is its foundation in anthropology or the study how people act in communities or formalized structures, and the significance or
meaning of work life (Louis, 1985). Organizational
cultures, therefore, are viewed as social constructions, symbolically formed and reproduced through
interaction (Smircich, 1985). The beliefs about work
show up in organizational policy statements. A nations prevailing tenets and expectations about the
nature of work, leisure, and employment are pivotal
to the work life of people; hence, there is an interplay between the macrocosm of a national/global
culture and the microcosm of specific organizations
(Eisenberg & Goodall, 1993). In recent years, economics has been a potent contestant in macro- and
microcultures. Now there is an ever greater concentration of economic and political power in a handful
of corporations, which separate their interests
which are usually profit-drivenfrom the interests
of human beings, which are life-centered (Korten,
1995). Health care and its activities are tightly inter-
woven into the social and economic fabric of nations. In the past decade, impacted by issues of cost
and profit, health-care systems have undergone immense change, particularly in the United States. Confidence in major health-care institutions and their
leaders has fallen so low as to put their legitimacy at
risk. Rather than working for the good of everyone,
these institutions are working for only a relative few,
such as chief executive officers and other financially
oriented administrators. Work life in all sectors has
been redefined by economic, business, technological, and political issues. Little account is taken by formal organizations of the spiritual and ethical dimensions of human beings. The actual work of health care
professionals, especially that of registered nurses
such as caring for the needy or sickis undervalued
in terms of both cost and worth. Human caring work
is viewed as unimportant and generally neglected.
The conflict between health care as a business and
health care as a human need has resulted in a crisis
for health-care organizations. Rather than professional nurse caring work valued as an expression of
ones soul or an expression of ones creative self,
work in health-care organizations is increasingly business and machinelike.
Bureaucracy, considered by some as a machinelike metaphor, plays a significant role in the meanings and symbols of organizations (Ray, 1989). 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 arrangement, predicted that
bureaucratization of enterprise would dominate the
world (Bell, 1974; Weber, 1999). This, of course, can
be witnessed by the current globalization of 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
some world governments. The concept of bureaucratization is thus a worldwide phenomenon (Ray,
1989). Britain and Cohen (1980) stated that, Like 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 (p. 27).
The characteristics of bureaucracies are as follows: a fixed division of labor, a hierarchy of offices,
a set of general rules that govern performances, a separation of the personal from the official, a selection of
personnel on the basis of technical qualifications,
equal treatment of all employees or standards of fairness, employment viewed as a career by participants,
and protection of dismissal by tenure (Eisenberg &
Goodall, 1993). Bureaucracy, while condemned by
Chapter 24 Marilyn Anne Ray The Theory of Bureaucratic Caring
423
some as associated with red tape and inflexibility,

continues to provide the most reasonable way in
which to view systems and facilitate the preservation
of organizations, particularly under the current mergers and acquisitions mentality. In the past two decades there has been a call for decentralization and
the flattening of organizational structuresto become less bureaucratic and more participative. Many
firms have begun to hold to new principles that
honor creativity and imagination (Morgan, 1997).
Even nursing has advanced in a more collaborative or
decentralized manner by its focus on primary nursing in hospitals and more decentralized control from
administration (Nyberg, 1998). But reengineering
and restructuring views have taken hold as economics has swept the globe. Authoritarian models have
replaced the short-lived participative movement toward decentralization and the building of workplace
communities. Power has been put back into the
hands of a few, and authoritarianism governs by
global economics and the market rules (Korten,
1995). As a result, the concept of bureaucracy does
not seem as bad as was once thought. It can be considered as much less radical than the new business
paradigm, which focuses on response to market
forces, subsequently eradicating standards of fairness
for human beings in the workplace. This can be witnessed by the actions taken to ignore the public interests for equity in employment, health security,
sufficient environmental protection, and so forth.
Defending and institutionalizing the rights of the
economically powerful to do whatever best serves
their immediate interests without public accountability for consequences seems to be the order of the day
(Korten, 1995). As such, the author joins with Perrow (1986), who defended bureaucracy as a superior
social tool because of its focus on rationality over

other forms of organization in the contemporary
workplace. Rationality from the authors interpretation relates to the Greek sense of logos or rationality as genesis: as that which brings things into being
(van Manen, 1982, p. 45)what makes human community possible and what is edifying to our spiritual
and intellectual lives.
Caring as the Unifying Focus of Nursing

Caring in nursing brings things into being. It is humane and rational. As such, caring is considered by
many nurse scholars to be the essence of nursing
(Boykin & Schoenhofer, 1993; Leininger, 1981, 1991,
1997; Morse, Solberg, Neander, Bottorff, & Johnson,
1990; Ray, 1989,1994a, 1994b; Swanson, 1991; Watson, 1985, 1988, 1997). Although not uniformly accepted, Newman, Sime, and Corcoran-Perry (1991;
Newman, 1992) characterized the social mandate of
the discipline of nursing as caring in the human
health experience. Caring thus is an influential concept, and the expression caring in the human health
experience emphasizes the social mandate to which
nursing has responded throughout its history and encompasses the extent of the discipline. Caring, however, is manifested in different and complex ways in
the nursing discipline and profession (Morse et al.,
1990; Newman, 1992). Various paradigms that enfold the care and caring ideal exist in nursing. A paradigm signifies a cluster of basic assumptions that
form a worldview, a way of screening knowledge and
experience to bring forth a new way of understanding the life world (Smircich, 1985). The totality (Fawcett, 1993), the simultaneity (Parse, 1987) and the
unitary-transformative (Newman, 1992) paradigms
have been the prevailing worldviews in nursing and
your thoughts
424
Spiritual/
Religious
Ethical
Educational/
Social
Economic
CARING
Technological/
Physiological
Political
Legal
Figure 241. The grounded theory of bureaucratic caring.
have directed nursing theories. The totality paradigm

demonstrates that nursing, person, society, environment, and health characterize the nature of nursing.
The simultaneity paradigm illuminates the human-environment integral nature of nursing. The unitarytransformative paradigm states that what constitutes
nursings reality is the view that the human being is
unitary and evolving as a self-organizing field embedded in a larger self-organizing field identified by pattern and interaction with the larger whole. Health is
considered expanded consciousness, and caring in
the human health experience is the focus of the discipline (Newman, 1986, 1992; Newman, Sime, &
Corcoran-Perry, 1991). Many caring theories correspond to one or all of these paradigms (Morse, Solberg, Neander, Bottorff, & Johnson, 1990). The
Theory of Bureaucratic Caring has its roots in all
these paradigms by its synthesis of caring and the organizational context (see Figure 24-1).
Bureaucratic Caring Theory:

Emergent Grounded Theory
The Theory of Bureaucratic Caring originated as a
grounded theory from a study of caring in the organizational culture and appeared in the literature in
1989. In the qualitative study of caring in the institutional context, the research revealed that nurses and
other professionals struggled with the paradox of
serving the bureaucracy and serving human beings,
especially clients, through caring. The discovery of
bureaucratic caring resulted in both substantive and
formal theories (Ray, 1984, 1989). The substantive
theory emerged as differential caring and showed

that caring in the complex organization of the hospital was complex and differentiated itself in terms of
meaning by its contextdominant caring dimensions related to areas of practice or units wherein
professionals worked and clients resided. Differential
Caring Theory showed that different units espoused
different caring models based on their organizational
goals and values. The formal Theory of Bureaucratic
Caring symbolized a dynamic structure of caring
which was synthesized from a dialectic between the
thesis of caring as humanistic, social, educational,
ethical, and religious/spiritual (elements of humanism), and the antithesis of caring as economic, political, legal, and technological (elements of bureaucracy) (Ray, 1989).
Although the model demonstrates that the dimension are equal, the research revealed that the economic, political, technical, and legal dimensions
were dominant in relation to the social and ethical/
spiritual dimensions. The theory reveals that nursing
and caring are contextual and are influenced by the
social structure or the culture (normative system)
that is given in the organization. Interactions and
symbolic systems of meaning are formed and reproduced from the constructions or dominant values
held within the organization. In some respect, we
are the organization, which is analogous to Wittgensteins (1969) adage, we are our language.
The theory has been embraced by researchers,
nursing administrators, and clinicians, who, after
witnessing changes in health-care policy in the past
decade, have begun to appreciate how the context
micro- and macroculturesinfluences nursing. Moving away from centering on patient care to the economic justification of nursing and health-care systems
has prompted professionals to desire a fuller understanding of how to preserve humanistic caring within
the business or corporate culture (Miller, 1989; Nyberg, 1989, 1991, 1998). The theory also has been
used in part as a foundation for additional research
studies of the nurse-patient relationship as an economic resource and its importance as financially
dominated integrated health-care systems have grown
(Ray & Turkel, 1998; Turkel, 1997).
PRACTICE THEORY REVIEWED:

EVOLUTION OF THEORY
DEVELOPMENT
Organizations are not working well today. In health
care, registered nurses are disillusioned with the total disregard for their honorable services and for the
425
profession dedicated to the well-being of others.

Everything is increasingly complex. Expectations for
success are diminished to such a point that nurses
are escaping hospitals, yet not fully realizing that
wherever they go they will be haunted by bureaucracies, some functional, most problematic. What, then,
is the deeper reality of nursing practice? The following is a presentation of theoretical views that relate
to bureaucratic caring theory, culminating in a vision
for understanding the deeper reality of nursing life.
Substantive and Formal Theory

Glaser and Strauss (1967; Glaser, 1978; Strauss &
Corbin, 1998) were the first social scientists to present the perspective of social theory, both substantive
and formal, discovered from inductive research processes. Substantive and formal theories emerge from
in-depth qualitative studies of social processesaction and interaction associated with the social world.
Social categories and their properties are generated
from simultaneous processing of collecting, coding,
and categorizing empiric data from interviews and
observations. The researcher considers evidence
about how one event affects another and explains
the things observed and recorded by developing theoretical relationships about the data. Theoretical
sampling (Glaser, 1978) refines, elaborates, and exhausts conceptual categories so that an actual integration of descriptors and categories can facilitate
the discovery of substantive theory. The discovery of
a basic social process is the foundation for substantive theory. The formal theory is generated from both
the inductive process, based on substantive knowledge/theory, and deductive approaches, which draw
upon cumulative knowledge from the social world to
examine the initial propositions advanced. A formal
theory reflects the structure of both processes.
In nursing, grounded theory has been used to
generate theories from and in practice. Qualitative
nurse researchers seek to identify and reveal the social (nursing) processes related to participation and
interaction with caregivers and clients, and depth of
living in the world of health care. On occasion,
methods are mixed to give more richness to the research. For example, ethnography, which is informed by the knowledge of culture, or phenomenology, which is informed by the philosophical
knowledge related to the study of the meaning of experience, can be used to advance theory (Ray, 1989).
Substantive and formal theories generated from practice convey the essential characteristics of nursing to
form a social process related to nursing practice. A
structure is arranged related to the specific concepts
of the theory or theories (Chinn & Kramer, 1995).
426
The Theory of Bureaucratic Caring integrated

knowledge from data that is associated with researching the meaning
and action of caring in The Theory of Bureaucratic
the institutional culture
of a hospital, which re- Caring originated from a
sulted in a substantive study of caring in the
theory of differential
organizational culture
caring. Narrative responses to the meaning of a hospital and led to a
of caring reported by
substantive theory of difdifferent health-care professionals and patients ferential caring.
produced varied beliefs
and values, ranging from humanistic definitions such
as empathy, love, and ethical-religious delineations
to legal, political-economic descriptions. The formal
theory evolved as a result of using the Hegelian dialectical process of examining and connecting codetermining polar opposites of the humanistic dimensions as the thesis of caring in relation to the
dimensions of economics, politics, law, and technology of the bureaucracy as the antithesis of caring.
The process was synthesized into a dialectical, formal Theory of Bureaucratic Caring. The laws of the
dialecticcodetermination of polar opposites, negation of each of the separate codetermining opposites, and synthesis of conceptualizations toward
transformation and changedemonstrated that the
understanding of institutional caring as a whole, or
the Theory of Bureaucratic Caring, is simply a representation of its integral nature in contemporary organizational culture. The theory shows that caring
reached its completeness through the process of its
own relevance (Ray, 1989).
Middle-Range Theory
Middle-range theory deals with a relatively broad
scope of phenomena but does not cover the full
range of phenomena of a discipline, as do grand theories that encompass the fullest range or the most
global phenomena in the discipline (Chinn & Kramer,
1995). As such, middle-range theories are generally
considered narrower in scope than grand theories,
and to some extent narrower than formal theory from
the grounded theory tradition. There is a paradox in
caring as middle-range theory. Caring in nursing, for
example, may be considered by some intellectuals in
the discipline as having a narrow scope or a foundation for a middle-range theory. However, others who
have adopted Newmans (1992) paradigmatic view
regarding the focus of the discipline of nursing as caring in the human health experience, or who have se-
riously studied caring, may see it as a broad enough

concept to capture the nature of nursing.
Is the Theory of Bureaucratic Caring a middlerange theory as well as a grounded theory? Middlerange theories are abstract enough to extend beyond
data generated in a specific space, place, and time,
but specific enough to allow for testing the theory in
different arenas or permitting interventions for practice to transform nursing practice (Moody, 1990).
The initial dialectical theory showed that living caring in organizational life with the meaning and symbols in an institutional culture reflects the culture of
the macro or dominant culture. The meaning of caring in the organization showed that that meaning
was constituted within a larger pattern of significance. Organizations are representations of our humanity (Smircich, 1985). Social forms and social
arrangements reflect the interplay between cultural
systems of thought and organization. The system reflected the symbols of political and economic power
and authority and psychodynamics of caring in human experience. Middle-range theory embodies the
perspective that these theories fall between the concrete world of practice and the grand theories that
guide nursing research and practice (Moody, 1990).
Bureaucratic caring reflects the concrete world of
practice and responds to the caring ideal that is
unique to nursing. Therefore, the Theory of Bureaucratic Caring is not only a grounded theory but also a
middle-range theory; it could also be considered a
grand theory because of the ubiquitousness of the
constructs of caring and culture.
Holographic Theory
The holographic paradigm in science recognizes that
the ontology or what is of the universe or creation
is the interconnectedness of all things, that the epistemology or knowledge that exists is in the relationship rather than in the objective world or subjective
experience, that uncertainty is inherent in the relationship because everything is in process, and that
information holds the key to grasping the holistic
and complex nature of the meaning of holography or
the whole (Battista, 1982; Harmon, 1998). Holography means that the implicit order (the whole) and
explicit order (the part) are interconnected, that
everything is a holon in the sense that everything is a
whole in one context and a part in anothereach
part being in the whole and the whole being in the
part (Harmon, 1998; Wilbur, 1982). It is the relational aspect of information that makes it a holistic
rather than a mechanistic construct.
Ray (1998) states: Complexity theory is a scientific theory of dynamical systems collectively referred to as the sciences of complexity(p. 91). Complexity theory has replaced other theories, such as
Newtonian physics and even Einsteins beliefs that
the physical world is governed by law and order.
New scientific views state that phenomena that are
antithetical actually coexistdeterminism with uncertainty, and reversibility with irreversibility (Nicolis & Prigogine, 1989). Thus, both linear and nonlinear and simple (e.g., gravity) and complex
(economic and cultural) systems exist together. One
of the tools 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 communication or choice point phases
or where old patterns disintegrate or new patterns
evolve (Ray, 1994a, 1998). This new science, which
signifies interrelationship of mind and matter, interconnectedness and choice, carries with it moral re-
your thoughts
427
sponsibility and the quest toward wisdom which includes awareness and creativity (Fox, 1994). Certain
nursing theorists have embraced the notion of nursing as complexity in which consciousness, caring,
and choice making are central to nursing (Davidson
& Ray, 1991; Newman, 1986, 1992; Ray, 1994,
1998).
REVISIONING THE THEORY OF

BUREAUCRATIC CARING AS
HOLOGRAPHIC THEORY
Can the Theory of Bureaucratic Caring be viewed as a
holographic theory? The theory arose initially from
the decisions that were made about the structure of
organization (consciousness), the caring transactions
that were engaged in (caring), and the effective negotiations or ability to make choices and reconcile
the system demands with the humanistic client care
needs (choice making). The theoretical processes of
awareness of viewing truth or seeing the good of
things (caring), and communication, are central to
the theory. The dialectic of caring (the implicit order) in relation to the various structures (the explicit
order) illustrates that there is room to consider the
theory as holographic. The synthesis of Bureaucratic
Caring Theory shows that everything is interconnected with caring and the system in a microcosm of
the whole of culture.
How can knowledge of caring interconnectedness motivate nursing to continue to embrace the human dimension within the current economic and
technologic environment of health care? Can higher
ground be reclaimed for the twenty-first century?
Higher ground requires that we make excellent
choices. It is therefore imperative that spiritual and
ethical caring thrive in complex systems. Figure
242, the Holographic Theory of Bureaucratic Caring, illustrates that through spiritual/ethical caring as
the choice point for communication in relation to
the complexity of the sociocultural system, nursing
can reclaim higher ground.
Reflections on the Theory as Holographic

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, a revision toward
this end is taking place in science based on the new
holographic scientific worldview. Nursing has the capacity to make creative and moral choices for a preferred future. Nursing theory can focus on the capacity to continue to direct the good. Nursing is being
428
Physical
SocialCultural
Educational
Legal
SPIRITUALETHICAL
CARING
Political
Technological
Economic
Figure 242. The holographic theory of bureaucratic caring.
shaped by the historical revolution going on in science, social sciences, and theology (Harmon, 1998;
Newman, 1992; Ray, 1998; Reed, 1997; Watson,
1997; Wheatley, 1994). In these new approaches,
constructs of consciousness and choice are central
and demonstrate that phenomena of the universe, including society, arise from the choices that are or are
not made (Freeman cited in Appell & Triloki, 1988;
Harmon, 1998). In the social sciences, the critical
task is to comprehend the relationship between
what is given in culture (the jural order) and what is
chosen (the moral and spiritual), between destiny
and decision. In nursing, the unitary-transformative
paradigm and the various theories of Newman,
Leininger, Parse, Rogers, and the Holographic
Theory of Bureaucratic Caring are challenging nursing to comprehend a similar relationship. The unitary-transformative paradigm of nursing and their
holographic tenets are consistent with the changing
images of the new science despite the reality that
nursing continues to be threatened by the business
model over its long-term human interests for facilitating health and well-being (Davidson & Ray, 1991;
Ray, 1994a, 1998; Reed, 1997; Vicenzi, White, & Begun, 1997). The creative, intuitive, ethical, and spiritual mind is unlimited, however. Through authentic
conscience (Harmon, 1998), we must find hope in
our creative powers.
In the revised theoretical model, everything is infused with spiritual/ethical caring (the center of the
model) by its integrative and relational connection to
the structures of organizational life. Spiritual/ethical
caring is both a part and a whole, and every part secures its purpose and meaning from each of the parts
that can also be considered wholes. In other words,
the model shows how spiritual/ethical caring is involved with qualitatively different processes or systems; for example, political, economic, technological, and legal. The systems, when integrated and
presented as open and interactive, are a whole and
must operate as such by conscious choice, especially
by the choice making of nursing, which always has,
or should have, the interest of humanity at heart.
The model presents a vision, but it is based on the
reality of practice. The model emphasizes a direction
toward the unity of experience. Spirituality involves
creativity and choice and refers to genuineness, vitality, and depth. It is revealed in attachment, love, and
community and comprehended within as intimacy
and spirit (Harmon, 1998; Secretan, 1997). Secretan
(p. 27) 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.
Fox (1994) calls for the theology of worka redefinition of work. Because of the crisis of our relationship to work, we
The synthesis of the Theory are challenged to reinvent it. For nursing, this
of Bureaucratic Caring is important because
shows that everything is work puts us in touch
with others, not only in
interconnected with caring
terms of personal gain,
and that the system is a mi- but also at the level of
service to humanity or
crocosm of the whole culthe community of cliture. The model presents a ents and other profesvision based on the reality sionals. Work must be
spiritual, with recogniof practice. tion of the creative
spirit at work in us.
Thus, 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 as
edifying the good through communication involve
never treating people simply as a means to an end or
as an end itself, but rather as beings who have the capacity to make choices. Ethical contentas principles of doing good, doing no harm, allowing choice,
being fair, and promise-keepingfunctions as the
compass in our decisions to sustain humanity in the
context of political, economic, and technological situations within organizations. Roach (1992) pointed
out that ethical caring is operative at the level of discernment of principles, in the commitment needed
to carry them out, and in the decisions or choices to

uphold human dignity through love and compassion.
Furthermore, Roach (1987) remarked that health is a
community responsibility, an idea that is rooted in
ancient Hebrew ethics. The expression of human caring as an ethical act is
inspired by spiritual Transformation can occur
traditions that emphasize charity. Spiritual/ even in the businesslike
ethical caring for nurs- atmosphere of today if
ing does not question
whether or not to care nurses reintroduce the
in complex systems, spiritual and ethical
but intimates how sincere deliberations and dimensions of caring.
ultimately the facilitation of choices for the good of others can or should
be accomplished. The scientist Sheldrake (1991, p.
207) remarks:
The recognition that we need to change the
way we live [work] is now very common. 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 an age is at hand.
Summary
As the millennium has arrived, nursing in organizations have to arrive as well. There must be an end to
the age of bureaucratic control where powerlessness
and helplessness have reigned. As the Theory of Bureaucratic Caring has demonstrated, caring is the primordial construct and consciousness of nursing. Revisioning the theory as holographic shows that
through creativity and imagination, nursing can
build the profession it wants. Nurses are calling for
expression of their own spiritual and ethical existence. The new scientific and spiritual approach to
nursing theory as holographic will have positive effects. The union of science, ethics, and spirit will engender a new sense of hope for transformation in the
work world. This transformation can occur even in
the businesslike atmosphere of today if nurses reintroduce the spiritual and ethical dimensions of caring. The deep values that underlie choice to do good
for the many will be felt both inside and outside organizations. We must awaken our consciences and act
on this awareness to no longer surrender to injustices and oppressiveness of systems that focus primarily on the good of a few. Healing a sick society
[work world] is a part of the ministry of making
429
whole (Fox, 1994, p. 305). The Holographic Theory

of Bureaucratic Caringidealistic, yet practical; visionary, yet realcan give direction and impetus to
lead the way.
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431
Chapter 24
Part 2
Applicability of Bureaucratic
Caring Theory to Contemporary
Nursing Practice: The Political
and Economic Dimensions
Current Context of Health-Care Organizations
Review of the Literature: Political and Economic Constraints
of Nursing Practice
Economic Implications of Theory of Bureaucratic Caring:
Research in Current Atmosphere of Health-Care Reform
Political/Economic Implications of Bureaucratic Caring
Summary
References
Marian C. Turkel
Ray (1989, p. 31) warned that the transformation of

America and other health care systems to corporate
enterprises emphasizing competitive management
and economic gain seriously challenges nursings humanistic philosophies and theories, and nursings administrative and clinical policies. Approximately 10
years later, in the current managed care environment, there is an intense focus on operating costs
and the bottom line, and caring is often not valued
within the corporate culture. However, nurse researchers, nurse administrators, and nurses in practice can use the political and/or economic dimensions of the Theory of Bureaucratic Caring as a
framework to guide practice and decision making.
Use of these dimensions of the theory integrates the
constructs of politics, economics, and caring within
the health-care organization.
The purpose of this chapter is to illuminate the
notion of political/economic caring in the current
health-care environment. Rays (1989) original
Theory of Bureaucratic Caring included political and
economic entities as separate and distinct structural
caring categories. However, the revised Theory of
Bureaucratic Caring is represented as a complex
holographic theory. Given this philosophical framework, the political and economic dimensions of bureaucratic caring as portrayed in this chapter are illuminated as interrelated constructs.
The political dimension of bureaucratic caring encompasses health-care reform at the national level,
and the economic dimension refers to the economic
impact of these changes at the institutional level. The
chapter includes sections on the current context of
health-care organizations, review of the literature related to the political and economic constraints of
nursing practice, economic caring research, political
and economic implications of bureaucratic caring,
and visions for the future.
CURRENT CONTEXT OF HEALTHCARE ORGANIZATIONS

In the wake of the controversial health-care reform
process that is currently being debated in the United
States, the central thesis in todays economic healthcare milieu in both the for-profit and not-for-profit
sectors is managed care (Kongstvedt, 1997). Managed care is an economic concept based on the
premise that purchasers of care, both public and private, are unwilling to tolerate the substantial growth
of the last several years in health-care costs. Managed
care involves managed competition, an economic
concept that is based on the premise that health-care
434
prices will fall if hospitals and providers are forced to

compete on the basis of cost and quality, like other
industries (Kenkel, 1992). Within traditional complex health-care organizations, community or public
health agencies, or alternative health systems such as
health maintenance organizations, financing in relation to managed care and managed competition is
becoming a topic of heated discussion in the development of operational goals. This new form of
health-care financing, based on the ratio of benefits
over costs or the highest quality services at the lowest available cost (Prescott, 1993a, p. 192), challenges the old ways of
competing for and payThe human dimension of
ing for health-care services. Cost-saving mea- health care is missing from
sures integrating patient
the economic discussion.
outcomes are paramount
to health-care organizational survival and the economic viability of professional nursing practice.
As the United States is in the midst of radical
health-care changes, the entire debate focuses on the
concept of economics. From an economic perspective, health-care organizations are a business. The
competition for survival among organizations is becoming stronger and cost controls are becoming
tighter. However, the human dimension of health
care is missing from the economic discussion.
In the economic debate, the belief in caring for
the patients as the goal of health-care organizations
has been lost. Ray (1989) questioned how economic
caring decisions are made related to patient care in
order to enhance the human perspective with a corporate culture. When patients are hospitalized, it is
the caring and compassion of the registered nurse
that the patients perceive as quality care and making
a difference in their recovery (Turkel, 1997). The
concerns of patients are not about costs or healthcare finance.
However, in a climate increasingly focused on
economics, it has become difficult to quantify the
economic value of caring. Consequently, newer cost
systems, such as managed care, do not look at human caring or the nurse-patient relationship when allocating resource dollars for reimbursement.
Historically, nursing care delivery has not been financed or costed out in terms of reimbursement as a
single entity. The prospective payment system of diagnostic related groups (DRGs) connected nursing
services to the bed rate for patients (Shaffer, 1985).
The current reimbursement systems, including health
maintenance organizations (HMOs), managed care,
Medicare, Medicaid, and private insurers, are reim-
bursing hospitals at a flat capitated rate. Subsequently, it is hospital administrators who must determine how these resource dollars will be allocated
within their respective institutions.
Thus, it is necessary for caring nursing interactions to be viewed as having value as an economic resource. When professional nursing salary dollars are
viewed as an economic liability that limits the potential profit margins of organizations, they are examined closely, and in many instances the number of
registered nurses has been significantly reduced
(Ketter, 1995). Hospital executives attribute these
workforce reductions to the declining reimbursements of a managed care environment. It is imperative to the future of professional nursing practice
that the economic value of caring be studied and
documented, so human caring is not subsumed by
the economics of health care.
REVIEW OF THE LITERATURE:

POLITICAL AND
ECONOMIC CONSTRAINTS
OF NURSING PRACTICE
In order to use the economic dimension of the
Theory of Bureaucratic Caring to guide research,
nursing administration, and clinical practice, it is
necessary to understand both the way in which
health care has been financed and the current reimbursement system. Nurses, who understand the economics of health-care organizations, will be able to
synthesize this knowledge into a framework for practice that integrates the dimensions of economics and
human caring.
Nursing had its origins in poorly paid domestic
work and charitable religious organizations (Dolan,
1985). Prior to the establishment of Medicare and
Medicaid in 1965, the health-care system was not
profitable for hospitals. Nursing students subsidized
hospitals, and hospital-based nursing care was not
considered an expense or source of revenue (Lynaugh & Fagin, 1988).
Nursing students provided the labor, and hospital
administrators made no attempt to identify the real
cost of nursing care. As nursing education moved
away from the hospital setting to universities in the
late 1950s and the role of the student nurse was reformed, hospital administrators began to account for
the actual cost and revenue of hospital nursing care
(Lynaugh & Fagin, 1988). However, the retrospective reimbursement of Medicare and Medicaid in
1965 allowed for hospital profitability and the issue
of nursing care costs was not confronted.
During this era of retrospective reimbursement

(1965 to 1983), the actual cost of nursing care was
unknown because it was embedded in the daily hospital room charge. However, acute care hospitals had
been under scrutiny because of the rapidly escalating
costs of health care. A 1976 report from the National
Council on Wage and Price Stability reported that
during the period of 1965 to 1976, hospital costs and
physicians fees rose more than 50% faster than the
overall cost of living (Walker, 1983). Hospital administrators were under considerable pressure to control
costs.
Nursing service represented the largest hospital
department and was singled out as a major cost in
operating expenditures (Porter-OGrady, 1979). It
was assumed that the rising costs of health care were
due to nurses salaries and the number of registered
nurses (Walker, 1983). Yet nursing costs as a percent
of hospital charges could not be identified, because
historically they had been tied to the room rate.
During the late 1970s and early 1980s, health-care
costs continued to rise. Health-care costs did not follow traditional economic patterns. Cost-based reimbursement altered the forces of supply and demand.
In the traditional economic marketplace, when the
price of a product or service goes up, the demand
decreases and consumers seek alternatives at lower
prices (Mansfield, 1991). However, in the healthcare marketplace, consumers did not seek an alternative as the price of hospital-based care continued to
rise (DiVestea, 1985). This imbalance of the supply
and demand curve occurred because consumers
paid little out-of-pocket expense for health care.
Government expenditure for the cost-based reimbursement system was predicted to bankrupt Social
Security by 1985 unless changes were made (Gapenski, 1993). In an attempt to control hospital costs,
the prospective payment system based on DRGs was
instituted.
As a result of the change to the prospective payment system, hospital administrators were pressured
to increase efficiency, reduce costs, and maintain
quality. Consequently, nursing administrators needed
to develop systems to gather information relative to
nursing costs and productivity. Research was conducted in order to examine the costs associated with
nursing (Bargagliotti & Smith, 1985; Curtin, 1983;
McCormick, 1986; Walker, 1983). Common to all
these studies was the use of a patient classification
system that was time-based, and a predictor of the
level of care needed for each class of patient. Data
derived from these studies were used to calculate
nursing costs per DRG, to predict expenditures, and
to determine nursing productivity.
Chapter 24 Marian C.Turkel Applicability of Bureaucratic Caring Theory
435
your thoughts
These studies identified the amount of times

nurses spent doing specific interventions, but underrepresented the wide variations and clinical complexity of nursing care. Nor did this cost-accounting
process include the humanistic, caring behaviors of
nurses; consequently, the costs associated with the
humanistic caring behaviors were not determined.
Foshay (1988) investigated 20 registered nurses
perceptions of caring activities, and the ability of patient classification systems to measure these caring
activities. Findings from this study revealed that patient classification systems could not address the
emotional needs of patients, the needs of the elderly,
or unpredictable events that required intensive nursing interventions (Foshay, 1988). Specific caring behaviors that could not be measured included giving a
reassuring presence, attentive listening, and providing information.
Other research of this time period focused on the
cost and outcomes of all registered nurse staffing patterns (Dahlen & Gregor, 1985; Glandon, Colbert, &
Thomasma 1989; Halloran, 1983; Minyard, Wall, &
Turner, 1986). These studies showed that nursing
units staffed with more registered nurses had decreased costs per nursing diagnosis, increased patient satisfaction, and decreased length of stay.
Helt and Jelinek (1988) examined registered
nurse staffing in five different hospitals over 2 years.
During this time period, the hospitals had increased
their nursing skill mix from 60% to 70% registered
nurses. It was shown that, although the acuity of
hospitalized patients increased, the average length of
stay dropped from 9.2 to 7.3 days (Helt & Jelinek,
1988). Nursing productivity improved and quality of
care scores increased with the increased registered
436
nurse staffing. The higher costs of employing registered nurses was offset by the productivity gains,
and the hospitals netted an average of 55% productivity savings (Helt & Jelinek, 1988).
Hospital administrators had made budgeting and
operating decisions based on the undocumented belief that nursing care accounted for 30 to 60% of patient charges. Thus, as stated earlier, nursing services
were considered to be a major cost for hospitals.
However, documented nursing research showed this
assumption to be in error. A study conducted at Stanford University Hospital found that actual nursing
costs constituted only 14 to 21% of total hospital
charges (Walker, 1983). Similarly, the Medicus Corporation funded a study in which data were collected
from 22 hospitals and 80,000 patient records. Direct
nursing care costs represented on average only
17.8% of the Medicare reimbursement for each of the
top 40 DRGs (McCormick, 1986). In a study of
Medicare reimbursement and operating room nursing costs, nursing represented only 11% of the total
operating costs (Jennings, 1991).
By the time nursing researchers had demonstrated the difficulty of costing out caring activities
with patient classification systems, and the effectiveness of registered nurse staffing on patient outcomes, patient satisfaction, and mortality, the move
toward managed care had already started. With the
introduction of managed care and increased corporatization of health care, the economic environment
was changing faster than nurse researchers could
document the impact of these changes on clinical
practice. In a managed care environment, reimbursement to hospitals had been further constrained. As a
response to shrinking operating budgets, many hos-
pital administrators have instituted registered nurse

staff reductions or used unlicensed nursing assistants
to replace registered nurses.
ECONOMIC IMPLICATIONS
OF BUREAUCRATIC CARING
THEORY: RESEARCH IN
CURRENT ATMOSPHERE
OF HEALTH-CARE REFORM
Investigation of the economic dimension of bureaucratic caring is being explicated in part in nursing research studies. Findings from these research studies
have been valuable when linking the concepts of politics, economics, caring, cost, and quality in the new
paradigm of health-care delivery. Although caring
and economics may seem paradoxical, contemporary health-care concerns emphasize the importance
of understanding the cost of caring in relation to
quality.
Miller (1987, 1995), Nyberg (1990, 1991), Ray
(1987, 1989, 1997), Ray and Turkel (1997, 1998),
and Valentine (1989, 1991) have examined the paradox between the concepts of human caring and economics. It was a challenge for nurses to combine the
science and art of caring within the economic context of the health-care environment. However, according to Nyberg (1990), human care is what patients want from the nursing profession.
Nyberg (1990) examined human care and economics in the hospital nursing environment. The Nyberg Caring Assessment Scale was used to determine
which caring attributes were important to nurses
and how often they used these caring attributes in
practice. At the end of the questionnaire, four openended questions were asked: Two concerned economics and two concerned caring. One hundred and
thirty-five nurses from seven hospitals participated in
the study. Interviews were conducted with the nurse
executives of each hospital. The executives were
asked to define human care and economics.
There was little significant difference in which
caring attributes were important to nurses among
the seven hospitals. However, correlation studies indicated that the ability to use these caring attributes
in practice was positively correlated to the number
of nursing hours per patient day used at the various
hospitals.
Open-ended questions suggested that nurses
were extremely frustrated over the economic pressures of the past 5 years, but that human care was
present in nurses day-to-day practice. According to
Nyberg (1989, p. 17), [T]odays economic environment constrains human care, but nurses see human
care as their responsibility and goal. Nurse executives agreed that care and economics must be viewed
as interdependent. One nurse administrator proposed caring as the mission of the hospital with economic and management as supporting facets (p.
14). Although human care is the goal of nursing, economics cannot be ignored.
Miller (1995, p. 30) used Nybergs Caring Assessment Tool to evaluate nurses ability to care on eight
different pediatric nursing units in seven Colorado
hospitals. Although there were organizational differences, results showed a high correlation of caring attributes among the various settings. Interviews conducted with nurses indicated a concern that their
ability to be caring was in jeopardy. Some of the responses they gave included financial pressure on the
hospital distracts us from our mission of caring and
managed care emphasizes the efficiency of nursing
tasks over caring (p. 30). These nurses felt that the
practice of caring was being seriously threatened by
the economic pressure associated with health-care
changes.
Ray (1997) interviewed six nurse administrators
to study the art of caring in nursing administration.
The theme, economic-political-ethical valuing and its
three attributes of exchanging commodity values, negotiating the politics, and valuing the ethic of caring,
showed that the caring expressions of nurse administrators are bound to the economics and politics of
the organization (Ray, 1997). Narrative examples of
the attribute, exchanging commodity values, were
making caring tangible and patient care is a commodity (economic good or value). Narrative examples of the attribute negotiating the politics were
the nurse administrator is a system coordinator,
nurses are the system and know what impinges on
them, and nurses are political beings (powerful in
the organization). Narrative examples of the attribute, valuing the ethics of caring, were the nurse
administrator needs to be caring and shouldnt be
like other administrators, and value of nursing
is to care holistically. Findings from this research
study validate the interwoven relationship among
caring, economics, and politics within organizational
culture.
What is the role of professional nursing in the current atmosphere of health care economic reform?
How are nurses preparing for changes, especially external control over the discipline and practice of
nursing? Concern by nurses for humanistic caring
and the preservation of the nurse-patient relationship in all aspects of clinical practice is growing.
437
In an attempt to answer these questions, nursing

inquiry over the last 2 decades has firmly established
that the focus of nursing is caring in the human
health experience (Boykin & Schoenhofer, 1993;
Leininger, 1981; Newman, Sime, & Corcoran-Perry,
1991; Ray, 1994; Watson, 1985). Caring between
nurse and patient occurs within the realm of the
nurse-patient relationship.
A recent nursing study demonstrated that highquality care is located in the reciprocal actions of the
interpersonal nurse-patient relationship (HoggardGreen, 1995). Turkel (1993) used an ethnographic
approach to study nurse-patient interactions in the
critical care environment. The subsequent theme
generated among all categories of interaction was the
nurse-patient relationship. In a qualitative study,
Price (1993) examined the meaning of quality nursing care from the perspective of parents of hospitalized children. A key category that emerged from the
data was a positive relationship between quality of
care and parents perspectives. In the wake of workplace restructuring as a result of health-care reform
and managed care, nurses are finding themselves in
a period of transition, moving from traditional inpatient hospital practice to community-based practice. In a research study conducted by Turkel, Tappen,
and Hall (1999), the development of a positive nursepatient relationship was shown to be seen as a reward
for nurses undergoing change in practice roles.
The foregoing studies identified the critical nature
of the nurse-patient relationship. However, these studies did not merge economic concepts into nursing research or theory. As the nursing practice environment
has continued to change, new research is needed to
explore how nurses can continue to provide humanistic care with limited economic resources.
Challenge to Researchers
The challenge to articulate the economic value of the
nurse-patient relationship as a commodity, just as
goods, money, and services are viewed in traditional
economics, is imperative. Foa (1971), an exchange
theorist, designed an economic theory that could
bridge the gap between economic and noneconomic
resources. In this model, noneconomic resources
(love, status, and information) were correlated with
economic resources (money, goods, and services).
According to Ray (1987, p. 40), [T]he inclusion of
these resources is necessary and will require a major
effort on the part of nurses and patients to see that
they become an integral part of the health care economic analysis.
In order to appraise the nurse-patient relationship
as an economic interpersonal resource, it is neces-
438
sary to conduct qualitative and quantitative research

studies to describe this unique relationship as an economic exchange process and economic resource.
The philosophical framework of the economic dimension of bureaucratic caring has served in part as
the basis for this type of needed nursing research.
Turkel (1997) interviewed nurses, patients, and administrators from the for-profit sector to examine the
process involved in the development of the nursepatient relationship as an economic resource. No
other published research has included the perspective of nonnursing hospital administrators when
studying the nurse-patient relationship. In addition,
this research was conducted as managed care penetration was having an enormous impact on the current health-care delivery system.
Interviewing participants was the primary source
of data collection for Turkels (1997) grounded
theory study. Participants descriptions of their experiences provided the researcher with rich data for
simultaneous data analysis. The initial interviews began with a general open-ended question. Nurses, for
example, were asked, Tell me about a typical day on
your unit. Start with I come to work. . . . Patients
were asked, Tell me about a day in the hospital.Administrators were asked, How would you describe a
typical day for a nurse from your understanding of
the experience?
As the interview process proceeded, more specific questions were asked, including inquiries about
specific nurse-patient interactions and the costs and
benefits associated with these interactions. Use of
the word costs was consistent with the challenge to
nurse researchers by Buerhaus (1986) to conduct interviews that provide economic or dollar value data
in relation to caring nursing interactions.
The researcher examined the data for relationships among categories for each group of participants: nurses, patients, and administrators. Subsequent relationships were also discovered by looking
at similarities and differences among these three
groups. The combined analysis of the responses of
nurses, patients, and administrators described the
process of establishing the nurse-patient relationship
within the ever-changing health-care environment.
Results from this research study were characterized
by the categories of sustaining the caring ideal while
simultaneously facing a new reality controlled by
costs.
Despite the economic changes of the current
health-care environment, all three groups of participants talked about the importance of a positive
nurse-patient relationship. The concept of caring between the nurse and the patient was recognized and
valued by the nurses, patients, and administrators.

Sustaining the caring ideal was operationally defined as acknowledging the relationship and differentiating caring.
The economic changes in health care brought
about a new reality for practice controlled by costs.
Nurses, patients, and
The economic changes in administrators were affected by these changes
health care brought about a and the subsequent imnew reality for practice pact on nursing care
delivery within the hoscontrolled by costs. pital. Facing a new reality was defined as enduring chaos, calculating the costs, and anticipating
future concerns.
Diminishing health-care resources was the basic social problem encountered by nurses, patients, and administrators. The basic social process of the nursepatient relationship as an economic resource was
struggling to find a balance, which referred to sustaining the caring ideal in a new reality controlled by costs.
In a study conducted by Ray and Turkel (1997),
qualitative interviews were accomplished in not-forprofit and military sectors of the health-care delivery
system. The purpose of this research was to continue
the study of the nurse-patient relationship as an economic interpersonal resource. Findings from this
study identified that the nurse-patient relationship
was both outcome and process. Categories, which
emerged during data analysis, included relationships,
caring, and costs.
In the study, a formal theory of the nurse-patient
relationship as an economic resource was generated
from the qualitative research. The formal theory
emerged as relationship (set of variables). The formal
theory consisted of two parts: (1) relationship as a
function of interactions or the intentionality and actions of nurses and patients; and (2) the value of the
interactions, or what are the important interactions.
Although this theory is described as a linear process,
the process is dynamic and holistic, and is considered both outcome and process. Relationship is intentional, action-oriented, and characterized by both
economic and caring dimensions. As testing of this
theory continues via quantitative research, it is
highly probable that this new theory will fall in the
category of nonlinear dynamic theory development.
Continued Research on
Economics and Caring
In order to measure the nurse-patient relationship as
an economic resource and to refine and test the
theory, Ray and Turkel (1998) developed the NursePatient Relationship Resource Analysis (NPRRA)
Questionnaires (patient and professional). It is anticipated that this research will facilitate understanding
of the value of nursing in the health-care system. Research conducted in practice settings provides an integrated link for theory, research, and practice.
Tool Development
The NPRRA Questionnaires are a 45-item instrument
for patients and professionals designed from qualitative research (Ray & Turkel, 1997) and validated and
established as reliable through quantitative research
(Ray & Turkel, 1998). Research questions were asked
of participants by means of interviews to elicit information describing benefits of the nurse-patient relationship and perceived costs related to this interaction. Patterns of interaction and knowledge of cost
parameters of the nurse-patient relationship were
the foundation for the construction of the questionnaire. Three central categories of relationships, caring, and costs, with related subscales and properties,
served as the basis for the items of the questionnaire.
Initially, the instrument response set was a Likerttype scale with six response choices; now there are
five response choices. Initial instrument testing included assessment of the level of readability and review by a panel of experts. At the outset, the initial
questionnaire consisted of 89 items; however, after a
prepilot cluster analysis was conducted, the questionnaire was made into two and the number of
items was reduced to 60, which was further reduced
to 45 items after a pilot study. The questionnaire was
then redistributed to a sample of over 300 nurses, patients, and administrators from the for-profit, not-forprofit, and military settings. Reliability of .81 was established using Cronbachs alpha and test/retest.
Validity was determined by the Index of Context Validity and factor analysis.
At this time, Ray and Turkel are in the process of
administering the questionnaires to over 600 respondents on a national level. Findings from this research
in process will use regression analysis to determine
whether or not there is a correlation between the
nurse-patient relationship and patient outcomes
such as health, well-being, satisfaction, and cost. The
long-term goal of this research is to establish the
nurse-patient relationship as an economic interpersonal resource. In order to successfully merge economics and caring, it is necessary for researchers to
examine the dynamic patterns of interpersonal relationships as economic resources and their subsequent effect on health, healing, nurse-patient satisfaction, and costs.
439
POLITICAL/ECONOMIC
IMPLICATIONS OF
BUREAUCRATIC CARING
Findings from current nursing research on the economic dimension of bureaucratic caring can be used
to guide administrative practice within health care
organizations. As a dimension of her 1997 research,
Turkel (1997) interviewed eight top-level hospital
and corporate-level administrators to gain an understanding of how they viewed the experiences of
nurses and patients in the hospital setting. Administrators were chosen to be interviewed because they
make the ultimate decision on how to allocate scarce
human and economic resources within the organizational setting.
Administrator participants explained the value
and importance of the nurse-patient relationship.
They discussed receiving letters from patients, scoring high on surveys, and getting positive verbal feedback from patients as indicators of caring nursepatient interactions. One administrator shared the
following with the researcher (Turkel, 1997, p. 148):
Lying in a bed like that, people feel vulnerable
and are vulnerable, and they want to know
that someone is there for them and will share
with them whats going on. And it has to do
with the caring. I hear [patients say] that my
nurse cared, she listened, and she kept me informed. I would say that more than half of the
positive comments I receive from patients
have to do with the nurses being caring. What
comes back to me is they cared about me, they
took time to talk to me, they were kind to me.
Health Care and Nursing Administration

The results of Turkels (1997) study showed that administrators value caring and high-quality care. However, their actions and the action of other administrators must then reflect these values to ensure that the
caring philosophy of the hospital remains in the forefront of organizational profit-making or economics.
The issue of time constraints and inadequate staffing
has been identified as problematic. Nurses and patients view lack of time as a hindrance to forming a
caring nurse-patient relationship. This points out the
need for administrators to restructure the organization so that the maximum of nursing time is focused
on direct nurse-patient interactions. Hospital administrators desire high levels of quality care and see financial benefits from return business when patients
are satisfied with nursing care. To maintain this standard, administrators must maintain adequate staffing
440
ratios in order to allow time for nurses to be with

their patients.
There has been limited published literature studying the nurse-patient relationship from a nonnursing
administrator perspective (Ray & Turkel, 1997;
Turkel, 1997). However, the changing health-care
environment has been addressed from an organizational perspective (Hammer & Champy, 1993; Iglehart, 1993; Korten, 1995; ODonnell & Sampson,
1994). The organizational focus was on maximizing
efficiency, making a profit, and economic survival.
In the research conducted by Ray and Turkel
(1997), administrator participants confirmed the
above, but also discussed the concomitant need for
maintaining care and quality. The challenge facing administrators in a managed care environment is the simultaneous management of costs, care, and quality.
Ray (1989) asserted that this can be accomplished if
administrators consider both the tangible and intangible benefits of services provided within the organization.
Administrators need to recognize caring as a
value-added interaction. From this point of view, the
benefits of the interaction outweigh the expense of
the registered nurse. Caring can be viewed as an opportunity cost or the cost of doing it right. This concept is applicable to contemporary health-care organizations. If people dont come back to a hospital
(because of poor care), youve lost an opportunity.
Administrative/Nursing Education
The Theory of Bureaucratic Caring is being used to
guide curriculum development in the master of science in nursing administration program at Florida Atlantic University in Boca Raton, Florida. The revised
nursing administration track is entitled Administrative and Financial Leadership in Nursing and Health
Care.Caring and humanizing of the health-care delivery system are key concepts in the cognate and concentration courses. Issues impacting caring, administrative roles, leadership, organizational culture,
health-care delivery systems, health-care policy, and
health-care finance are explored from ethical, spiritual, economic, technological, legal, political, and
social perspectives.
The economic dimension of bureaucratic caring is
a central component of the courses entitled Health
Care Delivery Systems, Health Care Policy, and
Health Care Finance. In Health Care Delivery Systems, students are challenged to analyze the current
economic and reimbursement structure of health
care from the perspective of a caring lens. Throughout the course, students develop strategies to challenge the present economic structure and shape the
future by advancing caring as a central component of

health-care delivery systems. The course culminates
in the creation of a futuristic model for humanizing
the health-care delivery system through the convergence of caring and economics.
In the course entitled Health Care Policy, the economic and political dimensions of bureaucratic caring
are explored. Emphasis is placed on the role of the
professional nurse on influencing the policy-making
process in terms of policy redesign. Students are encouraged to dialogue with members of the legislature
and discuss both the economic and political impact of
humanizing the health-care delivery system.
The Health Care Finance course is integral to the
students understanding of the synergy between
nursing and finance within organizational cultures.
As students prepare budgets and review financial
statements, they validate how health-care organizations respond to being known for caring and still remain financially viable. Given todays environment, it
is important for students to understand the fiscal and
resource constraints imposed by managed care. Students synthesize acquired knowledge grounded in
the perspective of caring to create a balance between caring and finance within organizations.
Nursing Practice
The economic dimension of bureaucratic caring can
be used to guide practice. A common yet challenging
goal of health-care organizations is to reduce cost
while simultaneously improving quality patient care.
Now is the time for professional nurses to become
proactive and use theory-based practice to shape
their future instead of having the future dictated by
others outside the discipline. Staff nurses can hold
close their core value that caring is the essence of

nursing, and still retain a focus on meeting the bottom line.
Recent quantitative studies have demonstrated
that higher registered nurse staffing ratios are linked
to better patient outcomes and decreased lengths of
stay (Blegen & Vaughn, 1998; Blegen, Goode, &
Reed, 1998; Brooten & Naylor, 1995; Duffy, 1990).
Other studies have linked nurse caring to increased
patient satisfaction and improved patient outcomes
(Duffy, 1992; Larson & Ferketich, 1993; Valentine,
1989, 1991, 1993).
Numerous qualitative studies have documented
the relationship between caring and positive patient
outcomes (Duffy, 1992; Eriksson, 1997; Ray &
Turkel, 1997; Valentine, 1998; Zerwekh, 1997). In
these studies, the definition of outcomes was expanded from the traditional measures of process and
product of care, mortality, morbidity, and adverse effects. Examining outcomes from the perspective of
caring involved vivid descriptions and stories of how
nurses transformed their patients lives.
In a slight departure from other qualitative studies, Boykin and Schoenhofer (1997) explored outcomes within the theoretical context of enhancing
personhood. The value and richness of nursing as
caring was explicated via a nursing situation. Outcomes drawn from this nursing situation included
one each for the nursed (patient), one for the nurse,
and one for the health-care agency. The following is
an example of outcome statements derived from the
nursing situations: [a]ffirmation of self as loving father, sense of personal connectedness, and demonstration of agency services as valuable and culturally
competent (Boykin & Schoenhofer, 1997, pp.
6364).
your thoughts
441
Nybergs recent (1998) research has focused on

the issue of equating patient outcomes with caring.
This demonstration project is designed to measure
caring outcomes after nurses receive education
about caring and caring/healing treatments. The purpose of the research is to obtain the objective measures of caring as required by todays health care
evaluation systems (p. 97).
These empirical studies have firmly established a
link between caring and positive patient outcomes.
Positive patient outcomes are needed for organizational survival in this competitive era of health care.
Given this, professional nursing practice must embrace and illuminate the caring philosophy.
Staff nurses describe the essence of nursing as
the caring relationship between nurse and patient
(Trossman, 1998). However, nurses are practicing 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 reimbursement; instead, it has become
the catalyst for change within corporate health-care
organizations.
Nurses are continuing to struggle with economic
changes. With a system goal of decreasing length of
stay and increasing staffing ratios, nurses need to establish trust and initiate a 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) and
being there from a patient perspective. For the
nurses, this means completing a task while simultaneously engaging with a patient. This holistic approach to practice means viewing the patient as a
person in all his or her complexity and then identifying the needs for professional nursing as they arise.
must be integrated into staff development curricula.

Nurses need to search continually for different approaches to professional practice that will incorporate caring in an increasingly technical and costdriven environment. Doing more with less no longer
works; nurses must move outside of the box to create innovative practice models based on nursing
theory.
Administrative nursing research needs to continue
to study the relationship among staff nursing caring,
patient outcomes, and organizational economic outcomes. Further research is required to firmly establish the nurse-patient relationship as an economic resource in the new paradigm of health-care delivery.
Findings from these research studies will continue to
validate the Theory of Bureaucratic Caring as a middle-range holographic practice theory.
Nurses need repeated exposure to the economics
and costs associated with health care. Lack of knowledge in this area means others outside of nursing will
continue to make the political and economic decisions concerning the practice of nursing. Having an
in-depth knowledge of the economics of health care
will allow nurses to
challenge and change Knowledge of the economthe system. A new
theory-based model can ics of health care will albe created for nursing low nurses to challenge
practice that supports
human caring in rela- and change the system.
tion to the organizations economic and political values. The political
and economic dimensions of bureaucratic caring
serve as a philosophical/theoretical framework to
guide both contemporary and futuristic theory-based
nursing practice.
Summary
References
The foundation for professional caring is the blending of the humanistic and empirical aspects of care.
In todays environment, the nurse needs to integrate
caring, knowledge, and skills all at once. Given political and economic constraints, the art of caring cannot occur in isolation from meeting the physical
needs of patients. When caring is defined solely as
science or as art, it is not adequate to reflect the reality of current practice.
Nurses need to be able to understand and articulate the politics and the economics of 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,
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Appendix
Evaluating Nursing
Theory Resources
Why Evaluate Resources for Nursing Inquiry Research?
Evaluation of Resources for Nursing Inquiry and Research
Preparing to Initiate a Search
A Search Example with Strategies
Summary
References
Marguerite J. Purnell
The study of nursing theory is a rich and exciting

journey into the heart and intention of nursing. Reflective appreciation of theory offers a fascinating living connection both to the history of nursing and to
its future. Through the development and use of theory, nursing is able to reflect upon itself and respond
purposefully to human need. The distilled nursing
knowledge that is captured as essence in theory
plainly speaks of nursing that is lived.
WHY EVALUATE RESOURCES

FOR NURSING INQUIRY
AND RESEARCH?
Previous chapters have addressed evaluation of nursing theory. This appendix offers guidelines to help
establish credibility of nursing resources used in inquiry and research. Resources that support development and dissemination of knowledge must themselves be consistent with the intent of nursing theory
and congruent with values expressed in reflective inquiry and research. Resources in nursing should be
authoritative, accurate, and current, and characterized by rich content. The guiding framework for evaluation of resources presented in these pages moves
toward a realistic understanding of the applicability
and utility of the resource. Practical pointers for application of these guidelines, a search example with
strategies, and a way to synthesize evaluation findings should help inquiring individuals maintain a
confident relationship with the resources that undergird inquiry and research in nursing.
Theory as Guiding
Framework for Evaluation
Theory-based practice provides nurses with a perspective (Raudonis & Acton, 1997), and expresses
the essential activity of nursing caring in the enacting, adapting, and adding to the nursing human
knowledge base. The framework for practice also becomes a framework for education, research, and administration (Boykin & Schoenhofer, 1993). Nursing
theory is integrated and lived out in the personhood
of the nurse, continuing to shape, guide, and focus
the nurse in all activities.
Ways of studying nursing are also becoming more
creative and reflect rapid changes in nursing practice
and in embedded and expressed societal values. The
thoughtful study of nursing theory includes not only
consideration of works contributed by the theorist,
but also those works contributed by practitioners
and critics of the theory present in multiple, complex forms of media.
446
The Confluence of Computer

Technology and Nursing
The rapid advance and integration of technology has
not only affected practice, but has also affected ways
in which nurses investigate, evaluate, and think
about practice (Turley, 1996). Computers increasingly dominate familiar environments (Brennan,
1996) and create their own electronic substitutes,
such as websites on the Internet. Ways of inquiry and
research have seemingly become more simple and
less laborious, yet are paradoxically more complex,
with linked and interlinking infrastructures of communication webs and bibliographic databases.
Major emphasis has been placed on evaluating
electronic media for the simple reason that electronic media and the Internet dominate communications, data processing, and storage, and the dissemination of knowledge. Riddlesperger et al. (1996, p.
599) observe that the last 20 years have witnessed
the electronic domain becoming the primary
method for academic and professional communication of research and information. A new science
called nursing information science has evolved
(Graves & Corcoran-Perry, 1996). Hard copy from libraries is routinely being uploaded onto the Internet
for online dissemination. Books and journals themselves are less attractive to many who now prefer the
accessibility and convenience of electronic media
and the redefined or reinvented electronic book or
journal.
Other forms of media, such as magnetic tape, audiotape, and microfiche, are falling into disuse at
varying speeds. Just like outmoded theories, they
too are being replaced by new types of media that
can accommodate greater and more complex information. Databasesvast electronic repositories of
informationhave allowed the capture and expression of the lives of millions of humans on a microchip, and provided the storage, sifting, and retrieval of generations of knowledge and living
encapsulated in the convenience of a small desktop
or laptop computer.
In nursing, also, new ways of searching the literature have transferred the library of the building to
the convenience of a computer hard drive. Time invested in library research has been dramatically reduced through the use of electronic tools. Multiple
databases of nursing literature, once confined to handtyped reference cards, can be accessed, sorted, and
published simultaneously and immediately through
electronic computer interfaces. In most libraries, a
thorough literature search can now no longer be accomplished without a computer. As the indispens-
Appendix Evaluating Nursing Theory Resources
able technology of a pioneer electronic generation in

nursing, computers provide portals to nursing science and to the artifacts of the world. It is through
these same portals we venture in our examination of
flow to evaluate resources for inquiry and research.
EVALUATION OF RESOURCES
FOR NURSING INQUIRY
AND RESEARCH
TheoryConceptual Transformation
Conceptual frameworks in the mind of the nurse provide the means of interfacing and transforming values of the contrived artifice of the electronic data bit
(Carlton, Ryan, & Siktberg, 1998). Located in the intransigence of the electronic nanosecond, virtual
data are fleeting, and only as permanent as the
source of power. Explicit and implicit claims to truth
and reality in electronic media, storage or otherwise,
cannot be easily disputed. To whom or to what does
one respond or carry concerns? A framework of vir-
TABLE APPENDIX1
tual values is thus engineered and deeply embedded

in electronic information technologies. The challenge for the nurse is to analyze, evaluate, and transform electronic frameworks of values into a conceptual framework of human values that are realized in
theory and actualized in practice. The ubiquitous
websitethe most numerous, frequent, and transient of electronic data or resource locators to which
information seekers turnis, for the most part, unregulated. It exists at the will of the website owner.
Claims of authority and ownership of those claims
often cannot be traced or are unprovable. Hebda,
Czar, and Mascara (1998) refer to the necessity for
authority of websites to be validated, and feel it is a
problem unless the source can be traced to a reputable institution, such as in education or government. Table Appendix1, detailing Internet sites
where website addresses of educational institutions
all over the world may be located, begins to address
that particular challenge.
In order to evaluate and substantiate resources for
nursing inquiry such as theorist home pages and
nursing information websites, layers of electronic in-
General Resources
College and University Home Pages

http://www.mit.edu:8001/people/cdemello/univ.html
This is a website that will enable you to search efficiently for college and university home pages by geographical region,
alphabetically, nationally, and internationally. One home page per college or university is available. Several thousand entries
are listed.
American Universities Home Pages

http://www.clas.ufl.edu/CLAS/american-universities.html
This is a linked site to College and University Home Pages. One home page per college or university is available.
In searching for information on theory or theorists, the web address of the home university or academic institution is
frequently elusive. The above websites should facilitate the beginning of the search process for nursing theory information.
The Nursing Theory Page

http://www.ualberta.ca/~jrnorris/nt/theory/html
This is a site at the University of Alberta that serves as a general clearinghouse, where theorists listed are linked back to
their home pages. Some newer, lesser known models and theories are listed. The Nursing Theory Page is created by the
Nursing Theory Page Development Group, whose members are listed with E-mail addresses on this site.
Searching Bibliographic Databases for Nursing Theory

http://www.ualberta.ca/~irnorris/nt/CINAHL/allen.html
Also at the University of Alberta, this page, which is authored by Margaret (Peg) Allen, MLS, AHIP, provides useful, detailed
information for searching CINAHL. Several links are provided to other useful search resource sites on the Internet.
447
formation must be peeled back to reveal those authoritative nurse scholars, scientists, and practitioners who are the source of disseminated nursing
knowledge. Since no two nursing information resources are exactly alike, guidelines for evaluation
should remain flexible and adaptable. Conceptual
frameworks for nursing practice become meaningful
when lived out in the reflective, intentional application of theory in the exchange and transfer of knowledge. The nursing research tool of electronic information must affirm the values both of the nurse
offering and the nurse receiving the transfer of
knowledge. In nursing, a call for nursing is a call for
transforming information; the response from nursing
should be a response with clarity and humility, regardless of the medium used. The consistent evaluation of resources is therefore an affirmation of the
values grounding the practice of nursing.
A Guiding Framework for

Evaluation of Resources
The questions following provide for flexible assessment and insightful evaluation of nursing theory
resources. Although these questions emphasize electronic media, they are also applicable in the evaluation of books, journals, physical archives, and other
resources.
Reflective Preparations:
What do you want to know?
What are your expectations of the resource?
How complex do you expect the information to
be?
How comprehensive do you intend your
analysis and evaluation to be?
Will you share the results of your evaluation
with colleagues?
Focus on Authority:
Who are authoritative sources for information
about development, evaluation, and use of the
theory you are inquiring about? Are they
contributors to the website or media you are
evaluating? For example, who speaks
authoritatively for continuing development for
theorists such as Martha Rogers, Hildegard
Peplau, or Dorothy Johnson?
Who are nursing authorities who speak, write
about, and use the theory? Who are the
practitioners? Are they contributors to this
website or media?
What are the professional attributes of these
persons?
448
What are the attributes of authorities, and

how does one become one?
Which other nurses should be considered
authorities? Why?
What are major resources, other than the one
you are now evaluating, that are authoritative
sources on the theory?
Books? Articles? Audiovisual media? Electronic
media?
What nursing societies share and support
work of the theory? Do they also have a
website?
What service and academic programs are
authoritative sources?
Focus on Content:
What is the purpose of the resource?
Is the resource dedicated to the work of one
theorist, or is it a general resource for the work
of many theorists?
Do sources for authoritative information show
their credentials on the webpage or provide
links to pages that do?
Does the website or media provide accurate
information in a logical and easily accessible
manner?
Is there clear reference to source data?
Where possible, are there specific HTML
links to that data?
Does the website or media provide
comprehensive information?
How detailed is the information presented?
Does it cover nursing research,
administration, and education?
Do related resources present the information
in greater depth?
Is the information presented even in quality and
quantity?
Is the information current? What evidence is
presented to verify currency?
Focus on the website:
Is the website or media well maintained? Are
you able to contact the Webmaster from an
onsite address?
Are there links to other, similar, websites? Are
these links active addresses? Are you informed
when you are seamlessly transferred to another
website?
Are there fees to access information?
Is the website or media aesthetically pleasing?

What unique characteristics enhance your
understanding and appreciation of the theorists
work?
Listed in Table Appendix2 are authoritative resources with which to begin a study of nursing theorists and their theories, and include home pages for
theorists such as Martha Rogers, Dorothea Orem,
and Rosemarie Parse. Home pages and websites are
listed where they are available. Use the guidelines offered to evaluate these websites. It will be helpful to
search out and evaluate other sites dedicated to nursing theory and compare your findings.
Table Appendix1 lists some useful general information on websites which can give you access to a
vast repertoire of nursing information resources
through educational institutions. These sites can also
be evaluated using the above guidelines. The information noted in this chapter is not intended to provide a compendium of websites, facilities, or venues
of information, but rather to facilitate and guide reflective evaluation of nursing theory and other nursing knowledge information resources.
PREPARING TO INITIATE A SEARCH

Begin at the Beginning with Yourself
Organizing and purposefully attending to self before
undertaking research will affirm the intention and focus of your philosophical perspective. Theoretical
frameworks become blueprints for action. Frustrations inherent in new methodologies, new technologies, and virtual information will be less able to deflect your nursing intention to uncover and integrate
nursing knowledge if you are prepared. Attending to
self in ways that are meaningful to you will quiet, focus, and center reflective inquiry.
Connecting with a Computer

If you are new to a computer search of nursing literature, be prepared to spend many, many hours searching for information. When first becoming acquainted
with the electronic world, be prepared to accept that
you will forget where you are on this electronic highway: It takes practice and intense focus to remain on
the elusive information trail. Forgive yourself if you
accomplish little, and forgive the computer if you are
dropped from a key theorist website and dont remember where it was or who the theorist was. Practice self-care by becoming organized and remaining
within the parameters of your inquiry.
Lingering in the Library

In order to conserve time and effort, it is beneficial
to know how to access the library computers to
search for locations of nursing journals, books,
videos, microfiches, and databases before commencing your search. Seek the help of experts before you
attempt the impossible and end up frustrated. Time
spent browsing books and journals because they are
interesting (yet irrelevant to your investigation) also
means time spent returning to the library on another
day to return all the books you dont have time to
read.
Aging in the Archives

Unless you have already used a computer to identify
a specific holding or collection in the archives that
you wish to investigate, engage the help of the
archivist to clarify and expedite your search. A
hands-on search of archived records involves
painstaking handling, lengthy and careful perusing,
and hours of time. Search nursing archives only if
you are unable to access the information elsewhere:
The pleasure of the spirit and feel of nursing history
in its tangible artifacts is enhanced without the constraints of time. Resolve to spend unpressured
leisure time in the nursing archives. In your goaldirected endeavors to balance time, effort, and outcome, however, it is preferable to reserve timerestricted activities for electronic inquiries.
How to Become Organized

Define the reason for your search:
Is your search preparation for creation of a
manuscript? What is the scope of the
manuscript topic?
Is your search the beginning of formal
research? What is the scope of the formal
research?
Is your search simply because you would like
to know more about a theorist or theory to
apply to your practice?
How much time will you be prepared to
invest?
Construct a preliminary time line and
begin a countdown:
When is the absolute deadline for producing
the end productfor example, manuscript
or formal research dissemination?
When is the absolute deadline for completion
of research activities?
449
TABLE APPENDIX2
Theorists:
Nursing Theorist Resources
Anne Boykin
Savina Schoenhofer
Theory:
Theory of Nursing as Caring
Website
The Caring Archives of the Christine E. Lynn Center for Caring

http://www.fau.edu/
This is the home page of Florida Atlantic University. Choose Colleges and then Nursing. A link is provided from the
College of Nursing Home Page to the home page of The Caring Archives of the Christine E. Lynn Center for Caring at FAU
College of Nursing.
These archives were recently instituted for the purpose of humanizing health care through the global dissemination of
caring nursing knowledge. The Caring Archives is beginning to accumulate a database of full text documents of caring
literature as well as a Signature Collection of multimedia information on the nursing theorists and their theories. Special
collections, such as the Nursing Poetry Collection, will house significant contributions to caring in nursing. Access to this
database is free. Watch this growing site for updates and special announcements.
A further link is provided from this website to the International Association for Human Caring (I. A. H. C.)
Theorist:
Virginia Avenel Henderson
Theory:
Basic Care Components
Videotape:
Celebrating Virginia Henderson

Available from: Center for Nursing Press,
550 West North Street, Indianapolis, IN 46202
Website:
Virgina Henderson International Nursing Library

http://www_son.hs.washington.edu/vhl.html
The Virginia Henderson International Nursing Library provides innovative data, information, and knowledge about nursing
research. These resources are provided through two electronic research subscription services: the Registry of Nursing
Research, and the Online Journal of Knowledge Synthesis for Nursing. Both services are maintained by Sigma Theta Tau.
The Online Journal of Knowledge Synthesis for Nursing is free to Sigma Theta Tau members. For more information about
the online services, contact Sigma Theta Tau International at (317) 634-8171 (Library Department), or E-mail:
library@ stti-sun.iupui.edu
Theorist:
Imogene King
Theory:
Archive:
Being developed by the Oakland University School of Nursing
Organization:
King International Nursing Group
Theorist:
Myra Levine
Theory:
Levines Conservation Model
Website:
Allentown College
http://www.allencol.edu
Select: Karen Schaefers home page, and you can choose the link to Levines Conservation Model. Currently, there exists an
up-to-date journal and book reference list. Future changes will include model updates, suggestions, and summaries of the
model.
Select: Shelly Yeagers home page, and a summary of key theorists, including Myra Levine, can be found.
450
TABLE APPENDIX2
Nursing Theorist Resources (Continued)
Theorist:
Betty Neuman
Theory:
Website:
http://www3.bc.sympatico.ca/neuman99/
Organization:
The Neuman Systems Model Trustees Group, Inc.

Neuman College, c/o Director of Library Media and Archives
Neuman College
One Neuman Drive
Aston, Pennsylvania 19014
Individuals interested in using the Neuman Systems Model may be interested in associate membership in order to
communicate and collaborate with trustees. Each member receives the Neuman News newsletter, and is included in the
mailing list for Call for Abstracts and Symposia brochure. Each member has access to the Neuman data base, and also
receives discounted fees for the Neuman Biennial Symposia.
The Biennial International Neuman Systems Model Symposia provide accumulated information about the model and ample
opportunities to work with people worldwide who are using the model.
Archives:
Neuman Archival Collection

Neuman College
Theorist:
Margaret Neuman
Theory:
Website:
http://www.tc.umnj.edu/~hoyin003/
This site at University of Minnesota details current works emanating from the Theory of Health as Expanding
Consciousness.
Theorist:
Website:
Clendening History of Medicine Library

Kansas University Medical Center
http://kumc.edu/service/clendening/florence/florence.html
This is a fascinating collection of Miss Nightingales letters, published online in the original text.
Website:
American Association for the History of Nursing (AAHN)

http://www.aahn.org/
P.O. Box 175
Lanoka Harbor, NJ 08734
This interesting website offers Gravesites of Prominent Nurses, in which Florence Nightingale and other historically
significant nurses gravesites are featured. Links connect with other sites of interest, including the Florence Nightingale
Museum Trust.
E-mail:
[email protected]
Organization:
Florence Nightingale International Nurses Association
451
TABLE APPENDIX2
Theorist:
Dorothea Orem
Theory:
Self-Care Deficit Nursing Theory
Website:
http://www.hsc.missouri.edu/~son/scdnt/scdnt.html
This site advises of the Dorothea Orem International Self-Care Deficit Conferences, in addition to publishing the Orem
Society Newsletters. A case study of advanced practice using the Self-Care Deficit Nursing Theory (SCDNT) is available
online. A linked site at Georgetown University School of Nursing provides information on a conceptual framework
developed using Dorothea Orems Self-Care Theory.
Discussion List: Subscribe through the home website.
Organization:
The International Orem Society for Nursing Science and Scholarship

S428 School of Nursing
University of Missouri
Columbia, MO 65211
Fax: (573) 884-4544
E-mail: K. Renpenning, <[email protected]>
Theorist:
Rosemarie R. Parse
Theory:
The Human Becoming School of Thought
Website:
The Parse Page

http://www.utoronto.ca/icps
List server:
Parse-L is an online discussion group.

To subscribe, send an E-mail to the server at:
[email protected]
In the body of the note, say ONLY sub parse-L Yourfirstname Yourlastname. For further information, E-mail Pat Lyon at
[email protected]
Videotapes:
The Human Becoming Theory: Living True Presence in Nursing Practice

(12'' VHS and PAL formats).
Parses Theory of Human Becoming: A Learning Guide. Videos are available from:
Pat Lyon, Rehabilitation Institute of Toronto
550 University Avenue, Toronto, Ontario, Canada M5G 2A2.
E-mail: [email protected]
CD-ROM:
Nurse Theorists: Portraits of Excellence: Rosemarie Rizzo Parse

Available from FITNE, Inc.
Telephone: 18006918480
Website: www.ev.net/fitne
When would you prefer to complete your

research activities?
How much time do you realistically have for
inquiry or research? Count the hours you
have available and list days on which they are
available, then reassess.
Produce a detailed, realistic schedule of time
available.
452
Define the focus of your search:

Will your inquiry center on one theory
only?
Will your inquiry also concern the
nursing theorist and be an additional
focus?
Will your inquiry center only on the life of
the theorist?
TABLE APPENDIX2
Theorist:
Hildegard E. Peplau
Theory:
Interpersonal Theory of Nursing
Website:
http://www.uwo.ca/nursing/homepg/peplau.html
This is the Hildegard Peplau Home Page at the University of Western Ontario School of Nursing.
Videotape:
The Nurse Theorists: Portraits of Excellence: Hildegard Peplau (1988)

The video is available from: Fuld Video Project, Studio III,
370 Hawthorne Avenue, Oakland, CA 94609
Audiotape:
Life of an Angel: Interview with Hildegard Peplau (1998). Hatherleigh Co.

The audiotape is available from the American Psychiatric Nurses Association,
http://www.apna.org/items/htm
Theorist:
Martha Rogers
Theory:
Rogers Science of Unitary Human Beings
Website:
Martha Rogers Home Page

http://www.uwcm.ac.uk/uwcm/ns/martha/homepage.html
Organizations: The Martha E. Rogers Center for the Study of Nursing Science
Division of Nursing, New York University
429 Shimkin Hall, 50 West 4th Street, New York, NY 100121165
New York University also cosponsors the Rogerian Conferences, held every 2 to 3 years.
The Society of Rogerian Scholars, Inc.
Canal Street Station, P.O. Box 1195, New York, 100130867
The Society of Rogerian Scholars, Inc. publishes the referred journal Visions: The Journal of Rogerian Nursing Science and
the newsletter Rogerian Nursing Science News.
List server:
NYU Division of Nursing, Martha E. Rogers Listserv:

To subscribe, send an E-mail to: [email protected]
List server:
Nurse-Rogers Listerv:
http://www.mailbase.ac.uk/lists/nurse-rogers/join.html
To subscribe, send an E-mail to: [email protected]
For further information contact:
Francis C. Biley
University of Wales College of Medicine
Cardiff, Wales, UK
Will your inquiry center only on practice

implications?
Define the scope of your search
acknowledge limits:
Will your search include critiques by
other nurses and articles from other
disciplines?
Will your search be limited by time, lack of

computer, location of computer, or location
of library?
What topics or focus will you not include?
Based on the answers to these questions, decide the
most convenient physical location where you will
base your search, and turn to consider the informa-
453
TABLE APPENDIX2
Theorist:
Sr. Callista Roy
Theory:
Website:
http://www2.bc.edu/~royca/
http://www.bc.edu/bc_org/avp/son/theorist/nurse-theorist.html
Organization:
Boston Based Adaptation Research in Nursing Society (BBARNS)
The purpose of this society is to advance nursing practice by developing basic and clinical knowledge based on the model.
It also provides scholarly colleagueship for knowledge development and research, and the dissemination of research.
Theorist:
Jean Watson
Theory:
The Theory of Human Caring
Website:
University of Colorado
http://www.uchsc.edu
Go to centers/institutes, then to Center for Human Caring/International
Center for Integrative Caring Practices.
Listserv:
Carenetan international discussion group.

To subscribe, send an E-mail message to:
<[email protected]>
In the body of the message, place the line
SUBSCRIBE CARENET Your full_name.
Video:
Applying the Art and Science of Human Caring (1988)
A video and monograph. New York: National League for Nursing Press.
Theorist:
Theory:
Wiedenbachs Prescriptive Theory
Archived
videotapes:
Historical Perspective of Nursing Midwifery
Videotaped interview, Ernestine Wiedenbach and Therese Gesse.

Audiotaped Interviews with Ernestine Wiedenbach (3).
Susan Nickel and Ernestine Wiedenbach.
Tape 1: October 20, 1980; Tape 2: February 2, 1981; Tape 3: May 22, 1981.
Copies in University of Miami School of Nursing Archives,
5801 Red Road, Miami, Florida 33124
Telephone: (305) 2841624.
tion media you will use. Expect your search to yield

surprising results, and accept that only experience
will assist you to sift through this process smoothly.
Expect also that during this journey you will transform expectations of yourself and of your inquiry.
The search example below will serve to outline a typ-
454
ical initial inquiry beginning from home or office,

which are both locations where computers have become commonplace. Basic strategies and alternative
approaches are designed to be helpful by acknowledging the absence of linearity in this process of experience and growth.
A SEARCH EXAMPLE
WITH STRATEGIES
Beginning from Home or Office
a Basic Literature Search
You decide to begin your preliminary search with a
survey of the nursing literature from your home or
office via the Internet. You access your library, and
then through your library you access CINAHL, the
nursing literature data base. From the abstracts you
find in CINAHL, you decide that you would like to review the literature more closely with specific search
words highlighted.
Relocating the Physical Search

from Your Home to the Library
Because the CINAHL database that is accessed from
the library computers has search words (finding
aids) highlighted, you choose to physically relocate
your search to the library itself, where you have access to microfiches as well as the full text of nursing
journals and books. You are reminded that there are
other sources of information available in the library,
such as newspapers, conference proceedings, government studies, microfiches, and so on.
Continuing the Literature Search

from Your Home or Office
However, you realize that part of the preliminary
search conducted from your home could have included a time-saving strategya visit to the nurse
theorists home page on the Internet. You did not realize that nurse theorist home pages are most often
located at the university of their academic home.
It is a tacit assumption that the theorists home
page is kept current, with the latest publications and
updated biographical information, including practice
and research, available. This, however, is frequently
not the case: The date on the home page noted by
the Webmaster as the last date of modification simply
records a visit to the home page data file, with or
without an update.
Continuing and Extending the Literature

Search from Your Home or Office
You decide that you would like access to different
perspectives concerning the nursing theorist as well
as information concerning other nurses who practice using this theory. You discover by browsing
with search engines such as Infoseek and Lycos that
you can retrieve many hits (Sparks & Rizzolo, 1998)
in your search for schools and colleges of nursing

with websites dedicated to nursing theorists. You
also discover that all websites are not created equal:
Although some sites are exciting to visit, the information is less dense or less specific on some nursing
theorist websites than on others. Given the multitude of websites, you wonder how you can evaluate
which sites are the most accurate sources of information in the electronic domain. You also wonder about
the credibility of website information used as a scholarly, authoritative reference.
Results of the Beginning Search

After considerable investment of time and energy in
your search, you have rapidly acquired growing familiarity with computers and databases. The results
of your initial efforts, however, can be seen in the abstracts of nursing journals extracted from your
search of CINAHL, and in the multitudes of website
addresses for nursing theory home pages and other
sites captured along the information trail. Unsubstantiated information worries you. There is little to
show for your efforts except experience. It occurs to
you that the information authority on some nursing
theory webpages may be tenuous and may constitute
a weak link in your research methodology. You conclude that evaluation of nursing theory resources,
electronic or otherwise, is of major importance in
laying the groundwork for consistent, credible, and
authoritative research findings.
This is a good time to reflect and
clarify and adjust your expectations
clarify and adjust your needs
clarify and adjust your methods
Now turn to the Guiding Framework for Evaluating Resources (p. 448) and choose, as an exemplar
for evaluation, a website from a theorist such as
Rosemarie Parse, Martha Rogers, or Dorothea Orem,
detailed in Table Appendix2. Begin evaluating this
theorist website, and as you thoughtfully consider
each question, assess whether or not the information
you gather from the resource meets the criteria. Remember that not all questions will apply to all websites, and may be modified by the purpose of the
website. When you have answered as many questions
as you are able to, use the following evaluation summary to synthesize your findings (Table Appendix3). Compare your findings with other websites
you have located. Which websites hold up under critical evaluation? Which website can you use as a
model?
455
TABLE APPENDIX3
Nursing ResourceEvaluation Summary
Resource:
Date Evaluated:
Authoritative sources are known.
Yes/No/Some
Nursing authorities contribute to the website.
Yes/No
Practitioners of nursing contribute to the website.
Yes/No
Comments:
Information presented is accurate.
Yes/No
Information is comprehensive.
Yes/No
Information is clear.
Yes/No
Comments:
The website is easy to use and well organized.
Yes/No
The website has unique characteristics.
Yes/No
The website is satisfying to visit and use.
Yes/No
I will recommend this website to colleagues.
Yes/No
Comments:
This nursing theory resource will ground my inquiry as a credible,

authoritative, and accurate source of information.
456
Yes/No
Nursing information resources, such as theorist

home pages and databases, are continually being developed and evolving. You are ultimately the one deciding the outcome of your evaluation. Regular evaluation of the resource each time you wish to use it
will assure accuracy, credibility, currency, and stability of the information that contributes to your learning and scholarly practice. See Table Appendix2 for
general resources.
Summary
The ability to access information freely and to contribute freely to knowledge in nursing is not only a
gift, but a responsibility without dimensions. Our endeavors as nurses always come with the reminder
that change is a constant, and that sometimes adapting to change takes superhuman effort. The twentieth century has seen unparalleled change, especially
in nursing. The compassionate endeavors of nursing
have meshed with commercial endeavors of business
megaliths. There is no return to old ways anymore.
The twenty-first century greets us with a challenge:
Nursing must expertly know, use, and control all
contemporary knowledge and technology that affects its domain, yet remain true to the values that
define it and give it reason for being. This appendix
on the evaluation of nursing resources holds the answer to this challenge.
References
Brennan, P. F. (1996). The future of clinical communication in an electronic environment. Holistic Nursing
Practice, 11(1), 97104.
Carlton, K. H., Ryan, M. E., & Siktberg, L. L. (1998).
Designing courses for the Internet. Nurse Educator,
23(3), 4550.
Graves, J. R., & Corcoran-Perry, S. (1996). The study of
nursing informatics. Holistic Nursing Practice,
11(1), 1524.
Hebda, T., Czar, P., & Mascara, C. (1998). Handbook of
informatics for nurses and health care professionals. Menlo Park, CA: Addison-Wesley.
Raudonis, B. M., & Acton, G. J. (1997). Theory-based
nursing practice. Journal of Advanced Nursing, 26,
138145.
Riddlesperger, K. L., Beard, M., Flowers, D. L., Hisley,
S., Pfeifer, K. A., & Stiller, J. J. (1996). CINAHL: An
exploratory analysis of the current status of nursing
theory construction as reflected by the electronic
domain. Journal of Advanced Nursing, 24,
599606.
Sparks, S., & Rizzolo, M. A. (1998). World Wide Web
search tools. Image: Journal of Nursing Scholarship, 30(2), 161171.
Turley, J. (1996). Nursing decision making and the science of the concrete. Holistic Nursing Practice,
11(1), 614.
457
Index
Abdellah, Faye G., 1112
Achievement behavior
children
chronically ill vs. healthy, 9597
Achievement subsystem, 90t
Action, 92
Adaptability, 106
Adaptation
Levines conservation model, 107
Adaptation Model
Roy. See Roy Adaptation Model
Adaptive reorganization, 8788
Adjunctive sciences
Administration
nursing. See Nursing administration
Adolescents
cystic fibrosis, 182
Advanced nursing science
Self-Care Deficit Nursing Theory, 180187
Advanced practice nurses
Theory of Nursing as Caring, 404, 407
Adverse patient events
staffing, 140
Affiliative subsystem, 90t
African-Americans
elderly
culture care, 387388
ethnonursing study, 379382, 381f
menarche, 184
Aged
cognitive impairment, 183
Agent
Wiedenbachs prescriptive theory, 74
Agent view
Aggressive/protective subsystem, 90t
Aging, 185
AIDS
Theory of Human Caring, 358359
AJN, 70
Alfano, Genrose, 138
Aloneness
alleviation, 162
American Journal of Nursing (AJN), 70
American Nurses Association (ANA), 57

ANA, 57
Anglican Church, 32
Anticontagionism, 4142
Appraisal of Self-Care Agency (ASA) Scale, 185
Appreciation, 20
vs. appraisal, 207
A priori nursing science
Rogerian inquiry, 216
Archives, 449
Army Nurse Corps, 56
Army School of Nursing
Walter Reed Army Hospital, 144
ASA Scale, 185
Ashjian, Ann, 392
Assessment
Levines conservation model, 110t, 113t
Assessment and Intervention Tool, 337
Assessment of Dream Experience Scale, 201,
219
Assumptions
Orlandos theory, 128129
Asthma
literature review, 300
Attentive presence with one in anguish, 249
Australia
Neuman Systems Model, 339
Authoritative sources, 20
Awareness, 19
Baccalaureate education
recognition, 133
Barrack Hospital
mortality rates, 38, 38f
Barretts Rogerian practice methodology for health
patterning, 207
synthesis, 208209
Barretts theory of power as knowing participation
in change, 198
Barritt, Evelyn R., 45
Basic conditioning factors, 181184
Basic nursing care
Hendersons fourteen components, 146
Basic Principles of Nursing Care, 145, 146
Battle of Alma, 3536
BBARNS, 316, 318319
459
BDI
negative thinking, 61
Bearing witness to suffering, 250t
Beck Depression Inventory (BDI)
negative thinking, 61
Behavioral change
motivation
JBSM, 88
Behavioral set, 89
Behavioral system
balance
JBSM, 87
client, 8994
subsystems, 8994, 90t91t
Being with, 415
Beland, Irene, 106
Beliefs
conceptual nursing models, 6
nursing discipline, 10
Bethov, Itzhak, 265
Bibliography, 149
Binding, 270
Birthing
Lebanese men, 387
Mexican-American males, 389
Black Sea
map, 36f
Boston-Based Adaptation Research Society in
Nursing (BBARNS), 316, 318319
Boston College School of Nursing, 316
Boston Floating Hospital, 144
Boykin, Anne, 392, 450t
Bracketing, 159
Buber, Martin, 152
Bureaucracies
characteristics, 423424
organizational cultures, 423424
Bureaucratic Caring
theory. See Theory of Bureaucratic Caring
Call for nursing, 393
Canada
Cancer
children
self-care, 183184
self-care, 183
spouses, 182
Cancer pain
control behaviors, 97
Capabilities, 177
CAPS, 320, 324
Carative factors, 345348
460
Cardiac patients
Netherlands, 184
Care
care, core, and cure model, 135136
defined, 368
Care, core, and cure model, 135141, 135f
background, 133134
nursing practice, 139140
nursing research, 140
replication, 139
Caring, 393
defined, 415
literary meta-analysis, 418419
miscarriage, 414
monitoring
intervention variable, 417418
NICU, 414415
nursing administration, 437
socially at-risk mothers, 415416
Caring between, 394
Caring (healing) consciousness, 349
Caring moment, 349
Caring occasion, 349
Caring Professional Scale, 418
Caritas, 345346
Case management
pregnant substance abusers
Catastrophic events
Catholicism
Roy, Sister Callista, 316
Catholic University, 153
Center for Human Caring, 344
Centering, 270
Change
leading, 253
Children
cancer
self-care, 183184
chronically ill vs. healthy
achievement behavior, 9597
Choice, 92, 270
Choice point, 270
Choice points of action potential
Health as Expanding Consciousness, 269270
Christian feminist, 44
Chronic illness
mother-infant interaction, 96
Chronic lung disease
self-care, 183
Index
Chronic renal disease

self-care agency, 183
CINAHL, 455457
Clear focus
cognitive processing, 324
Client-client system
client variables, 335336
flexible line of defense, 333
lines of resistance, 335
Neuman Systems Model, 331336, 333f
normal line of defense, 333
structure, 335
Clients
behavioral system, 8994
concerns
literature review, 296, 298, 299t300t, 300
difficult, 398
Humanistic Nursing Theory, 155, 157f
liking, 398
literature review, 293294, 295t296t
pattern appreciation verification, 208
unconscious, 398399
Client systems
Clinical caritas processes, 346348
Clinical Nurse Specialist program
psychiatric-mental health nursing, 57
Clinical Nursing:A Helping Art, 7677
Clinical Nursing Models Project, 415
Clinical practice
Wiedenbachs prescriptive theory, 7681, 76f,
78f80f
Clinical supervision
Humanistic Nursing Theory, 164165
Clinical teaching
Cognitive adaptation processes
hearing impaired elderly, 324
Cognitive adaptation processing
conceptual basis, 320
instrument development, 320321
Roy Adaptation Model, 319322
Cognitive Adaptation Process Scale (CAPS), 320, 324
Cognitive-behavioral techniques
negative thinking
depression, 61
Cognitive impairment
elderly, 183
Cognitive processing
clear focus, 324
knowing awareness, 324325
self-perception, 325
Index
Collaborative practice model, 139

Colleges. See also specific colleges
websites, 447t
Columbia University, 5657
Communication
reflective method, 139
Communication: Key to Effective Nursing, 70
Communication networks
Community
Community-based care
Levines conservation model, 111112, 113t
Community health
Theory of Goal Attainment, 283
Community of nurses
Computer technology, 446447
Concept development
literature review, 288, 290, 290t
Conceptual models
vs. theories, 67
Conceptual nursing models, 6
Conceptual set, 89
Conceptual transformation
resource evaluation, 447449
Confirmability, 382
Confirming, 253
Congregational Health Model, 243f
Connecting-separating, 230
Consciousness, 320
Conservation
theory, 117, 450t
Conservation
Conservation model
Levines. See Levines conservation model
Contagionism, 41
Continuity
JBSM, 87
Continuous quality improvement
Theory of Goal Attainment, 284, 309
Control
Cook, Thomas, 32
Core
Coronary artery disease, 185
Cosmic unity, 317
Cost-based reimbursement, 435
Cowlings pattern appreciation practice method,
207208
synthesis, 208209
461
Coxcombs, 38
Created environment
Neuman model, 336
Creation
Credibility, 382
Crimea
map, 36f
Crimean War
Nightingale, Florence, 3335
Criteria of Rogerian Inquiry, 215217
Cross-cultural nursing research
Csikszentmihalyis Theory of Flow, 212
Cultivating purpose, 213
Cultural care commonalities, 366
Cultural care diversity, 368
Cultural care universality, 368
Cultural feminism, 4344
Culturally congruent care, 369, 370f
Culturally decontextualized, 387
Culture, 368
Culture care, 368
accommodation, 369
Lebanese Muslims, 386387
maintenance, 368369
Mexican-American pregnant women, 388389
negotiation, 369
preservation, 368369
repatterning, 369
restructuring, 369
Culture Care Diversity and Universality
theory. See Theory of Culture Care Diversity and
Universality
Culture of care, 252
Cumulative Index to Nursing and Allied Health
Literature (CINAHL), 455457
Cure
Curriculum
Henderson, Virginia Avenel, 147
Theory of Nursing as Caring, 397
Cystic fibrosis
adolescents, 182
Databases, 446
Database searching, 449, 452454
DBSM, 95
Deaconesses, 33
Deaver, George, 145
Decentering, 270
Deliberate action, 73
Deliberative mutual patterning, 207
462
Demographic Profile, 324

Denver Nursing Project in Human Caring (DNPHC),
357359
Dependency subsystem, 90t
Depersonalization, 134
Depression
negative thinking
cognitive-behavioral techniques, 61
Peplaus process, 6062
self-care, 182
Derdiarian, Anayis, 95
Derdiarian Behavioral System Model (DBSM), 95
Descartes, 266
Developmental variables
client-client system, 335
Dewey, John, 138
DHFPS, 219
Diabetes mellitus
family, 182
Diet kitchen
Difficult client, 398
Discipline and Teaching of Nursing Process:An
Evaluative Study, 127
Disclosing, 253
Discontinuity
JBSM, 88
Discovering, 253
Disease
nature and origin, 4142
Dissipative Structures
theory, 269270
Diversity of Human Field Pattern Scale (DHFPS),
219
DNPHC, 357359
Doctoral research, 194
Doctors orders, 138
Documentation system
Dodd, Marylin J., 183
DOI, 371
ethnonursing research method, 379
Doing for, 415
Domain
Domain of inquiry (DOI), 371
Dombro, Marcia, 70
Dying
four-dimensional awareness, 198
Dynamic nurse-patient relationship, 126130
Dynamic Nurse-Patient Relationship: Function,
Process, and Principles, 126127
Index
EBM, 306308
Economic constraints
nursing practice
Economics, 369
Theory of Bureaucratic Caring, 435449
Education, 369
baccalaureate
recognition, 133
clinical
Nightingale, W. E., 33
nursing. See Nursing education
Peplau, Hildegard, 56
Wiedenbach, Ernestine, 70
Educational Revolution in Nursing, 194
Elderly
cognitive impairment, 183
Electronic media
evaluation, 446
Eliminative subsystem, 91t
Embley Park, 3233
Emergence of Paranormal Phenomena
theory, 198
Emergent design
Emotion, 320, 325
Empirical indicators, 1011
Enablers
ethnonursing research method, 379382, 380t
Enabling, 415
Enabling-limiting, 230
Energy conservation
Energy fields, 196
Enfolding health-as-wholeness-and-harmony, 214
Environment, 369
created, 336
external, 108, 336
internal, 336
JBSM, 9293
Neuman Systems Model, 334f, 336
Nightingale model, 42, 46
Ethnohistory, 369
Index
Ethnonursing analysis for qualitative data

Leiningers, 383f
Ethnonursing observation-participation-reflection
phases
Leiningers, 379t, 380381
Ethnonursing research method, 378384
domain of inquiry, 379
enablers, 379382, 380t
evaluation, 382383, 383t
key and general informants, 379
philosophical features, 378379
purpose, 378379
qualitative paradigm, 378
quantitative paradigm, 378
steps, 383385
Ethnonursing study
Lebanese Muslims, 386387
Ethos, 378
Evaluation
electronic media, 446
ethnonursing research method, 382383,
383t
nursing care, 147
nursing theory, 2021
nursing theory resources, 446457
self-enhancing, 325
theory, 446
Evaluative medicine, 134
Evangelicalism, 42
Evers, Georges, 184
Evidence-based medicine (EBM), 306308
Evidence-based practice
Evolutionary interpretation
Expanding the now in light of beliefs and doubts,
249250
Explicating, 253
External environment
Neuman model, 336
Extraction-synthesis process, 248249, 248t
249t
Extroversion, 183
Falls, Caroline, 70
Family
diabetes mellitus, 182
Mexican-Americans
pregnancy, 388389
nursing home residents, 388
visitation, 138
Family Centered Maternity Nursing, 71
463
Family health
Farr, William, 4142
Fatalistic worldview
Mexican-Americans, 388
Fear
response, 109
Female modesty
Lebanese women, 387
Feminism
cultural, 4344
Notes on Nursing, 4243
Feminist
Christian, 44
Fermentation
chemical vs. vitalistic process, 42
Field
Rogers, 265
Fit
Fleidner, Theodore, 33
Flight/fight response, 109
Florida Atlantic University, 392, 400, 422
Flow, 213
Folk care, 368
Food
Forging resolve, 213
Format for Prevention as Intervention, 337
338
Four-dimensional awareness
dying, 198
Four-dimensionality, 196
Framework
Fromm, Eric, 56
General resources
websites, 447t
General System Theory, 277
Generic care, 368
Geriatric Depression Scale, 324
Gestalt, 155, 156f
Global applications
Global presence
Human Becoming School of Thought, 232
233
Goal Attainment
theory. See Theory of Goal Attainment
Goal attainment scale
464
Goals
nursing
Nightingale model, 47
Goodrich, Annie W., 144
Grand nursing theory, 7
Hall, Lydia, 132141
background, 133134
care, core, and cure model, 135141, 135f
death, 133
life, 132133
nursing vision, 134135
Hard-won serenity amidst ongoing joy-sorrow,
250251
Hartnett-Rauckhorst, Louise, 176
Hastings-Tolsma Diversity of Human Field Pattern
Scale, 201
Healing arts paradigms
eighteenth century, 41
Healing consciousness, 349
Health
JBSM, 93
Leininger defined, 368
Parses phenomenological method, 247
Roy definition, 317
Health Action Model for Partnership in Community,
242246, 244f245f
objectives, 246
choice points of action potential, 269270
debut, 266
insights, 273274
new paradigm, 267268
nurse-client interaction, 271272
nursing, 270271
research process, 272273
sequential configurations of pattern evolving over
time, 268269
uniqueness and wholeness of pattern, 266267
website, 274, 451t
Health-as wholeness-and-harmony
enfolding, 214
Healthcare
Kings framework
literature review, 304, 305t
Health-care financing, 434436
Health-care organizations
current context, 434435
Index
Health care professionals

genderization, 44
Health/healing
Healthiness
theory, 199
Health patterning, 200
Health promotion
literature review, 298, 300
self-care, 184
Health state variations
psychopathology, 182
Health Status Questionnaire, 324
Hearing impaired elderly
Helicy, 197
Henderson, Virginia Avenel, 71, 144149
international nursing, 146
libraries, 148149
nursing education, 146
personal background, 144
research, 148149
website, 450t
Henry Street Visiting Nurse Agency, 144
Herbert, Liz, 3637
Herbert, Sidney, 3637
Hermeneutic dialectic research method, 272
HFMIS, 201, 219
HFMT, 219
Hierarchy
JBSM, 88
History, 107
HIV
Holistic
vs. organismic, 105
Holographic theory
Theory of Bureaucratic Caring, 427429, 428f
Holography, 422423
Homeodynamics, 197
Homeophoresis, 106
Homeorhesis, 87
Homeostasis, 87
Hope:An International Human Becoming
Perspective, 228, 232
Hospitals
Howland Systems Model, 277
Human Becoming Hermeneutic Method, 231,
251252, 251t
global presence, 232233
metaperspective, 229
Index

nursing leadership, 252257
nursing profession, 228229
parish nursing, 241242
philosophical assumptions, 229230
practice methodology, 231246, 241t
principles, 229230
research methodologies, 230231, 246252
teaching-learning process, 259f
website, 452t
Human being
unitary, 265
Human Caring
theory. See Theory of Human Caring
Human energy field, 207
Human Field Image Metaphor Scale (HFMIS), 201,
219
Human Field Motion Test (HFMT), 219
Human health service
nursing, 172
Human imagination
Human instruments
Humanistic Nursing, 153, 155
Humanistic Nursing Theory, 152167, 401
clinical applications, 162167
clinical supervision, 164165
community, 162
community of nurses, 166167
conceptual framework, 155, 156f
humanity, 167
many to paradoxical one, 161162
methodological background, 157162
nurse complementarily synthesizing known
others, 160161, 161f
nurse knower preparation, 158159
nurse knowing other, 159160, 159f
nurse knowing other scientifically, 160, 160f
nurses reflection, 162163
nursing, 154
patients reflection, 163164
phenomenological study, 157158
philosophical background, 157162
psychiatric day hospital, 165166
research, 165166
schizophrenia, 165
Humanity
Human relationships
465
Humans
broader views, 174175
nursing-specific views, 172174
Orems view, 172
Self-Care Deficit Nursing Theory views, 175176
Human spirit
Hypotheses
Ida Jean Orlando:A Nursing Process Theory, 126
Identification
Identity
JBSM, 87
Illness
chronic
mother-infant interaction, 96
JBSM, 93
Illness-maintaining behaviors, 57
Image, 316
Imaging, 230
IN, 194
Independent Nurse (IN), 194
Index of Field Energy, 201
Individual responsibility, 82
Infectious disease
zygomatic, 4142
Inflammatory response, 109
Informants
Ingestive subsystem, 91t
INI, 149
Insights
Institution for the Training of Deaconesses, 33
Instrument development
Integrality, 197
Intensive care units
Interacting systems framework application
Interactive-integrative perspective, 267
Internal environment
Neuman model, 336
International applications
International Association for Human Caring, 392
International nursing
International Nursing Index (INI), 149
466
International nursing research

International presence
Internet
general resources, 447t
Interpersonal Relations in Nursing, 56
Interpersonal systems, 14, 276, 277f
Interventions
Interviews
Introduction to Clinical Nursing, 105
Introduction to the Theoretical Basis of Nursing,
194
Intuition
Irreducible human-environmental energy fields
JBSM. See Johnson Behavioral System Model
Johnson, Dorothy E., 8699, 316
death, vi
life, 86
Johnson Behavioral System Model (JBSM), 8689
concepts, 8994
environment, 9293
health, 93
illness, 93
nursing therapeutics, 9394
paradigmatic origins, 8689
Journal of Transcultural Nursing, 362, 382, 422
Jowett, Benjamin, 35
Judaism, 104
Kaiserwerth, 3334
Kaleidoscoping in Lifes Turbulence
theory, 212213
King, Imogene M., 276, 450t
Kings framework
healthcare
knowledge development, 305
managed care, 309
multicultural applications
literature review, 304305, 306f
nursing process, 304, 304t, 308309
nursing specialties
literature review, 300, 300t301t, 302
Index
performance improvement, 309

standardized nursing language, 308309
technology, 309
work settings
literature review, 302, 303t, 304
Kinship, 369
Knowing, 415
vs. appreciation, 209
Knowing awareness
Knowing participation in change, 208
Knowing self as caring, 397398
Knowledge
nursing. See Nursing knowledge
Knowledge development, 317318
Lady with the Lamp, 38
Laissez-faire, 43
Language
Languaging, 230
Lay care, 368
Leadership
change, 253
nursing
Lea Hurst, 32, 39
Lebanese Muslims
Leddy Healthiness Scale, 202
Leininger, Madeleine M., 362
Leiningers ethnonursing observation-participationreflection phases, 379t, 380381
Leiningers phases of ethnonursing analysis for
qualitative data, 383f
Leiningers stranger to trusted friend enabler guide,
380t, 381382
Leininger Templin Thompson (LTT) Qualitative
Software Data Program, 383
Levine, Myra, 104119
death, 104
Jewish faith, 104
life, 104
philosophical notes, 104110
website, 405t
Levines conservation model
adjunctive sciences, 106
community-based care, 111112, 113t
composition, 106109
nursing process, 110t
research, 114115
Index
theories, 116117
twenty-first century, 115118
Levines foundations for clinical nursing, 105106
Levy, David, 56
Libraries, 446447, 449
nursing, 148
Linear structural relations (LISREL), 218
Line of defense
Lines of resistance
LISREL, 218
Literature
nursing, 446447
Literature review
asthma, 300
chronic illness, 300
clients, 293294, 295t296t
client systems, 294296, 297t298t
concept development, 288, 290, 290t
diabetes, 300
health promotion, 300
instrument development, 292293, 293t
interacting systems framework application, 288,
289t
middle-range theories, 292, 293t
nursing specialties
King framework, 300, 300t301t, 302
Theory of Goal Attainment, 290, 291t292t
work settings
King framework, 302, 303t, 304
Literature searches, 20, 446447
Literature searching, 449, 452454
example, 455457
nursing, 449, 452454
strategies, 455457
Living a Caring-based Program, 392, 397
Loeb Center for Nursing and Rehabilitation,
132134, 137139
Longfellow, Henry Wadsworth, 39
LTT Qualitative Software Data Program, 383
Lung disease
chronic
self-care, 183
Maintaining belief, 415
Making Choices, Taking Chances, 276
Managed care
Kings framework, 309
467
Man-Living-Health:A Theory of Nursing, 229

Martha E. Rogers: Her Life and Her Work, 195
Meaning
Human Becoming School of Thought, 230,
241t
Meaning-in-context, 382
Medical care
phases, 134
Medicare, 133
Medication ordering
nurses, 128
Meeting the Realities in Clinical Teaching, 72, 81
Meleis, Afaf I., 46
Menarche
African-Americans, 184
Mental Health Act of 1946, 5657
Merton, Robert, 7
Messenger-attendant, 137
Metaparadigm, 56
alternative concepts, 6
Mexican-Americans
pain, 184
pregnant
Mexicans
female
self-care, 185
Miasmas, 41
Middle-range theories, 7
Mid-range Rogerian practice theories, 211215
Mill, John Stuart, 35
Milnes, Richard Monckton, 42
Ministration
Wiedenbachs prescriptive theory, 77, 79f
Miscarriage
caring, 414
Miscarriage Caring Project, 416418
Mitral valve prolapse
symptomatic
self-care, 183
Models and Metaphors, 177
Mohl, Mary Clarke, 44
Moran, Barbara Smith, 316
Mortality rates
Barrack Hospital, 38, 38f
Mother-infant interaction
chronically ill infants, 96
Motivation
behavioral change
JBSM, 88
468
Multicultural applications
Kings framework
literature review, 304305, 306f
Multidimensionality, 196
Muslims
religious rituals, 387
Mutual Exploration of the Healing Human FieldEnvironmental Field Relationship, 202, 219,
220
National League for Nursing (NLN), 57
National Resource Center for Health and Safety in
Child Care, 359360
Natural settings
Nature of Nursing, 145, 147
Negative thinking
BDI, 61
cognitive-behavioral techniques, 61
Neonatal nursing care
Netherlands
cardiac patients, 184
Neuman, Betty, 330, 451t
Neuman Nursing Process format, 337
client-client system, 331336, 333f
conceptual model, 331, 332f, 333
environment, 334f, 336
Fawcetts analysis, 330331
global applications, 338340
health, 336337
nursing, 337338
propositions, 330331
twenty-first century, 340341
website, 451t
Neuroticism, 183
Newborn intensive care unit (NICU)
caring, 414415
Newman, Margaret A., 264265, 451t
Rogers influence, 265
Nickel, Susan, 70
NICU
caring, 414415
assumptions, 4749
caring expressions, 4547
Index
Crimean War, 3335

description, 3839
diet kitchen, 38
early life, 3234
education, 3334
family, 3234
feminist, 4245
independence, 33
medical milieu, 4042
moral authority, 39
photograph, 40f
physical demeanor, 39
poem, 39
rebel, 45
sketch, 33f
spirituality, 3435
travel, 33
voice, 39
website, 451t
Nightingale, W. E., 3233
education, 33
sketch, 334
Nightingale legend, 38
Nightingale model, 49f
environment, 42, 45
health, 47
nurse, 4748
nursing goal, 47
perspective, 48f
Nightingale Songs, 392
NLIUs, 139140
NLN, 57
Noninvasive modalities, 200
Non-nursing functions, 148
Notes on Nursing
feminism, 4243
nursing defined, 4546
spirituality, 35
Noyes, Arthur, 56
NPRRA Questionnaire, 439
NSI, 149
Nurse-client interaction
pattern recognition, 271272
Nurse complementarily synthesizing known others
Nurse knower
Nurse knowing other
Nurse knowing other scientifically
Nurse-patient relationship, 130
dynamic, 126130
Index
Nurse-Patient Relationship Resource Analysis

(NPRRA) Questionnaire, 439
Nurse psychotherapists
preparation, 57
Nurses
central purpose
daily experiences, 8
future requirements, 116
health care leaders, 116
medication ordering, 128
unique function, 145
Nurse staffing patterns, 436
Nursing
concepts, 173t
defined, 129
focus, 195, 267
Henderson definition, 144147
human health service, 172
Orems general theory, 180181
parish
psychiatric, 5663
Clinical Nurse Specialist program, 57
team, 134
transcultural
conception, 363
rationale, 364366
Nursing: Concepts of Practice, 185
Nursing administration
caring, 437
JBSM, 9799
nursing theory study, 2526
Nursing as Caring
theory. See Theory of Nursing as Caring
Nursing as Caring:A model for Transforming
Practice, 392
Nursing care
evaluation, 147
Nursing care planning, 147
Nursing Development Conference Group, 24
Nursing diagnosis
Rogers, 206
469
Nursing discipline, 810

beliefs, 10
communication networks, 910
conceptual structures, 9
domain, 89
education systems, 10
human imagination, 8
literature, 910
specialized language, 9
syntactical structures, 9
tradition, 10
values, 10
Nursing education
JBSM, 97
Nursing focus
Nursing goals
Nursing home facilities
Nursing home residents
Nursing intention
Nursing interventions
Peplaus process, 60
Nursing knowledge
conceptual development, 5
metaparadigm, 56
nursing philosophy, 6
nursing theory, 57
Nursing leadership
Nursing-Led In-Patient Units (NLIUs), 139140
Nursing libraries, 148
Nursing literature, 446447
Nursing literature searching, 449, 452454
Nursing paradigm
changes, 5
Nursing philosophy, 6
Nursing practice
470
economic constraints
impact, 7
JBSM, 9799
nursing theory study, 1718, 2425
Theory of Bureaucratic Caring, 423425, 441442
Theory of Culture Care Diversity and Universality,
385389
Nursing practice theory, 78
Nursing process
Levines conservation model, 110t
Nursing profession
229
Nursing professional practice, 1011
Nursing regulatory decisioning model, 257259,
258f
Nursing research. See also Research
international
JBSM, 9497
Nursing Science, 194
Nursing Science: Major Paradigms, Theories, and
Critiques, 247
Nursing science development
Nursing Science Quarterly, 228, 340
Nursing situations, 19
values, 19
Nursing specialization, 133
Nursing specialties
King framework
literature review, 300, 300t301t, 302
Nursing Studies Index (NSI), 149
Nursing Systems
theory, 180
Nursing systems
concepts, 173t
Index
Nursing theorist resources, 450t454t

Nursing theory
analysis and evaluation, 2021
defined, 45
future, 1112
nursing knowledge, 57
nursings need, 811
purpose, 10, 16
resources
evaluation, 446457
social utility, 181
study, 1621
exercise, 1820
nursing practice, 1718, 2425
reasons, 1617
theory selection, 18
types, 78
Nursing therapeutics
JBSM, 9394
Nursing tools
Nybergs Caring Assessment Tool, 437
Object view
Observation
On Caring, 401
Openness, 196
Optimal health
Neuman defined, 338
Order
JBSM, 87
Ordered to Care:The Dilemma of American
Nursing, 43
Orem, Dorothea E., 172, 452t
Orems general theory of nursing, 180181
Organismic
vs. holistic, 105
Organismic response
Organizational cultures
bureaucracies, 423424
Originating, 230
Orlando, Ida Jean, 71, 126130
conversation, 127128
life, 126127
Orlandos theory
assumptions, 128129
concepts, 129
health-care system applicability, 129
Outcomes, 7, 38, 140, 284
Index
Pain
control behaviors, 97
Pandimensional awareness
Pandimensionality, 196
Paradigm, 5, 424
nursing
changes, 5
Parish nursing
242
Parker, Marilyn E., 392
Parse, Rosemarie Parse, 228, 452t
Parses phenomenological method, 231, 247251
Particulate-deterministic paradigm, 267
Paterson, Josephine, 152154
Patient advocacy, 127128
Patient-centered care, 144
Patient classification system
JBSM, 97, 98f, 99
Patient variables
Pattern, 196
Pattern knowing and appreciation
Pattern manifestation
Pattern manifestation appraisal, 207, 209
Pattern manifestation knowing and appreciation,
207, 209210
Pattern profile, 208
Pattern recognition
nurse-client interaction, 271272
Patterns
evolving over time, 268269
measurement, 201
Pattern synthesis
Pelletier, Ida Jean Orlando. See Orlando, Ida Jean
Peplau, Hildegard, 5663, 127
career, 57
death, vi
education, 56
honors, 5758
international activities, 58
life, 5658
third-generation student, 58
website, 452t
Peplaus practice-based process
future, 6263
research, 6062
Peplaus process of practice-based theory
development, 5860
471
Perceived Dissonance
theory, 199, 212
Perceptions, 106
Perceptual response, 109
Performance improvement
Person
Personal integrity
Personal interests, 17
Personalized Nursing LIGHT Model, 200
Personalized Nursing LIGHT Practice model, 214215
Personal systems, 276, 277f
Person-Environment Participation Scale, 201202,
219
Personhood, 106
Person view
Phenomenological method
Parses, 231, 247251
Phenomenological movement, 157158
Philosophy
nursing, 6
Physiological variables
PKPCT, 201, 210, 212, 219
Political activism, 194
Political factors, 369
Postmodern Nursing and Beyond, 344
Postoperative complications
staffing, 140
Potential freedom, 270
Power as Knowing Participation in Change
Barretts theory, 198
theory of, 211212
Power as Knowing Participation in Change Tool
(PKPCT), 201, 210, 212, 219
Powering, 230
Practice-based process
Peplaus
future, 6263
research, 6062
Practice methodology for health patterning
Rogerian, 207
Pregnancy
Mexican-American
substance abusers
case management, 340
Prescription
Wiedenbachs prescriptive theory, 73, 81
472
Presence, 162163
Prevention as intervention
Prigogine, Ilya, 269270
Principles and Practice of Nursing, 145
Processes, 284
Barretts, 207
Process of Inquiry
Rogerian, 220
Process of practice-based theory development
Peplaus, 5860
Professional care, 368
Professional-technical system, 14
Profile of Mood States, 417
PRO-SELF, 183
Prospective payment system, 435
Protection
Psychiatric day hospital
Psychiatric nursing, 5663
Clinical Nurse Specialist program, 57
Psychiatric problems
war, 56
Psychological variables
Psychopathology
health state variations, 182
Psychotherapists
nurse
preparation, 57
Purposive sampling
Quarantine, 41
Randomized controlled trials (RCT), 306
Ray, Marilyn Anne, 422
RCT, 306
Realities
Wiedenbachs prescriptive theory, 7376, 81
Recipient
Reconstitution, 338
Recovering harmony, 213214
Recurrent patterning, 382
Redundancy
theory, 118
Redundancy, 107
Reflective-in-action, 82
Reflective method
communication, 139
Registered nurse staffing patterns, 436
Rehabilitation, 137
Index
Reichmann, Freida Fromm, 56

Religion, 369
Religious rituals
Muslims, 387
Renal disease
chronic
self-care agency, 183
Reorganization
vs. stabilization
JBSM, 88
Research. See also Nursing research
Peplaus practice-based process, 6062
Science of Unitary Human Beings, 215223
386
Researcher
Resonancy, 197
Resources, 17
evaluation summary, 456t
nursing theorist, 450t454t
nursing theory
evaluation, 446457
websites, 447t
Response
stress, 109
Restorative subsystem, 91t
Revealing-concealing, 230
Reveille in Nursing, 194
Reverby, Susan, 43
Rhondda, Margaret, 44
Rhythmical Correlates of Change
theory, 198
Rhythmicity
Human Becoming School of Thought, 230, 241t
Robinson, Connie, 316
Rogerian concepts
measurement, 219220
Rogerian nursing science
postulates, 196
Rogerian practice methodology for health
patterning
Barretts, 207
Rogerian practice models, 206215
synthesis, 208209
Index
Rogerian practice theories

mid-range, 211215
Rogerian Process of Inquiry, 220
Rogerian research designs
potential, 217218
Rogerian science-based practice, 200201
Rogerian science-based research, 201202
Rogers, Carl, 138
Rogers, Martha E.
death, 195
influence on Newman, 265
life, 194195
nursing diagnosis, 206
theories, 197199
website, 452t
worldview, 195196
Roy, Sister Callista, 316317
Catholicism, 316
website, 454t
assumptions, 317
cognitive adaptation processing, 319322
concepts, 317
exemplar application, 325326
data, 324
findings, 324
problem, 322323
research hypotheses, 323
sample, 323324
study design, 323324
variables, 324
research framework, 317319
self-consistency, 321322
website, 454t
Roy Adaptation Model-based Research, 316
Santa Filomena, 39
Saturation, 382
Schizophrenia
Schmieding, Norma Jean, 126
Schoenhofer, Savina O., 392
Schon, Donald, 82
Schools
Science of Unitary Human Beings
historical evolution, 195
overview, 195197
research, 215223
methodological issues, 215
Rogerian inquiry criteria, 215217
473
Science of Unitary Human Beings (cont.)

theories, 197199
website, 453t
Science philosophy
SCS, 324
Self-analysis, 320, 325
Self-awareness, 320
Self-care
agency, 174175, 181184
depression, 182
Orem defined, 180
theory, 172, 180
advanced nursing science, 180187
cross-cultural nursing research, 184186
environmental conditions, 173
humans, 172174
international nursing research, 184186
model building, 176177
nursing science development, 181182
patient variables, 173
theory development, 176177
website, 452t
Self-consistency
conceptual development, 321
instrument development, 321322
Self-Consistency Scale (SCS), 324
Self-enhancing evaluation, 325
Self-esteem, 321322
Self-perception
Sensitivity
Sentience Evolution
theory, 199
Sexually transmitted disease
unmarried women, 182183
Sexual subsystem, 91t
Shared description
Shared understanding
Share human experience, 155, 157f
Sickness
Nightingale defined, 41
Sigma Theta Tau International Library, 149
Simmons, Leo W., 148
Smith, Fanny, 3233
Smith, William, 32
474
SNL
Social factors, 369
care outcomes, 366
Socially at-risk mothers
caring, 415416
Social systems, 276, 277f
Social utility
nursing theory, 181
Societal system, 14
Society for Advancement in Nursing, 194
Sociocultural variables
Soldiers, 144
psychiatric problems, 56
South Dakota Board of Nursing model, 257259, 258f
Specialized language
Specificity, 107
Spiritual care
Spiritual factors, 369
Spiritual variables
Spouses
cancer, 182
Stabilization
JBSM, 87
vs. reorganization, 88
Staffing
adverse patient events, 140
nursing patterns, 436
postoperative complications, 140
Standardized nursing language (SNL)
Strachey, Lytton, 38, 45
Stranger to trusted friend enabler guide
Leiningers, 380t, 381382
Stress, 106
response, 109
Structure, 284
Student
Peplau, Hildegard, 58
Substance abusers
case management
Subsystems, 8994, 90t91t
Suggestions for Thought to Searchers after
Religions Truth, 35, 39
Suggestions for Thought to the Searchers after
Truth among the Artisans of England, 35
Index
Sullivan, Harry Stack, 56, 138

Sunrise Model, 369372, 370f, 380, 385
Supervision
clinical
Swanson, Karen M., 412419
dissertation, 414
doctoral studies, 413414
postdoctoral study, 414415
predoctoral experiences, 412413
Synopsis, 207
System
Neuman defined, 330
System thinking
JBSM, 87
Tate, Barbara, 412
Teachers College, 132, 144145, 194
Teaching. See also Education
clinical
Teaching-learning process
Human Becoming School of Thought, 259f
Team nursing, 134
Technology, 369
computer, 446447
Temporal Experience Scale (TES), 201, 219
Tertiary prevention, 338
TES, 201, 219
Textbook of the Principles and Practice of Nursing,
145
Theorist, 17
Theory
defined, 4, 72
evaluation, 446
websites, 447t
Theory of accelerating evolution, 197198
development, 425428
economic dimension, 435449
formal theory, 426
grounded theory, 425, 425f
holographic theory, 422423, 427429, 428f
middle-range theory, 426427
nursing focus, 424425
nursing practice, 423425, 441442
political implications, 440442
research, 438439
substantive theory, 426
Theory of Conservation, 117, 450t
Index

362392
current status, 372374
development, 363364
future, 374375
research, 386
success factors, 372374
Sunrise Model, 369372, 370f, 385
tenets, 366369
theoretical assumptions, 367369
Theory of Dissipative Structures, 269270
Theory of Emergence of Paranormal Phenomena,
198
Theory of Flow
Csikszentmihalyis, 212
Theory of Goal Attainment. See also Kings
framework
beginning, 277
community health, 283
conceptual system, 276277, 277f
continuous quality improvement, 284, 309
design, 278279
documentation system, 280
evidence-based practice, 306308
family health, 283
future, 284285
goal attainment scale, 280281
hospitals, 283
research, 283284
science philosophy, 277278
transaction process model, 279280, 279f
utilization, 281
website, 450t
Theory of Healthiness, 199
carative factors, 345348
caring (healing) consciousness, 349
caring moment/caring occasion, 349
health/healing, 357
human being, 356357
human relationships, 356357
human spirit, 356357
new contexts, 356
overview, 344
transpersonal caring relationship, 348349
website, 454t
Theory of Kaleidoscoping in Lifes Turbulence,
212213
475

advanced practice nurses, 404, 407
application, 405407
assumptions, 392393
call for nursing, 393
caring between, 394
case presentation, 405
current development, 400401
historical perspective, 400401
lived meaning, 394396
nurse administrators, 400
nurse educators, 400
nursing focus, 393
nursing intention, 393
nursing process, 399
nursing response, 393394
nursing roles, 395397
nursing situation, 393
personhood, 393
practicality, 399400
questions, 397400
research, 400
story, 405407
themes, 393395
website, 450t
Theory of Nursing Systems, 180
Theory of Perceived Dissonance, 199, 212
Theory of Power as Knowing Participation in
Change, 211212
Barretts, 198
Theory of Redundancy, 118
Theory of Rhythmical Correlates of Change, 198
Theory of Self-Care, 172, 180
Theory of Sentience Evolution, 199
Theory of Therapeutic Intention, 117118
Therapeutic Intention
theory, 117118
Thorndike, Edward, 145
Thoughts of God, 35
Time, 162
Toward a Theory of Nursing, 278
Tradition
Transaction Process Model, 284
Theory of Goal Attainment, 279280, 279f
Transcendence
Human Becoming School of Thought, 230, 241t
Transcultural nursing
conception, 363
rationale, 364366
476
Transcultural Nursing Society, 362

Transferability, 382383
Transforming, 230
Transpersonal caring relationship, 348349
Triad of Systems, 14
Triangulation, 114
Trophicognosis
True presence, 231232
Truth, 422
UFPP research method, 202, 220222, 221f
Unconscious clients, 398399
Understandability
Uniqueness and wholeness of pattern
Unitarians, 3235
Unitary Case Inquiry, 222223
Unitary Field Pattern Portrait (UFPP) research
method, 202, 220222, 221f
Unitary human being
Rogers, 265
Unitary pattern appreciation, 207
template, 201
Unitary-transformative perspective, 267268
United Kingdom
Universities. See also specific universities
websites, 447t
University of Alberta
websites, 447t
University of Chicago, 104
University of Colorado, 344
University of Massachusetts Medical Center,
412413
University of Pennsylvania, 413
University of Washington Medical Center, 414
Unmarried women
sexually transmitted disease, 182183
User of symbols view
Utilitarianism, 42
VA Hospital, 153
Validation
Wiedenbachs prescriptive theory, 77, 80f
Values, 19
nursing situations, 19
Valuing, 230
Veritivity, 317
Index
Veterans Administration (VA) Hospital, 153

Victoria, Queen, 45
Vigilance
Visioning, 253
Visitation
families, 138
Visual Analog Scale, 324
Voluntary mutual patterning, 207, 209, 210
211
Wald, Florence, 149
Walter Reed Army Hospital
Army School of Nursing, 144
War
psychiatric problems, 56
Watson, Jean, 344, 412, 454t
Websites
general resources, 447t
nursing theorist resources, 274, 450t454t
Wholeness, 106, 116
JBSM, 87
Widerquist, Joann G., 34
Wiedenbach, Ernestine, 7083
career, 70
death, vi
education, 70
Index
life, 7071
website, 454t
clinical practice, 7681, 76f, 78f80f
clinical teaching, 8182
evolution, 71
example, 7374
website, 454t
Winstead-Fry, Patricia, 46
Wisdom
Women
employment, 44
redundancy, 42
Womens emancipation
attitude toward, 43
Work settings
literature review
Kings framework, 302, 303t, 304
Worldview, 5
care outcomes, 366
defined, 369
Rogers, Martha E., 195196
Wu, Ruth, 316
Yale University, 148
Zderad, Loretta, 152154
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outline at the beginning of each chapter provides a

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that is nursing practice. Over the years, I have been

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wisdom, kindness, and understanding of nursing.

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