alligood 8th edition_Neat

482 UNIT IV Nursing Theories

burden about? What does it mean? What does The nurse may have expertise in other areas,
Mrs. Brown think will happen if her daughter gets based on her knowledge and experience, and
upset? Thinking about and picturing an anticipated trusts that persons will seek information when
event is, according to Parse (1990, 1998), an oppor- ready.
tunity to rehearse and to clarify how best to be in 4. Mrs. Brown spoke about being tired. The nurse
light of anticipated consequences. In this way, the might explore this further. How does the tired-
person is helped with decisions about how best ness show itself? What does Mrs. Brown find
to go forward or how to change the situation. The helpful? What would she like to do about it? Until
practice dimensions and processes happen all- these things are known, the nurse cannot know
at-once as nurses honor the other’s unfolding how to proceed. The nurse may discover helpful
meanings, rhythms, and ways of moving forward. suggestions to offer. The nurse guided by human-
2. Articulate the judgments that are called for in the becoming offers information as people indicate
humanbecoming theory. The nurse refrains from their readiness to hear it. The nurse believes that
summarizing, comparing, judging, or labeling providing information or suggestions as persons
Mrs. Brown, as she struggles with the possibilities seek it in the flow of dialogue and listening is the
and choices in her situation. The unconditional most respectful and meaningful way of teaching.
regard called for by the humanbecoming theory is 5. Specify three benefits for humanity when nurses
extremely challenging. It can be much easier to follow the humanbecoming theory. Humanbe-
give advice or to try to teach, but the outcomes in coming practice is consistent with what people
the nurse-person process, the opportunities for say they want from health professionals. Persons
Mrs. Brown to see her situation differently, will have indicated in numerous reports and publica-
vary according to different nursing words and tions that they want to be listened to, respected,
actions. What might you say to Mrs. Brown? involved in their care, and provided with mean-
3. Where does experience lie for nurses guided by ingful information—when they want and need
the humanbecoming theory? The nurse guided by it. People want competent professionals, but if
humanbecoming theory believes that Mrs. Brown respect for the client’s reality is not the founda-
knows the best way to proceed—the nurse cannot tion of the nurse-person process, it does not
possibly know the way for another person’s qual- matter how expert or knowledgeable the profes-
ity of life. Mrs. Brown said she cannot take much sional. People do not want to be judged or labeled
more in her life, and yet she is burdened with her when it comes to their choices or ways of living.
secret. This struggle is hers to wrestle with and Persons want to be believed, understood, and
choose a way to move on. The mother knows her respected. Humanbecoming theory provides a
daughter, and she also knows how much upset guide for nurses who want to practice in ways
she can take in her life. The nurse’s true presence that clients want. It has been shown that nurses
and theory-guided questions can help Mrs. Brown guided by the humanbecoming perspective are
to figure out how to be in light of her value pri- more vigilant, more inclined to act on client
orities in the moment. The nurse also knows concerns, and more likely to involve clients and
that Mrs. Brown’s value priorities may change at families in their care (Mitchell & Bournes, 1998;
any time, leading to a different course of action. Parse, 2011c).

POINTS FOR FURTHER STUDY
n Parse, R. R. (2004). A human becoming teaching- n Parse, R. R. (2007b). The humanbecoming school
learning model. Nursing Science Quarterly, 17, of thought in 2050. Nursing Science Quarterly, 20,
33–35. 308–311.
n Parse, R. R. (2007a). Hope in “Rita Hayworth and n Parse, R. R. (2008a). The humanbecoming leading-
Shawshank Redemption”: A human becoming following model. Nursing Science Quarterly, 21,
hermeneutic study. Nursing Science Quarterly, 20, 369–375.
148–154.

CHAPTER 24 Rosemarie Rizzo Parse 483

n Parse, R. R. (2008b). The humanbecoming mentor- n Parse, R. R. (2011c). What people want from
ing model. Nursing Science Quarterly, 21, 195–198. professional nurses. Nursing Science Quarterly,
n Parse, R. R. (2008e). Truth for the moment: Per- 24, 93.
sonal testimony as evidence. Nursing Science n Parse, R. R. (2012b). New humanbecoming
Quarterly, 21, 45–48. conceptualizations and the humanbecoming
n Parse, R. R. (2009a). The humanbecoming family community model: Expansions with sciencing
model. Nursing Science Quarterly, 22, 305–309. and living the art. Nursing Science Quarterly,
n Parse, R. R. (2010). Human dignity: A humanbe- 25, 44–52.
coming ethical phenomenon. Nursing Science n Parse interview. Nurse Theorists: Portraits of Excel-
Quarterly, 23, 257–262. lence, distributed by Fitne, Inc. (5 Depot Street,
n Parse, R. R. (2011a). Humanbecoming leading- Athens, OH 45701).
following: The meaning of holding up the mirror. n www.discoveryinternationalonline.com
Nursing Science Quarterly, 24, 169–171. n www.humanbecoming.org
n Parse, R. R. (2011b). The humanbecoming modes n www.nursingchannel.org/programs.html\
of inquiry: Refinements. Nursing Science Quarterly,
24, 11–15.



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Parse, R. R. (1989). Martha E. Rogers: A birthday celebra- 7(2), 55–64.
tion. Nursing Science Quarterly, 2(2), 55. Parse, R. R. (1994). Martha E. Rogers: Her voice will not
Parse, R. R. (1989). Qualitative research: Publishing and be silenced. Nursing Science Quarterly, 7(2), 47.
funding. Nursing Science Quarterly, 2(1), 1–2. Parse, R. R. (1994). Quality of life: Sciencing and living the
Parse, R. R. (1990). A time for reflection and projection. art of human becoming. Nursing Science Quarterly,
Nursing Science Quarterly, 3(4), 143. 7(1), 16–21.
Parse, R. R. (1990). Health: A personal commitment. Nursing Parse, R. R. (1994). Scholarship: Three essential processes.
Science Quarterly, 3(3), 136–140. Nursing Science Quarterly, 7(4), 143.
Parse, R. R. (1990). Nursing theory–based practice: A chal- Parse, R. R. (1995). Again: What is nursing? Nursing Science
lenge for the 90s. Nursing Science Quarterly, 3(2), 53. Quarterly, 8(4), 143.
Parse, R. R. (1990). Parse’s research methodology with an Parse, R. R. (1995). Building the realm of nursing knowledge.
illustration of the lived experience of hope. Nursing Sci- Nursing Science Quarterly, 8(2), 51.
ence Quarterly, 3(1), 9–17.

488 UNIT IV Nursing Theories

Parse, R. R. (1995). Commentary: Parse’s theory of human Parse, R. R. (1999). Expanding the vision: Tilling the field
becoming: An alternative to nursing practice for pedi- of nursing knowledge. Nursing Science Quarterly, 12, 3.
atric oncology nurses. Journal of Pediatric Oncology Parse, R. R. (1999). Integrity and the advancement of nurs-
Nursing, 12(3), 128. ing knowledge. Nursing Science Quarterly, 12(3), 187.
Parse, R. R. (1995). Nursing theories and frameworks: The Parse, R. R. (1999). Nursing science: The transformation of
essence of advanced practice nursing. Nursing Science practice. Journal of Advanced Nursing, 30(6), 1383–1387.
Quarterly, 8(1), 1. Parse, R. R. (1999). Nursing: The discipline and the profession.
Parse, R. R. (1995). Nursing theory based research and Nursing Science Quarterly, 12(4), 275.
practice. A conference coming to Japan. Tokyo, Japan: Parse, R. R. (1999). Witnessing as true presence. Illuminations:
Igacu Shoin. Medical News Weekly. Newsletter for the International Consortium of Parse
Parse, R. R. (1996). Building knowledge through qualita- Scholars, 8(3), 1.
tive research: The road less traveled. Nursing Science Parse, R. R. (2000). Into the new millennium. Nursing Science
Quarterly, 9(1), 10–16. Quarterly, 13(1), 3.
Parse, R. R. (1996). Critical thinking: What is it? Nursing Parse, R. R. (2000). Language: Words reflect and co-create
Science Quarterly, 9(3), 138. meaning. Nursing Science Quarterly, 13(3), 187.
Parse, R. R. (1996). Hear ye, hear ye: Novice and seasoned Parse, R. R. (2000). Obfuscating: The persistent practice of
authors! Nursing Science Quarterly, 9(1), 1. misnaming. Nursing Science Quarterly, 13(2), 91–92.
Parse, R. R. (1996). Nursing theories: An original path. Parse, R. R. (2000). Paradigms: A reprise. Nursing Science
Nursing Science Quarterly, 9(2), 85. Quarterly, 13(4), 275–276.
Parse, R. R. (1996). Quality of life for persons living with Parse, R. R. (2001). Contributions to the discipline. Nursing
Alzheimer’s disease: A human becoming perspective. Science Quarterly, 14(1), 5.
Nursing Science Quarterly, 9(3), 126–133. Parse, R. R. (2001). Nursing: Still in the shadow of medicine.
Parse, R. R. (1996). Reality: A seamless symphony of becom- Nursing Science Quarterly, 14(3), 181.
ing. Nursing Science Quarterly, 9(4), 181–183. Parse, R. R. (2001). The lived experience of contentment: A
Parse, R. R. (1996). The human becoming theory: Challenges study using the Parse research method. Nursing Science
in practice and research. Nursing Science Quarterly, 9(1), Quarterly, 14, 330–338.
55–60. Parse, R. R. (2001). The universe is flat. Nursing Science
Parse, R. R. (1997). Concept inventing: Unitary creations. Quarterly, 14(2), 93.
Nursing Science Quarterly, 10(2), 63–64. Parse, R. R. (2002). 15th anniversary celebration. Nursing
Parse, R. R. (1997). Investing the legacy: Martha E. Rogers’ Science Quarterly, 15, 3.
voice will not be silenced. Visions: The Journal of Rogerian Parse, R. R. (2002). Aha! Ah! Haha! Discovery, wonder,
Science, 5, 7–11. laughter. Nursing Science Quarterly, 15, 273.
Parse, R. R. (1997). Joy-sorrow: A study using the Parse re- Parse, R. R. (2002). Mentoring moments. Nursing Science
search method. Nursing Science Quarterly, 10(2), 80–87. Quarterly, 15, 97.
Parse, R. R. (1997). Leadership: The essentials. Nursing Sci- Parse, R. R. (2002). Transforming healthcare with a unitary
ence Quarterly, 10(3), 109. view of human. Nursing Science Quarterly, 15, 46–50.
Parse, R. R. (1997). New beginnings in a quiet revolution. Parse, R. R. (2002). Words, words, words: Meanings,
Nursing Science Quarterly, 10(1), 1. meanings, meanings!Nursing Science Quarterly, 15, 183.
Parse, R. R. (1997). The human becoming theory: The was, Parse, R. R. (2003). A call for dignity in nursing. Nursing
is, and will be. Nursing Science Quarterly, 10(1), 32–38. Science Quarterly, 16, 193.
Parse, R. R. (1997). Transforming research and practice Parse, R. R. (2003). Research approaches: Likenesses and
with the human becoming theory. Nursing Science differences. Nursing Science Quarterly, 16, 5.
Quarterly, 10(4), 171–174. Parse, R. R. (2003). Silos and schools of thought. Nursing
Parse, R. R. (1998). Moving on. Nursing Science Quarterly, Science Quarterly, 16, 101.
11(4), 135. Parse, R. R. (2003). The lived experience of feeling very
Parse, R. R. (1998). The art of criticism. Nursing Science tired: A study using the Parse research method. Nursing
Quarterly, 11(2), 43. Science Quarterly, 16, 319–325.
Parse, R. R. (1998). Will nursing exist tomorrow? A reprise. Parse, R. R. (2003). What constitutes nursing research?
Nursing Science Quarterly, 11(1), 1. Nursing Science Quarterly, 16, 287.
Parse, R. R. (1999). Authorship: Whose responsibility? Parse, R. R. (2004). A human becoming teaching-learning
Nursing Science Quarterly, 12(2), 99. model. Nursing Science Quarterly, 17, 33–35.
Parse, R. R. (1999). Community: An alternative view. Nursing Parse, R. R. (2004). New directions. Nursing Science
Science Quarterly, 12(2), 119–124. Quarterly, 17, 5.

CHAPTER 24 Rosemarie Rizzo Parse 489

Parse, R. R. (2004). Power in position. Nursing Science Parse, R. R. (2007). A human becoming perspective on
Quarterly, 17, 101. quality of life. Nursing Science Quarterly, 20, 217.
Parse, R. R. (2004). A human becoming teaching-learning Parse, R. R. (2007). Building a research culture. Nursing
model. Nursing Science Quarterly, 17, 33–35. Science Quarterly, 20, 197.
Parse, R. R. (2004). Quality of life: A human becoming Parse, R. R. (2007). Data-based articles and duplicate pub-
perspective. Japanese Journal of Nursing Research, 37(5), lication. Nursing Science Quarterly, 20, 301.
21–26. Parse, R. R. (2007). Hope in “Rita Hayworth and Shawshank
Parse, R. R. (2004). Person-centered care. Nursing Science Redemption”: A human becoming hermeneutic study.
Quarterly, 17, 193. Nursing Science Quarterly, 20, 148–154.
Parse, R. R. (2004). The many meanings of unitary: A plea Parse, R. R. (2007). Nursing knowledge and health policy.
for clarity. Nursing Science Quarterly, 17, 293. Nursing Science Quarterly, 20, 105.
Parse, R. R. (2004). The ubiquitous nature of unitary: Ma- Parse, R. R. (2007). The humanbecoming school of thought
jor change in human becoming language. Illuminations: in 2050. Nursing Science Quarterly, 20, 308.
Newsletter for the International Consortium of Parse Parse, R. R. (2007). Twenty years of commitment to nursing’s
Scholars, 13(1), 1. uniqueness as a discipline. Nursing Science Quarterly, 20, 5.
Parse, R. R. (2004). Another look at vigilance. Illumina- Parse, R. R. (2008). Is there a tipping point for congruence in
tions: Newsletter for the International Consortium of nursing knowledge? Nursing Science Quarterly, 21, 193.
Parse Scholars, 13(2), 1. Parse, R. R. (2008). Nursing knowledge development:
Parse, R. R. (2005). A community of scholars. Nursing Who’s to say how? Nursing Science Quarterly, 21, 101.
Science Quarterly, 18, 119. Parse, R. R. (2008). Proliferation of degrees in nursing: A
Parse, R. R. (2005). Attentive reverence. Illuminations: call for clarity. Nursing Science Quarterly, 21, 5.
Newsletter for the International Consortium of Parse Parse, R. R. (2008). The humanbecoming leading-following
Scholars, 14(2), 1. model. Nursing Science Quarterly, 21, 369–375.
Parse, R. R. (2005). Challenges for global nursing. Nursing Parse, R. R. (2008). The humanbecoming mentoring
Science Quarterly, 18, 285. model. Nursing Science Quarterly, 21, 195–198.
Parse, R. R. (2005). Choosing a doctoral program in nurs- Parse, R. R. (2008). Truth for the moment: Personal
ing: What to consider. Nursing Science Quarterly, 18, 5. testimony as evidence. Nursing Science Quarterly,
Parse, R. R. (2005). Nursing and medicine: Continuing 21, 45–48.
challenges. Nursing Science Quarterly, 18, 5. Parse, R. R. (2008). Time: The inevitable presence. Nursing
Parse, R. R. (2005). Parse’s criteria for evaluation of theory Science Quarterly, 21, 281–282.
with a comparison of Parse and Fawcett. Nursing Sci- Parse, R. R. (2009). Knowledge development and programs
ence Quarterly, 18, 135–137. of research. Nursing Science Quarterly, 22, 5–6.
Parse, R. R. (2005). Scientific standards: A renewed alert. Parse, R. R. (2009). Mixed methods or mixed meanings in
Nursing Science Quarterly, 18, 97. research? Nursing Science Quarterly, 22, 101.
Parse, R. R. (2005). Symbols and meanings in academia. Parse, R. R. (2009). Visionary leadership: Making a difference
Nursing Science Quarterly, 18, 197. in healthcare through research. Nursing Science Quarterly,
Parse, R. R. (2005). The human becoming modes of in- 22, 197–198.
quiry: Emerging sciencing. Nursing Science Quarterly, Parse, R. R. (2009). What a difference a word makes. Nursing
18, 297–300. Science Quarterly, 22, 301.
Parse, R. R. (2005). The meaning of freely choosing. Illu- Parse, R. R. (2009). The humanbecoming family model.
minations: Newsletter for the International Consortium Nursing Science Quarterly, 22, 305–309.
of Parse Scholars, 14(1), 1–2. Parse, R. R. (2010). Imagine! Nursing Science Quarterly, 23, 97.
Parse, R. R. (2006). Concept Inventing: Continuing Clarifi- Parse, R. R. (2010). Respect! Nursing Science Quarterly,
cation. Nursing Science Quarterly, 19, 289. 23, 193.
Parse, R. R. (2006). Feeling respected: A Parse method Parse, R. R. (2010). Human dignity: A humanbecoming
study. Nursing Science Quarterly, 19, 51–57. ethical phenomenon. Nursing Science Quarterly, 23,
Parse, R. R. (2006). Nursing and medicine: Continuing 257–262.
challenges. Nursing Science Quarterly, 19, 5. Parse, R. R. (2010). Nursing education: Issues reminiscent
Parse, R. R. (2006). Outcomes: Saying what you mean. of the last century. Nursing Science Quarterly, 23, 273.
Nursing Science Quarterly, 19, 189. Parse, R. R. (2011). The humanbecoming modes of inquiry:
Parse, R. R. (2006). Research findings evince benefits of Refinements. Nursing Science Quarterly, 24, 11–15.
nursing theory-guided practice. Nursing Science Quar- Parse, R. R. (2011). What people want from professional
terly, 19, 87. nurses. Nursing Science Quarterly, 24, 93.

490 UNIT IV Nursing Theories

Parse, R. R. (2011). Humanbecoming leading-following: Baumann, S. L. (1997). Qualitative research with children
The meaning of holding up the mirror. Nursing Science as participants. Nursing Science Quarterly, 10(2), 68–69.
Quarterly, 24, 169–171. Baumann, S. L. (1999). Art as a path of inquiry. Nursing
Parse, R. R. (2012). The 25-year evolution of Nursing Science Science Quarterly, 12(2), 106–110.
Quarterly: Keeping the dream alive. Nursing Science Baumann, S. L. (2003). The lived experience of feeling very
Quarterly, 25, 5–6. tired: A study of adolescent girls. Nursing Science Quar-
Parse, R. R. (2012). New humanbecoming conceptualiza- terly, 16, 326–333.
tions and the humanbecoming community model: Baumann, S., & Braddick, M. (1999). Out of their element:
Expansions with sciencing and living the art. Nursing Fathers of children who are “not the same.” Journal of
Science Quarterly, 25, 44–52. Pediatric Nursing, 14(6), 269–278.
Parse, R. R. (2012). The things we make, make us. Nursing Baumann, S. L., Dyches, T. T., & Braddick, M. (2005). Being
Science Quarterly, 25, 125. a sibling. Nursing Science Quarterly, 18, 51–58.
Parse, R. R. (2012). Impact factor—one-size-fits-all: What’s Baumann, S. L., & Englert, R. (2003). A comparison of
wrong with this picture? Nursing Science Quarterly, 25, three views of spirituality in oncology nursing. Nursing
209–210. Science Quarterly, 16, 52–59.
Parse, R. R., Bournes, D. A., Barrett, E. A. M., Malinski, V. M., Baumann, S. L. & Söderhamn, O. (2005). Considering and
& Phillips, J. R. (1999). A better way: 10 things health enjoying tomorrow: Global aging through a human be-
professionals can do to move toward a more personal coming lens. Nursing Science Quarterly, 18, 353–358.
and meaningful system. On Call: A Magazine for Nurses Benedict, L. L., Bunkers, S. S., Damgaard, G. A., Duffy, C.
and Healthcare Professionals, 2(8), 14–17. E., Hohman, M. L., & Vander Woude, D. L. (2000). The
South Dakota board of nursing theory–based regula-
Secondary Sources tory decisioning model. Nursing Science Quarterly,
Allchin-Petardi, L. (1998). Weathering the storm: Persever- 13(2), 167–171.
ing through a difficult time. Nursing Science Quarterly, Bournes, D. A. (2000). A commitment to honoring people’s
11(4), 172–177. choices. Nursing Science Quarterly, 13(1), 18–23.
Andrus, K. (1995). Parse’s nursing theory and the practice Bournes, D. A. (2000). Concept inventing: A process for
of perioperative nursing. Canadian Operating Room creating a unitary definition of having courage. Nursing
Nursing Journal, 13(3), 19–22. Science Quarterly, 13(2), 143–149.
Aquino-Russell, C. E. (2006). A phenomenological study: Bournes, D. A. (2002). Having courage: A lived experience
The lived experience of persons having a different sense of human becoming. Nursing Science Quarterly, 15,
of hearing. Nursing Science Quarterly, 19, 339–348. 220–229.
Aquino-Russell, K., Struby, F. V. M., & Reviczky, K. (2007). Bournes, D. A. (2002). Research evaluating human becom-
Living attentive presence and changing perspectives with ing in practice. Nursing Science Quarterly, 15, 190–195.
a web-based nursing theory course. Nursing Science Bournes, D. A. (2006). Human becoming-guided practice.
Quarterly, 20, 128–134. Nursing Science Quarterly, 19, 329–330.
Arndt, M. J. (1995). Parse’s theory of human becoming in Bournes, D. A. (2007). Rosemarie Rizzo Parse over the
practice with hospitalized adolescents. Nursing Science years. Nursing Science Quarterly, 20, 305.
Quarterly, 8(2), 86–90. Bournes, D. A., Bunkers, S. S., & Welch, A. J. (2004).
Baumann, S. (1994). No place of their own: An explor- Human becoming: Scope and challenges. Nursing
atory study. Nursing Science Quarterly, 7(4), 162–169. Science Quarterly, 17, 227–232.
Baumann, S. (1995). Two views of children’s art: Psycho- Bournes, D. A., & Das Gupta, T. L. (1997). Professional
analysis and Parse’s human becoming theory. Nursing practice leader: A transformational role that addresses
Science Quarterly, 8(2), 65–70. human diversity. Nursing Administration Quarterly,
Baumann, S. (1996). Feeling uncomfortable: Children in 21(4), 61–68.
families with no place of their own. Nursing Science Bournes, D. A., & Ferguson-Paré, M. (2005). Persevering
Quarterly, 9(4), 152–159. through a difficult time during the SARS outbreak in
Baumann, S. (1996). Parse’s research methodology and the Toronto. Nursing Science Quarterly, 18, 324–333.
nurse-researcher-child process. Nursing Science Quar- Bournes, D. A., & Ferguson-Paré, M. (2007). Human becom-
terly, 9(1), 27–32. ing and 80/20: An innovative professional development
Baumann, S. (1997). Contrasting two approaches in a model for nurses. Nursing Science Quarterly, 20, 237–253.
community-based nursing practice with older adults: Bournes, D. A., & Flint, F. (2003). Mis-takes: Mistakes in
The medical model and Parse’s nursing theory. Nursing the nurse-person process. Nursing Science Quarterly,
Science Quarterly, 10(3), 124–130.
16, 127–130.

CHAPTER 24 Rosemarie Rizzo Parse 491

Bournes, D. A., & Linscott, J. (1998). Patient-focused care: Cody, W. K. (1994). Nursing theory–guided practice: What
A process of discovery. Theoria,.(4), 3–5. it is and what it is not. Nursing Science Quarterly, 7(4),
Bournes, D. A., & Mitchell, G. J. (2002). Waiting: The experi- 144–145.
ence of persons in a critical care waiting room. Research Cody, W. K. (1994). Radical health care reform: The person as
in Nursing & Health, 25, 58–67. case manager. Nursing Science Quarterly, 7(4), 180–182.
Bournes, D. A., & Naef, R. (2006). Human becoming practice Cody, W. K. (1995). All those paradigms: Many in the
around the globe: Exploring the art of living true presence. universe, two in nursing. Nursing Science Quarterly,
Nursing Science Quarterly, 19, 109–115. 8(4), 144–147.
Bunkers, S. S. (1998). A nursing theory–guided model of Cody, W. K. (1995). The meaning of grieving for families liv-
health ministry: Human becoming in parish nursing. ing with AIDS. Nursing Science Quarterly, 8(3), 104–114.
Nursing Science Quarterly, 11(1), 7–8. Cody, W. K. (1996). Drowning in eclecticism. Nursing Sci-
Bunkers, S. S. (1998). Considering tomorrow: Parse’s theory- ence Quarterly, 9, 86–88.
guided research. Nursing Science Quarterly, 11(2), 56–63. Cody, W. K. (1996). Occult reductionism in the discourse
Bunkers, S. S. (1999). Emerging discoveries and possibili- of theory development. Nursing Science Quarterly, 9(4),
ties in nursing. Nursing Science Quarterly, 12(1), 26–29. 140–142.
Bunkers, S. S. (1999). The teaching-learning process and Cody, W. K. (1997). The many faces of change: Discomfort
the theory of human becoming. Nursing Science Quar- with the new. Nursing Science Quarterly, 10(2), 65–67.
terly, 12(3), 227–232. Cody, W. K. (1998). Critical theory and nursing science:
Bunkers, S. S. (2002). Lifelong learning: A human becoming Freedom in theory and practice. Nursing Science Quar-
perspective. Nursing Science Quarterly, 15, 294–300. terly, 11(2), 44–46.
Bunkers, S. S. (2003). Understanding the stranger. Nursing Cody, W. K. (1999). Affirming reflection. Nursing Science
Science Quarterly, 16, 305–309. Quarterly, 12(1), 4–6.
Bunkers, S. S. (2004). The lived experience of feeling cared Cody, W. K. (1999). Middle-range theories: Do they foster
for: A human becoming perspective. Nursing Science the development of nursing science? Nursing Science
Quarterly, 17, 63–71. Quarterly, 12(1), 9–14.
Bunkers, S. S. (2006). Reflections of the prairie as a creative Cody, W. K. (2000). Paradigm shift or paradigm drift? A
teaching-learning process. Nursing Science Quarterly, meditation on commitment and transcendence. Nursing
19, 25–29. Science Quarterly, 13(2), 93–102.
Bunkers, S. S. (2007). The experience of feeling unsure for Cody, W. K. (2000). The challenge of unitary conceptualiza-
women at end of life. Nursing Science Quarterly, 20, 56–63. tions: An exemplar. Nursing Science Quarterly, 13(1), 4.
Bunkers, S. S., Michaels, C., & Ethridge, P. (1997). Advanced Cody, W. K. (2003). Diversity and becoming: Implications
practice nursing in community: Nursing’s opportunity. of human existence as coexistence. Nursing Science
Advanced Practice Nursing Quarterly, 2(4), 79–84. Quarterly, 16, 195–200.
Butler, M. J. (1988). Family transformation: Parse’s theory Cody, W. K., & Mitchell, G. J. (1992). Parse’s theory as a
in practice. Nursing Science Quarterly, 1(2), 68–74. model for practice: The cutting edge. Advances in Nursing
Butler, M. J., & Snodgrass, F. G. (1991). Beyond abuse: Science, 15(2), 52–65.
Parse’s theory in practice. Nursing Science Quarterly, Costello-Nickitas, D. M. (1994). Choosing life goals: A
4(2), 76–82. phenomenological study. Nursing Science Quarterly,
Carson, M. G., & Mitchell, G. J. (1998). The experience of 7(2), 87–92.
living with persistent pain. Journal of Advanced Nursing, Daly, J., & Jackson, D. (1999). On the use of nursing theory in
28(6), 1242–1248. nursing education, nursing practice, and nursing research
Chan, E. A. (2005). The influence of the human becoming in Australia. Nursing Science Quarterly, 12(4), 342–345.
theory on teaching-learning stories in Hangzhou, Daly, J., Mitchell, G. J., & Jonas-Simpson, C. M. (1996).
China. Nursing Science Quarterly, 18, 306–312. Quality of life and the human becoming theory:
Cody, W. K. (1991). Grieving a personal loss. Nursing Science Exploring discipline-specific contributions. Nursing
Quarterly, 4, 61–68. Science Quarterly, 9(4), 170–174.
Cody, W. K. (1991). Multidimensionality: Its meaning and Doucet, T., & Bournes, D. A. (2007). Review of research
significance. Nursing Science Quarterly, 4, 140–141. related to Parse’s theory of human becoming. Nursing
Cody, W. K. (1993). Norms and nursing science: A ques- Science Quarterly, 20, 16–32.
tion of values. Nursing Science Quarterly, 6(3), 110–112. Fawcett, J. (2001). The nurse theorists: 21st-century updates—
Cody, W. K. (1994). Meaning and mystery in nursing science Rosemarie Rizzo Parse. Nursing Science Quarterly, 14,
and art. Nursing Science Quarterly, 7(2), 48–51. 126–131.

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Fisher, M. A., & Mitchell, G. J. (1998). Patients’ views of Karnick, P. M. (2007). Nursing practice: Imaging the possi-
quality of life: Transforming the knowledge base of bles. Nursing Science Quarterly, 20, 44–47.
nursing. Clinical Nurse Specialist, 12(3), 99–105. Kelley, L. S. (1991). Struggling with going along when you
Florczak, K. L. (2006). The lived experience of sacrificing do not believe. Nursing Science Quarterly, 4(3), 123–129.
something important. Nursing Science Quarterly, 19, Kelley, L. S. (1995). Parse’s theory in practice with a group
133–141. in the community. Nursing Science Quarterly, 8(3),
Hamalis, P. (1999). Reaching out. Nursing Science Quarterly, 127–132.
12(4), 346. Kelley, L. S. (1999). Evaluating change in quality of life
Hansen-Ketchum, P. (2004). Parse’s theory in practice. from the perspective of the person: Advanced practice
Journal of Holistic Nursing, 22, 57–72. nursing and Parse’s goal of nursing. Holistic Nursing
Huch, M. H., & Bournes, D. A. (2003). Community dwellers’ Practice, 13(4), 61–70.
perspectives on the experience of feeling very tired. Nurs- Kruse, B. G. (1999). The lived experience of serenity: Using
ing Science Quarterly, 16, 334–339. Parse’s research method. Nursing Science Quarterly,
Huchings, D. (2002). Parallels in practice: Palliative nurs- 12(2), 143–150.
ing practice and Parse’s theory of human becoming. Lee, O. J., & Pilkington, F. B. (1999). Practice with persons
American Journal of Hospice and Palliative Care, 19, living their dying: A human becoming perspective.
408–414. Nursing Science Quarterly, 12(4), 324–328.
International Consortium of Parse Scholars. (1999). A nurs- Legault, F., & Ferguson-Paré, M. (1999). Advancing nursing
ing position on global healthcare: Our commitment to practice: An evaluation study of Parse’s theory of human
humankind. Nursing Science Quarterly, 12(4), 347. becoming. Canadian Journal of Nursing Leadership, 12(1),
Jacono, B. J., & Jacono, J. J. (1996). The benefits of Newman 30–35.
and Parse in helping nurse teachers determine methods Letcher, D. C., & Yancey, N. R. (2004). Witnessing change
to enhance student creativity. Nursing Education Today, with aspiring nurses: A human becoming teaching-
16, 356–362. learning process in nursing education. Nursing Science
Janes, N. M., & Wells, D. L. (1997). Elderly patients’ expe- Quarterly, 17, 36–41.
riences with nurses guided by Parse’s theory of human Liehr, P. R. (1989). The core of true presence: A loving
becoming. Clinical Nursing Research, 6, 205–224. center. Nursing Science Quarterly, 2(1), 7–8.
Jonas, C. M. (1992). The meaning of being an elder in Markovic, M. (1997). From theory to perioperative practice
Nepal. Nursing Science Quarterly, 5(4), 171–175. with Parse. Canadian Operating Room Nursing Journal,
Jonas-Simpson, C. M. (1996). The patient-focused care 15(1), 13–16.
journey: Where patients and families guide the way. Mattice, M. (1991). Parse’s theory of nursing in practice:
Nursing Science Quarterly, 9(4), 145–146. A manager’s perspective. Canadian Journal of Nursing
Jonas-Simpson, C. (1997). Living the art of the human be- Administration, 4(1), 11–13.
coming theory. Nursing Science Quarterly, 10(4), 175–179. Mattice, M., & Mitchell, G. J. (1990). Caring for confused
Jonas-Simpson, C. M. (1997). The Parse research method elders. The Canadian Nurse, 86(11), 16–18.
through music. Nursing Science Quarterly, 10(3), 112–114. Melnechenko, K. L. (2003). To make a difference: Nursing
Jonas-Simpson, C. M. (2001). Feeling understood: A mel- presence. Nursing Forum, 38, 18–24.
ody of human becoming. Nursing Science Quarterly, 14, Milton, C. L. (2000). Beneficence: Honoring the commit-
222–230. ment. Nursing Science Quarterly, 13(2), 111–115.
Jonas-Simpson, C. M. (2003). The experience of being lis- Milton, C. L. (2003). A graduate curriculum guided by hu-
tened to: A human becoming study with music. Nursing man becoming: Journeying with the possible. Nursing
Science Quarterly, 16, 232–238. Science Quarterly, 16, 214–218.
Jonas-Simpson, C. J. (2006). The possibility of changing Milton, C. L. (2003). The American Nurses Association
meaning in light of space and place. Nursing Science Code of Ethics: A reflection on the ethics of respect
Quarterly, 19, 89–94. and human dignity with nurse as expert. Nursing
Jonas-Simpson, C., & McMahon, E. (2005). The language of Science Quarterly, 16, 301–304.
loss when a baby dies prior to birth: Co-creating human Milton, C. L., & Buseman, J. (2002). Co-creating anew in
experience. Nursing Science Quarterly, 18, 124–130. public health nursing. Nursing Science Quarterly, 15,
Kagan, P. N. (2008). Feeling listened to: A lived experience of 113–116.
humanbecoming. Nursing Science Quarterly, 21, 59–67. Mitchell, G. J. (1986). Utilizing Parse’s theory of man-
Karnick, P. M. (2005). Human becoming theory with children. living-health in Mrs. M’s neighborhood. Perspectives,
Nursing Science Quarterly, 18, 221–226. 10(4), 5–7.

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Mitchell, G. J. (1988). Man-living-health: The theory in Mitchell, G. J. (2006). Human becoming criticism—a
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the day. Nursing Science Quarterly,.(2), 92–93. Research-based theatre: The making ofI’m Still Here!
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Quarterly, 10(1), 8–9. quences of personal choices for persons with diabetes:
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Care, 7(4), 31–34. Mitchell, G. J., & Pilkington, F. B. (1990). Theoretical
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Nurse, 13(5), 10–13. 18, 215–220.

25

CHAP TER



















Helen C. Erickson Evelyn M. Tomlin Mary Ann P. Swain
1937 to present 1929 to present 1941 to present


Modeling and Role-Modeling


Margaret E. Erickson



“Unconditional acceptance of the person as a human in the process of Being and Becoming
is basic to the Modeling and Role-Modeling paradigm. It is a prerequisite to facilitating
holistic growth . . . Unconditional acceptance of the person as a human being who has an
inherent need for dignity and respect from others, and for connectedness—that kind of
Unconditional Acceptance is based on Unconditional Love”
(Erickson, 2006, p. 343).




Credentials and Background began in the emergency room of the Midland Com-
of the Theorists munity Hospital in Midland, Texas, where she was
Head Nurse; she then worked as Night Supervisor at
Helen C. Erickson the Michigan State Home for the Mentally Impaired
Helen C. Erickson received a diploma in 1957 from and Handicapped in Mount Pleasant. In 1960, she
Saginaw General Hospital in Saginaw, Michigan. Her moved to Puerto Rico with her husband and was
degrees include a baccalaureate in nursing in 1974, Director of Health Services at Inter-American Uni-
dual master’s degrees in psychiatric nursing and versity in San German, Puerto Rico, until 1964. On
medical-surgical nursing in 1976, and a doctor of return to the United States, she was a staff nurse at
educational psychology in 1984, all from the Univer- St. Joseph’s and University Hospitals in Ann Arbor,
sity of Michigan. Erickson’s professional experience Michigan. Erickson later was a mental health nurse


Previous authors: Margaret E. Erickson, Jane A. Caldwell-Gwin, Lisa A. Carr, Brenda Kay Harmon, Karen Hartman, Connie Rae
Jarlsberg, Judy McCormick, and Kathryn W. Noone.
The authors express appreciation to Helen C. Erickson, Evelyn M. Tomlin, and Mary Ann P. Swain for critiquing earlier editions of
this chapter.

496

CHAPTER 25 Helen C. Erickson, Evelyn M. Tomlin, and Mary Ann P. Swain 497

consultant to the Pediatric Nurse Practitioner Pro- Nursing was established in her honor in 1997 at the
gram at University of Michigan and University of University of Texas at Austin. The biennial lectureship
Michigan Hospitals—Adult Care. highlights international holistic nursing leaders.
Erickson’s academic career began as Assistant Erickson consults on research with the Modeling
Instructor in the RN Studies Program at the University and Role-Modeling Theory and presents seminars,
of Michigan School of Nursing, and later as Chairper- conferences, and papers on the theory nationally and
son of the Undergraduate Program and Dean for internationally. She consults on implementation of
Undergraduate Studies. She was Assistant Professor at the theory in practice at the University of Michigan
the University of Michigan from 1978 to 1986. In Medical Center, Brigham and Women’s Hospital in
1986, she moved to the University of South Carolina Boston, Oregon Health Science University Hospital in
College of Nursing, where she served as Associate Portland, and the University of Pittsburgh hospitals.
Professor, Assistant Dean for Academic Programs, She consults with faculty members on use of the the-
and Associate Dean for Academic Affairs. In 1988, she ory into their curricula and practice in schools of
became Professor of Nursing, Chair of Adult Health, nursing and service agencies. Humboldt University
and Special Assistant to the Dean, Graduate Programs, School of Nursing in Arcata, California, was first
at the University of Texas School of Nursing in Austin. to use the Modeling and Role-Modeling Theory as
In 1997, she became Emeritus Professor at the Uni- a conceptual curriculum base. Metropolitan State
versity of Texas at Austin. She has maintained an University at St. Paul adopted the Modeling and
independent nursing practice since 1976. Role-Modeling Theory for RN, baccalaureate, and
Erickson is a member of the American Nurses master’s programs. St. Catherine’s College in St. Paul,
Association, American Nurses Foundation, the Charter Minnesota, and the Joanne Gay Dishman Depart-
Club, American Holistic Nurses Association, Texas ment of Nursing at Lamar University have adopted it
Nurses Association, Sigma Theta Tau, and the Institute for their associate degree program.
for the Advancement of Health. She served as Presi- Erickson has been invited to speak at many
dent of the Society for the Advancement of Modeling national and international conferences. She has
and Role-Modeling from 1986 to 1990; as chairperson been involved in activities of the American Holistic
of the First National Symposium on Modeling and Nurses’ Association, served as a content expert for
Role-Modeling in 1986; and on the planning boards certification curricula, and was included in a book
for many national biannual conferences. featuring nurse healers (H. Erickson, personal com-
Erickson was in Who’s Who Among University munication, July 1992). Although retired from the
Students and is a member of Phi Kappa Phi. She University of Texas at Austin, Erickson continues to
received the Sigma Theta Tau Rho Chapter Award be actively involved in the promotion of holistic
of Excellence in Nursing in 1980 and the Amoco nursing, serving as Chair for the Board of Directors
Foundation Good Teaching Award in 1982. She was of the American Holistic Nurses’ Certification Cor-
accepted into ADARA (a University of Michigan poration (AHNCC) from 2002 to 2012, and she
honor society for women in leadership) in 1982. In remains involved and committed to the work of the
1990, she received the Faculty Teaching Award from AHNCC. She provides consultation, educational
the University of Texas School of Nursing, a Founders programs nationally and internationally, and is
award from the Sigma Theta Tau International Honor actively involved in the Society for the Advance-
Society in Nursing. She also received the Excellence ment of Modeling and Role-Modeling (H. Erickson,
in Education Award from the Epsilon Theta Chapter personal communication, June 10, 2000).
in 1993 and the Graduate Faculty Teaching Award
from the University of Texas School of Nursing in Evelyn M. Tomlin
1995. Erickson was inducted as a Fellow into the Evelyn M. Tomlin’s nursing education began in
American Academy of Nursing in 1996. She received Southern California. She attended Pasadena City
the Distinguished Faculty citation from Humboldt College, Los Angeles County General Hospital
State University in California in 2001. The Helen School of Nursing, and the University of Southern
Erickson Endowed Lectureship in Holistic Health California, where she received her bachelor of science

498 UNIT IV Nursing Theories

degree in nursing. She received a master of science healing prayer, stating that she has always been inter-
degree in psychiatric nursing from the University of ested in the interface of the Modeling and Role-
Michigan in 1976. Modeling Theory and Judeo-Christian principles. She
Tomlin’s professional experiences are varied. She is now retired after many years on the board of direc-
began as a clinical instructor at Los Angeles County tors and as a volunteer at Wayside Cross Ministries in
General Hospital School of Nursing and later lived in Aurora, Illinois, where she taught and counseled
Kabul, Afghanistan, where she taught English at the homeless women, many of whom were single mothers.
Afghan Institute of Technology. She served as a school
nurse and practiced family nursing in the overseas Mary Ann P. Swain
American and European communities where she Mary Ann P. Swain’s educational background is in
lived and participated in more than 46 home deliver- psychology. She received her bachelor’s degree in psy-
ies with a certified nurse-midwife. After she estab- chology from DePauw University and her master’s
lished medical services at the United States Embassy and doctoral degrees in psychology from the Univer-
Hospital, she practiced as a staff nurse. Upon return- sity of Michigan. Swain taught psychology, research
ing to the United States, she was employed by the methods, and statistics as a teaching assistant at
Visiting Nurse Association (VNA) in Ann Arbor, DePauw University and later as a lecturer and pro-
Michigan. At the VNA, she was coordinator and fessor of psychology and nursing research at the
clinical instructor for student practical nurses. In University of Michigan. At the University of Michigan,
addition, she was a staff nurse in a coronary care unit, she was Director of the Doctoral Program in Nurs-
worked in the respiratory intensive care unit, and ing in 1975 for 1 year, Chairperson of Nursing Research
was Head Nurse in the emergency department at from 1977 to 1982, and became Associate Vice Presi-
St. Joseph’s Mercy Hospital in Ann Arbor. She later dent for Academic Affairs in 1983.
taught fundamentals of nursing as Assistant Professor Swain is a member of the American Psychological
in the RN Studies Program at the University of Association and an associate member of the Michigan
Michigan. During this time, she served as mental Nurses Association. She developed and taught classes
health consultant to the pediatric nurse practitioner in psychology, research, and nursing research methods
program at the University of Michigan. and collaborated with nurse researchers on projects,
Tomlin was among the first 16 nurses in the United including health promotion among diabetic patients
States to be certified by the American Association of and ways to influence compliance among patients with
Critical Care Nurses. With several colleagues, she hypertension. She helped Erickson publish a model
opened one of the first offices for independent nursing that assessed an individual’s potential to mobilize
practice in Michigan and continued independent resources and adapt to stress, which is significant to the
practice until 1993. She is a member of Sigma Theta Modeling and Role-Modeling Theory.
Tau Rho Chapter, California Scholarship Federation, Swain received the Alpha Lambda Delta, Psi Chi,
and the Philomathian Society. Tomlin presented pro- Mortar Board, and Phi Beta Kappa awards while at
grams based on the Modeling and Role-Modeling DePauw University. In 1981, she was recognized by
Theory, with emphasis on clinical applications. She the Rho Chapter of Sigma Theta Tau for Contributions
was the first editor for the newsletter of the Society to Nursing, and in 1983 she became an honorary
for the Advancement of Modeling and Role-Modeling member of Sigma Theta Tau. In 1994, she moved
(E. Tomlin, curriculum vitae, 1992). to Appalachia, New York, with her husband, where
In 1985, Tomlin moved to Big Rock, Illinois, where she served as Provost and Vice President for Academic
she enjoyed teaching small community and nursing Affairs for Binghamton University for nearly 20 years.
groups and working in a community shelter serving She is director of the doctoral (PhD in Nursing) pro-
the women and children of Fox Valley. She later gram at Decker School of Nursing and Chair of
moved to Geneva, Illinois, where she resides with her the Department of Student Affairs. Her research inter-
husband. Tomlin identifies herself as a Christian in ests are health development across the life span and
retirement from nursing for pay, but not from nursing interrelationships among life stressors, healthy devel-
practice. She is pursuing interests in the practice of opment, and illness.

CHAPTER 25 Helen C. Erickson, Evelyn M. Tomlin, and Mary Ann P. Swain 499

individual’s future since it connotes something
Theoretical Sources still in progress” (Erickson, Tomlin, & Swain, 2002,
The theory and paradigm Modeling and Role-Modeling pp. 62–63).
was developed with a retroductive process. The origi- The works of Winnicott, Klein, Mahler, and
nal model was derived inductively from Erickson’s Bowlby on object attachment were integrated with
clinical and personal life experiences. The works of the original model to develop and articulate the con-
Maslow, Erikson, Piaget, Engel, Selye, and M. Erickson cept of affiliated individuation (AI). Object relations
MD were then integrated and synthesized into the theory proposes that an infant initially forms an
original model to label, further articulate, and refine a attachment to his or her caregiver after having
holistic theory and paradigm for nursing. H. Erickson repeated positive contacts. As the child grows and
(1976) argued that people have mind-body relations begins to move toward a more separate and indi-
and an identifiable resource potential that predicts viduated state, a sense of autonomy develops and
their ability to contend with stress. She articulated a he or she usually transfers some attachment to an
relationship between needs status and developmental inanimate object such as a cuddly blanket or a teddy
processes, satisfaction with needs and attachment bear. Later, the child may attach to a favorite base-
objects, loss and illness, and health and need satisfac- ball glove, doll, or pet, and finally onto more abstract
tion. Tomlin and Swain validated and affirmed Erickson’s things in adulthood, such as an educational degree,
practice model and helped her expand and articulate professional role, or relationship. Erickson drew on
labeled phenomena, concepts, and theoretical rela- the work of these individuals and proposed a theo-
tionships. retical relationship between object attachment and
Maslow’s theory of human needs was used to label need satisfaction, theorizing that when an object
and articulate their personal observations that “all repeatedly meets an individual’s basic needs, attach-
people want to be the best that they can possibly be; ment or connectedness to that object occurs. From
unmet basic needs interfere with holistic growth synthesis of these theoretical linkages and research
whereas satisfied needs promote growth” (Erickson, findings, a new concept of AI was identified and
Tomlin, & Swain, 2002, p. 56; Erickson, M., 1996a, defined as the inherent need to be connected with
1996b, 2006; Jensen, 1995). Erickson further devel- significant others at the same time that there is a
oped the model to state that unmet basic needs create sense of separateness from them (Erickson, H., 2006,
need deficits that can lead to initiation or aggravation 2010; Erickson, Erickson, & Jensen, 2006; Erickson,
of physical or mental distress or illness, while need Tomlin, & Swain, 1983; Erickson, M., 1996b). From
satisfaction creates assets that provide resources the time of birth until a person takes their last
needed to contend with stress and promote health, breath, AI and object attachment are essential to
growth, and development. need satisfaction, adaptive coping, and healthy
Piaget’s theory of cognitive development provides growth and development. Furthermore, “object loss
a framework for understanding the development of results in basic need deficits” (Erickson, Tomlin, &
thinking, while integration of Erik Erikson’s work on Swain, 2002, p. 88). Loss is real, threatened, or per-
the stages of psychosocial development through the ceived; it may be a normal part of the developmental
life span provides a theoretical basis for understand- process, or it may be situational. Loss always results
ing the psychosocial evolution of the individual. Each in grief; normal grief is resolved in approximately
of his eight stages represents developmental tasks. As 1 year. When loss occurs and only inadequate or
an individual resolves each task, he or she gains inappropriate objects are available to meet needs,
strengths that contribute to character development morbid grief results. Morbid grief interferes with the
and health. As an outcome of each stage, people de- individual’s ability to grow and develop to their
velop a sense of their own worth and projection of maximal potential (Erickson, Tomlin, & Swain,
themselves into the future. “The utility of Erikson’s 2002; Erickson, M., 2006). The work of Selye and
theory is the freedom we may take to view aspects Engel, as cited by Erickson, Tomlin, and Swain
of people’s problems as uncompleted tasks. This (1983), provided additional conceptual support for
perspective provides a hopeful expectation for the the propositions regarding loss and an individual’s

500 UNIT IV Nursing Theories

stress responses to loss or losses. Selye’s theory per- Erickson (1976) and later described in publication by
tains to an individual’s biophysical responses to Erickson and Swain (1982).
stress, and Engel explores the psychosocial responses Erickson credits Milton H. Erickson with influenc-
to stressors. ing her clinical practice and providing inspiration and
The integration and synthesis of these theories, direction in the development of this theory. Initially,
with the integration of Erickson’s clinical observations he articulated the formulation of the Modeling and
and lived experiences, resulted in the conception of Role-Modeling Theory when he urged Erickson to
the Adaptive Potential Assessment Model (APAM). “model the client’s world, understand it as they do,
The APAM focuses on an individual’s ability to mobi- then role-model the picture the client has drawn,
lize resources when confronted with stressors rather building a healthy world for them” (H. Erickson, per-
than adapt to them. This model was first developed by sonal communication, November 1984).

MAJOR CONCEPTS & DEFINITIONS
Modeling This is an interactive, interpersonal process that
The act of Modeling is the process the nurse uses as nurtures strengths to enable the development,
she develops an image and an understanding of the release, and channeling of resources for coping
client’s world—an image and understanding devel- with one’s circumstances and environment. The
oped within the client’s framework and from the goal is to achieve a state of perceived optimum
client’s perspective . . . The art of Modeling is the health and contentment (Erickson, Tomlin, &
development of a mirror image of the situation from Swain, 2002, p. 49).
the client’s perspective . . . The science of Modeling
is the scientific aggregation and analysis of data col- Nurturance
lected about the client’s model (Erickson, Tomlin, & Nurturance fuses and integrates cognitive, physiolog-
Swain, 2002, p. 95). Modeling occurs as the nurse ical, and affective processes, with the aim of assisting
accepts and understands her client (Erickson, Tomlin, a client to move toward holistic health. Nurturance
& Swain, 2002, p. 96). implies that the nurse seeks to know and understand
the client’s personal model of his or her world, and to
Role-Modeling appreciate its value and significance for that client
The art of Role-Modeling occurs when the nurse plans from the client’s perspective (Erickson, Tomlin, &
and implements interventions that are unique for the Swain, 2002, p. 48).
client. The science of Role-Modeling occurs as the
nurse plans interventions with respect to her theoreti- Unconditional Acceptance
cal base for the practice of nursing . . . Role-Modeling Being accepted as a unique, worthwhile, important
is . . . the essence of nurturance . . . Role-Modeling individual—with no strings attached—is imperative
requires an unconditional acceptance of the person as if the individual is to be facilitated in developing his
the person is while gently encouraging the facilitating or her own potential. The nurse’s use of empathy
growth and development at the person’s own pace and helps the individual learn that the nurse accepts and
within the person’s own model (Erickson, Tomlin, & respects him or her as is. The acceptance will facili-
Swain, 2002, p. 95). Role-Modeling starts the second tate the mobilization of resources needed as this
the nurse moves from the analysis phase of the nurs- individual strives for adaptive equilibrium (Erickson,
ing process to the planning of nursing interventions Tomlin, & Swain, 2002, p. 49).
(Erickson, Tomlin, & Swain, 2002, p. 95).
Person
Nursing People are alike because they have holism, lifetime
Nursing is the holistic helping of persons with growth and development, and their need for AI.
their self-care activities in relation to their health. They are different because they have inherent

CHAPTER 25 Helen C. Erickson, Evelyn M. Tomlin, and Mary Ann P. Swain 501

MAJOR CONCEPTS & DEFINITIONS—cont’d
endowment, adaptation, and self-care knowledge concrete operations, and formal operations (Erickson,
(Erickson, Tomlin, & Swain, 1983). Tomlin, & Swain, 2002, pp. 63–64).
How People are Alike Affiliated Individuation
Holism Individuals have an instinctual need for affiliated
Human beings are holistic persons who have multiple individuation. They need to be able to depend on
interacting subsystems. Permeating all subsystems support systems while simultaneously maintaining
are the inherent bases. These include genetic makeup independence from these support systems. They
and spiritual drive. Body, mind, emotion, and spirit need to feel a deep sense of both the “I” and the “we”
are a total unit, and they act together. They affect and states of being, and to perceive freedom and accep-
control one another interactively. The interaction of tance in both states (Erickson, Tomlin, & Swain,
the multiple subsystems and the inherent bases cre- 2002, p. 47).
ates holism: Holism implies that the whole is greater
than the sum of the parts (Erickson, Tomlin, & Swain, How People are Different
2002, pp. 44–45). Inherent Endowment
Each individual is born with a set of genes that will
Basic Needs to some extent predetermine appearance, growth,
All human beings have basic needs that can be sat- development, and responses to life events . . . Clearly,
isfied, but only from within the framework of the both genetic makeup and inherited characteristics
individual (Erickson, Tomlin, & Swain, 2002, p. 58). influence growth and development. They might in-
Basic needs are met only when the individual fluence how one perceives oneself and one’s world.
perceives that they are met (Erickson, Tomlin, & They make individuals different from one another,
Swain, 2002, p. 57). each unique in his or her own way (Erickson, Tomlin,
& Swain, 2002, pp. 74–75).
Lifetime Development
Lifetime development evolves through psychological Adaptation
and cognitive stages, as follows: Adaptation occurs as the individual responds to
n Psychological Stages external and internal stressors in a health-directed
Each stage represents a developmental task or a and growth-directed manner. Adaptation involves
decisive encounter resulting in a turning point, a mobilizing internal and external coping resources.
moment of decision between alternative basic atti- No subsystem is left in jeopardy when adaptation
tudes (e.g., trust versus mistrust or autonomy versus occurs (Erickson, Tomlin, & Swain, 2002).
shame and doubt). As a maturing individual negoti- The individual’s ability to mobilize resources is
ates or resolves each age-specific crisis or task, the depicted by the APAM. The APAM identifies three
individual gains enduring strengths and attitudes different coping potential states: (1) arousal, (2)
that contribute to the character and health of the in- equilibrium (adaptive and maladaptive), and (3)
dividual’s personality in his or her culture (Erickson, impoverishment. Each of these states represents a
Tomlin, & Swain, 2002, p. 61). different potential to mobilize self-care resources.
n Cognitive Stages “Movement among the states is influenced by one’s
Consider how thinking develops rather than ability to cope [with ongoing stressors] and the
what happens in psychosocial or affective develop- presence of new stressors” (Erickson, Tomlin, &
ment . . . Piaget believed that cognitive learning Swain, 2002, pp. 80–81).
develops in a sequential manner, and he has identi- Nurses can use this model to predict an individual’s
fied several periods in this process. Essentially, potential to mobilize self-care resources in response to
there are four periods: sensorimotor, preoperational, stress.
Continued

502 UNIT IV Nursing Theories

MAJOR CONCEPTS & DEFINITIONS—cont’d

Mind-Body Relationships or her effectiveness or fulfillment (given circum-
We are all biophysical, psychosocial beings who stances), or promote his or her growth (Erickson,
want to develop our potential, that is, to be the best Tomlin, & Swain, 2002, p. 48).
we can be (Erickson, Tomlin, & Swain, 2002, p. 70). n Self-Care Resources
Self-care resources are “the internal resources, as
Self-Care well as additional resources, mobilized through self-
Self-care involves the use of knowledge, resources, care action that help gain, maintain, and promote an
and actions, as follows: optimum level of holistic health” (Erickson, Tomlin,
n Self-Care Knowledge & Swain, 2002, pp. 254–255).
At some level, a person knows what has made n Self-Care Action
him or her sick, lessened his or her effectiveness, or Self-care action is “the development and utiliza-
interfered with his or her growth. The person also tion of self-care knowledge and self-care resources”
knows what will make him or her well, optimize his (Erickson, Tomlin, & Swain, 2002, p. 254).



Use of Empirical Evidence
Several studies provided initial evidence for philo-
sophical premises and theoretical linkages implied in Equilibrium
the original book by Erickson, Tomlin, and Swain Adaptive/maladaptive
(1983) and later specified by Erickson (1990b). The Stressor Arousal
APAM (Figures 25–1 and 25–2) has been tested as
a classification model (Barnfather, 1987; Erickson, Impoverishment
1976; Kleinbeck, 1977) as a predictor for health status FIGURE 25-1 Adaptive Potential Assessment Model. (From
(Barnfather, 1990b) for length of hospital stay (Erickson Erickson, H. C., Tomlin, E. M., & Swain, M. A. P. [1983]. Modeling
& Swain, 1982), and as it relates to basic needs status and role-modeling: A theory and paradigm for nursing. Engle-
(Barnfather, 1993). Findings from these studies pro- wood Cliffs, (NJ): Prentice Hall.)
vide beginning evidence for the proposed three-state
model across populations, a relationship between
health and ability to mobilize resources, and an ability
to mobilize resources and needs status. Two other
studies have shown relationships among stressors Equilibrium
(measured as life events) and propensity for accidents
(Babcock & Mueller, 1980) and resource state and
ability to take in and use new information (Clementino Stressor
& Lapinske, 1980). Benson (2003, 2006, 2011) studied Coping
the APAM as applied to small groups. Coping Stressor
Relationships among self-care knowledge, resources,
and activities have been demonstrated in several studies
(Acton, 1993; Baas, 1992; Irvin, 1993; Jensen, 1995; Stressor
Miller, 1994). The self-care knowledge construct, first Arousal Stress Impoverishment
studied by Erickson (1985), was replicated and found to FIGURE 25-2 Dynamic relationship among the states of the
be significantly associated with perceived control (Cain Adaptive Potential Assessment Model. (From Erickson, H. C.,
& Perzynski, 1986); perceived autonomy (Hertz & Tomlin, E. M., & Swain, M. A. P. [1983]. Modeling and role-
Anschutz, 2002; Matsui & Capezuti, 2008); and quality modeling: A theory and paradigm for nursing. Englewood Cliffs,
of life (Baas, Fontana, & Bhat, 1997). Self-directedness, (NJ): Prentice Hall.)

CHAPTER 25 Helen C. Erickson, Evelyn M. Tomlin, and Mary Ann P. Swain 503

need for harmony (affiliation), and need for autonomy and evolving spiritual identity (Clayton, 2001), the
(individuation) were found when multidimensional quality of life of older adults with urinary inconti-
scaling was used to explore relationships among self- nence (Liang, 2008), and the human-environment
care knowledge, resources, and actions. The author relationship when healing from an episodic illness
concluded that a positive attitude was a major factor (Bowman, 1998).
when health-directed self-care actions were assessed Case study methods have shown relationships
(Rosenow, 1991). Physical activity in patients after among needs, attachment, and developmental resid-
myocardial infarction was shown to be affected by life ual needs (Kinney, 1990, 1992; Kinney & Erickson,
satisfaction (not physical condition); life satisfaction 1990) and coping (Jensen, 1995), and challenges in
was predicted by availability of self-care resources and the treatment of Factitious Disorder (Hagglund,
resources needed; and resources needed served as a 2009).
suppressor for resources available (Baas, 1992). In a Studies revealed relationships among mistrust and
sample of caregivers, social support predicted for stress length of stay in hospitalized subjects (Finch, 1990);
level and self-worth had an indirect effect on hope perceived enactment of autonomy, self-care, and
through self-worth (Irvin, 1993; Irvin & Acton, 1997), holistic health in older adults (Anschutz, 2000; Hertz
whereas persons with diabetes with spiritual well-being & Anschutz, 2002); perceived enactment of autonomy
were better able to cope (Landis, 1991). and self-care resources among senior center users
When the Modeling and Role-Modeling Theory was (Matsui & Capezuti, 2008) ; perceived enactment of
used as a guideline, interviews were used to determine autonomy, self-care, perceived support, control, and
the client’s model of the world. The following seven well being in older adults (Chen, 1996); perceived
themes emerged (Erickson, 1990a): enactment of autonomy and related sociodemo-
1. Cause of the problem, which was unique to the graphic factors among older adults (Hwang & Lin,
individual 2004); loss, morbid grief, and onset of symptoms
2. Related factors, also unique to the individual of Alzheimer’s disease (Erickson, Kinney, Becker,
3. Expectations for the future et al., 1994; Irvin & Acton, 1996); and basic needs
4. Types of perceived control satisfaction and health-promoting self-care behaviors
5. Affiliation in adults (Acton & Malathum, 2000).
6. Lack of affiliation Other studies addressed linkages between role-
7. Trust in the caregiver modeled interventions and outcomes (Erickson,
Each was unique and warranted individualized Kinney, Becker, et al., 1994; Hertz, 1991; Irvin, 1993;
interventions. Other qualitative research studies on Jensen, 1995; Kennedy, 1991, Lamb, 2005; Sung &Yu,
self-care knowledge showed that acutely ill patients 2006). University students who perceived satisfaction
perceived monitoring, caring, presence, touch, and of needs were more successful in school (Smith,
voice tones as comforting (Kennedy, 1991); healthy 1980), older adults who felt supported reported
adults sought need satisfaction from the nurse practi- higher need satisfaction and were better able to cope
tioner in primary care (Boodley, 1990, 1986); and (Keck, 1989), adolescent mothers who felt supported
hospice patients benefited from nurse empathy and perceived need satisfaction had a more positive
(Raudonis, 1991). Additional studies addressed the maternal-infant attachment (Erickson, M., 2006;
experience of persons 85 years of age and older as Erickson, 1996a, 1996b), those with a strong social
they manage their health (Beltz, 1999), the percep- network reported better health (Doornbos, 1983),
tions of hope in elementary school children (Baldwin, and persons convicted of sexual offenses who were
1996), the experiences and perceptions of mothers provided with support to remodel their worlds were
utilizing child health services in South Africa (Jonker, able to develop new behaviors and move on with their
2012), the experiential meaning of well-being and the lives (Scheela, 1991). Families and post–myocardial
lived experience of employed mothers (Weber, 1995, infarction patients who were able to participate in
1999), the meaning and impact of suffering in people planning their own care through contracting had less
with rheumatoid arthritis (Dildy, 1992), the relation- anxiety and better perceived control and perceived
ship between experiences of prolonged family suffering support (Holl, 1992). Caregivers of adults with

504 UNIT IV Nursing Theories

dementia who experienced theory-based nursing Studies have also been used to explore perceived
using the Modeling and Role-Modeling Theory per- enactment of autonomy and life satisfaction in older
ceived that their needs were met and were healthier adults (Anschutz, 2000), self-care knowledge in infor-
(Hopkins, 1995), and they were encouraged, which mants in the hospital (Erickson, 1985), developmen-
helped them accept the situation and transcend the tal growth in adults with heart failure (Baas, Beery,
experience of caregiving (Hopkins, 1995). Self-care Fontana, & Wagoner, 1999), the ability to mobilize
resources, measured as needs, are related to perceived coping resources and basic needs (Barnfather, 1990a),
support and coping in women with breast cancer the relationship between basic needs satisfaction and
(Keck, 1989), physical well-being in persons with emotionally motivated eating (Timmerman & Acton,
chronic obstructive pulmonary disease (Leidy, 1990; 2001; Cleary, & Crafti, 2007), and relations among
Kline,1988), and anxiety in hospitalized patients hostility, self-esteem, self-concept, and psychosocial
who have had cardiac surgery and their families residual in persons with coronary heart disease
(Holl, 1992). Finally, when AI was tested as a buffer (Sofhauser, 1996, 2003). Research has also been con-
between stress and well-being, a mediation effect ducted that explores the relationship between spiritual
was found (Acton, 1997; Acton, 1993; Acton, Irvin, well-being and heart failure (Beery, Baas, Fowler, &
Jensen, et al., 1997). Allen, 2002); spirituality in caregivers of family mem-
Additional studies that operationalize self-care bers with dementia (Acton & Miller, 1996); the imple-
resources by measuring developmental residuals have mentation of a mind, body, spirit self-empowerment
shown that identity resolution in adolescents with program for adolescents (Nash, 2007a); and spiritual-
facial disfiguration can be predicted by previous ity in women with breast cancer (Kinney, Rodgers,
developmental residual (Miller, 1986). Chen (1996) Nash, & Bray, 2003). Baas (2004) studied self-care
found that feelings of control over one’s health (health resources and quality of life in patients following myo-
control orientation) status in older adults with hyper- cardial infarction and self-care resources and well-
tension correlated highly with self-efficacy and self- being in clients with cardiac disorders (2011). She and
care. In addition, her work supported that health colleagues also examined the psychosocial aspects of
control orientation, self-efficacy, and self-care were heart failure management (Baas & Conway, 2004),
associated with well-being. Through interviews of explored body awareness in heart failure or transplant
older adults living independently, Hertz, Rossetti, and patients (Baas, Beery, Allen, et al., 2004), and reported
Nelson (2006) were able to identify categories of self- patient adjustments to the cardiac devices (Beery,
care actions that encompassed important self-care Baas, & Henthorn, 2007).
activities. Tools that have been developed to test the Model-
Other researchers found that trust predicts for ing and Role-Modeling Theory include the Basic
adolescent clients’ involvement in the prescribed Needs Satisfaction Inventory (Kline, 1988), the Erikson
medical regimen (Finch, 1987); perceived support Psychosocial Stage Inventory (Darling-Fisher &
and adaptation are related to developmental residual Leidy, 1988), the Perceived Enactment of Autonomy
in families with newborn infants (Darling-Fisher, tool designed to measure a prerequisite to self-care
1987; Darling-Fisher & Leidy 1988); and mistrust actions in the elderly (Hertz, 1991, 1999; Hertz &
predicts length of hospital stay, and positive residual Anschutz, 2002), the Self-Care Resource Inventory
serves as a buffer (Finch, 1987). Positive residual (Baas, 1992, 2011), an adjustment scale designed
in the intimacy stage of healthy adults predicts to measure self-report with implanted devices in car-
for health behaviors (MacLean, 1987, 1990, 1992). diac patients (Beery, Baas, Mathews, et al., 2005), the
Developmental residual predicts for hope, trust- Robinson Self-Appraisal Inventory designed to mea-
mistrust residual predicts for generalized hope, sure denial (the first stage in the grief process) in
autonomy-shame and doubt residual predicts for patients after myocardial infarction (Robinson, 1992),
particularized hope in the elderly (Curl, 1992); and the Erickson Maternal Bonding-Attachment Tool
negative residual is related to speed and impatience designed to measure self-care knowledge as motiva-
behaviors in a healthy sample of military personnel tional style (deficit or being motivated) and self-care
(Kinney, 1992). resource (maternal need satisfaction) (Erickson, 1996b),

CHAPTER 25 Helen C. Erickson, Evelyn M. Tomlin, and Mary Ann P. Swain 505

a theory-based nursing assessment (Finch, 1990),
and the Hopkins Clinical Assessment of the APAM Theoretical Assertions
(Hopkins, 1995). The theoretical assertions of the Modeling and Role-
Modeling Theory are based on the linkages between
Major Assumptions completion of developmental tasks and basic needs
satisfaction; among basic needs satisfaction, object
Nursing attachment and loss, and developmental tasks; and
“The nurse is a facilitator, not an effector. Our nurse- between the ability to mobilize coping resources and
client relationship is an interactive, interpersonal need satisfaction. Three generic theoretical assertions
process that aids the individual to identify, mobilize, constitute theoretical linkages implied in the theory
and develop his or her own strengths to achieve as follows:
a perceived optimal state of health and well-being” 1. “The degree to which developmental tasks are
(H. Erickson, personal communication, 2004). Rogers resolved is dependent on the degree to which
(1996) has defined this relationship as facilitative- human needs are satisfied” (Erickson, Tomlin, &
affiliation. The five aims of nursing interventions are Swain, 2002, p. 87).
to build trust, affirm and promote client strengths, 2. “The degree to which needs are satisfied by object
promote positive orientation, facilitate perceived attachment depends on the availability of those
control, and set health-directed mutual goals (Erickson, objects and the degree to which they provide com-
Tomlin, & Swain, 2002). fort and security as opposed to threat and anxiety”
(Erickson, Tomlin, & Swain, 1983, p. 90).
Person 3. “An individual’s potential for mobilizing resources,
Differentiation is made between patients and clients the person’s state of coping according to the APAM,
in this theory. A patient is given treatment and in- is directly associated with the person’s need satis-
struction; a client participates in his or her own care. faction level” (Erickson, Tomlin, & Swain, 2002,
“Our goal is for nurses to work with clients” (Erickson, p. 91).
Tomlin, & Swain, 2002, p. 21). “A client is one who is
considered to be a legitimate member of the decision-
making team, who always has some control over Logical Form
the planned regimen, and who is incorporated into The Modeling and Role-Modeling Theory was formu-
the planning and implementation of his or her own lated using retroductive thinking. The theorists went
care as much as possible” (Erickson, Kinney, Stone, through four levels of theory development and then
et al., 1990, p. 20; Erickson, Tomlin, & Swain, 2002, cycled from inductive to deductive to inductive to
p. 253). deductive reasoning (H. Erickson, personal communi-
cation, March 30, 1988). Erickson identified theoretical
Health concepts and relationships to label and define her
“Health is a state of physical, mental, and social well- practice-based observations. These observations were
being, not merely the absence of disease or infirmity. then tested within the context of the theoretical bases
It connotates a state of dynamic equilibrium among identified. Integration and synthesis of the theoretical
the various subsystems [of a holistic person]” (Erickson, concepts and linkages with the clinical observations
Tomlin, & Swain, 2002, p. 46). resulted in the development of a “new multidimen-
sional theory and paradigm for nursing—Modeling
Environment and Role-modeling” (H. Erickson, personal communi-
“Environment is not identified in the theory as an cation, November 1984). Modeling and Role-Modeling
entity of its own. The theorists see environment in the may be viewed as a theory and a paradigm according
social subsystems as the interaction between self and to Merton (1968), who said that paradigms “provide
others both cultural and individual. Biophysical stress- a compact arrangement of central concepts and their
ors are seen as part of the environment” (H. Erickson, interrelations that are utilized for description and
personal communication, March 30, 1988). analysis” (p. 70).

506 UNIT IV Nursing Theories

Acceptance by the Nursing Community July 6, 1992). Nurses at Brigham and Women’s Hospi-
tal use an adaptation of the assessment tool developed
Practice at the University of Michigan Medical Center. At the
The book Modeling and Role-Modeling: A Theory and Fourth National Conference on Modeling and Role-
Paradigm for Nursing (Erickson, Tomlin, & Swain, Modeling (Boston, October 1992) implementation of
2002), chapters in nursing theory texts, and published the professional practice model at Brigham and
research studies have exposed nurses in practice to Women’s Hospital and case studies were first pre-
this theory. Based on the applicability and interest in sented by the staff nurses (J. James, personal commu-
using this theory to guide holistic nursing practice, nication, July 6, 1992). Nurses at the University of
the Modeling and Role-Modeling Theory has been Pittsburgh Medical Center, Children’s Hospital of the
implemented in many hospitals throughout the country. University of Wisconsin at Madison, University of
For example, nurses on surgical units at the Univer- Tennessee Medical Center in Knoxville, Oregon Health
sity of Michigan Medical Center use an assessment Sciences University Hospital, University Health Sys-
tool based on the Modeling and Role-Modeling The- tem in San Antonio, Texas, Salina Regional Health
ory. The tool is used to gather information to identify Center, and other hospitals and state agencies across
the client’s need assets, deficits, developmental resid- the United States have also adopted the Modeling
ual, attachment-loss and grief status, and potential and Role-Modeling Theory as the foundation for
therapeutic interventions (see Appendix at the end of their professional practice. Finally, the theory has
this chapter) (Bowman, 1998; H. Erickson, personal provided a theoretical foundation for the implemen-
communication, 1988). tation of nursing projects and care in diverse settings
Helen Erickson has lectured extensively, nationally (Alligood, 2011; Haylock, 2008, 2010; Raudonis &
and internationally, and held one-on-one consultations Acton, 1997; ).
with nurses from various practice and educational
backgrounds. Nurses who practice in adult health; case Education
management; community health; critical and intensive The Modeling and Role-Modeling Theory is intro-
care; infant, adolescent, and family health; gerontology; duced into the curriculum in nursing programs
mental health; emergency rooms; and hospices use this throughout the country. Faculty members have con-
theory. The beauty of the theory is that it can be applied tacted and continue to contact Erickson regarding the
within any setting and with any population. Erickson use of the theory in their curricula and for specific
noted that what seemed to be a revolutionary idea as courses. Metropolitan State University in St. Paul,
recently as 1972 (calling for the client to be the head Minnesota, selected Modeling and Role-Modeling as
of the healthcare team) has gained acceptance, as has the conceptual framework for their curriculum, and
the notion that nurses can practice independently students are taught theory-based practice throughout
(H. Erickson, personal communication, November the program. Other programs that use Modeling
1984). According to Erickson, negative responses to and Role-Modeling Theory as a basis for curriculum
the theory came from individuals who cannot accept include but are not limited to: St. Catherine’s Univer-
the idea of listening to the client first, or who do not sity in St. Paul, Minnesota; the Alternate Entry Master’s
take the concept of holism seriously (H. Erickson, per- nursing program at the University of Texas at Austin;
sonal communication, November 1984). the University of Texas at Brownsville; Lamar Univer-
Brigham and Women’s Hospital in Boston has sity, Joanne Gay Dishman Department of Nursing in
used the Modeling and Role-Modeling Theory as a Beaumont, Texas; State University of New York at
theoretical basis for the professional practice model Buffalo; University of Tennessee at Knoxville; Capital
for years. The nurses use the theory as a framework to University in Columbus, Ohio; and Foo Yin College
structure care planning and case conferences. Jenny of Nursing and Medical Technology in Taiwan.
James, former vice president for nursing, stated that
“consistency of language, the way care is talked about Research
and planned” is one of the major advantages of using Nurses throughout the world use Modeling and
this theoretical basis (J. James, personal communication, Role-Modeling as the theoretical framework for their

CHAPTER 25 Helen C. Erickson, Evelyn M. Tomlin, and Mary Ann P. Swain 507

research. Findings from research studies continue to major constructs and theoretical linkages of the
support and validate the self-care knowledge con- theory (Erickson, 1990a). Hertz, Baas, Curl, and
struct and the importance of support and control as Robinson (1994) conducted an integrative review
well as other theoretical linkages. Erickson’s initial of research from 1982 to 1992 using Modeling
study provided evidence that psychosocial factors are and Role-Modeling as a theoretical basis. Empirical
significantly related to physical health problems evidence has provided bases for validation, refine-
(1976). A follow-up study in 1988 conducted by ment, and revision of the theory. Research will
Erickson, Lock, and Swain (H. Erickson, curriculum continue to expand the Modeling and Role-Modeling
vitae, February 1988) supported these findings, and Theory.
subsequent research has provided for the expansion
and enrichment of major theoretical concepts. As
described earlier in the chapter, perceived support, Further Development
perceived control, hope for the future, satisfaction As this theory is practiced, explored, examined, and
with daily life, need satisfaction, perceived auton- researched, much potential exists for further develop-
omy, AI, self-care knowledge, self-care actions, and ment. The theory continues to gain national and in-
self-care resources are some of the key concepts that ternational attention. One reason for this increased
have been supported and validated through research attention was the founding of the Society for the
studies. Several master’s and doctoral students at the Advancement of Modeling and Role-Modeling. The
University of Michigan School of Nursing, the Uni- society was formed to develop a network of col-
versity of Texas at Austin, and other universities have leagues who could advance the development and
pursed various research questions based on this the- application of the Modeling and Role-Modeling
ory. Campbell, Finch, Allport, Erickson, and Swain Theory. One of the society’s goals is to promote
(1985) conducted a research study at the University continued research related to the theory. The society
of Michigan Medical Center and hypothesized that held its first national symposium in 1986 and has met
the length of hospital stay correlated with the stages biennially thereafter. At the 1988 conference, held at
of development. They used a nursing assessment tool Hilton Head, South Carolina, the membership chair
adapted from the assessment model to measure announced that society members came from 12 states
a patient’s psychosocial development and to relate (H. Erickson, personal communication, 1988). By the
developmental status to the length of hospitalization 1990 conference in Austin, Texas, members repre-
and the number of health problems identified during sented more than 33 states (H. Erickson, personal
hospitalization. Results indicated that the balance of communication, July 1, 1992). These conferences
trust-mistrust accounts for a large percentage of the continue to provide a forum for researchers, educa-
variance in the length of hospitalization. No signifi- tors, and practitioners to disseminate knowledge
cant relationship was evident between psychosocial pertaining to the Modeling and Role-Modeling
coping skills and the number of health problems Theory and paradigm (H. Erickson, personal com-
identified. munication, 1988).
Erickson was the principal investigator of a research The Fourth National Conference on Modeling and
project, Modeling and Role-Modeling with Alzheimer’s Role-Modeling Theory and Paradigm, held in Boston
Patients, funded by the National Institutes of Health, in October 1992, demonstrated the breadth and depth
National Center for Nursing Research. This research of the use and research for the Modeling and Role-
project included 10 other investigators. Results sup- Modeling Theory. Presentations included studies
ported the constructs of self-care knowledge, adaptive based in critical care units and community-based
potential, and AI (H. Erickson, personal communica- practice, in multiple types of educational settings, and
tion, July 1, 1992). across the age span. In 2010, nurses from all over the
Numerous graduate students have used the Mod- United States as well as Egypt, Canada, South Africa,
eling and Role-Modeling Theory as a basis for China, and Great Britain attended the conference
theses and dissertations. In addition, extensive work held in San Antonio, Texas. The international biennial
has been published that substantiates many of the conferences continue to provide an opportunity for

508 UNIT IV Nursing Theories

nurses to discuss interrelationships among holistic grounded in observable reality. The theory has oper-
nursing practice, theory, research, and education. ationally defined concepts, identifiable subconcepts,
Many of the research data related to the theory are and clearly defined and denotative definitions. The
yet to be published. Erickson stated, “Every part of major concepts, Modeling and Role-Modeling, are
it [the theory] needs further development . . . There reality-based, making them empirical. Definitions
are a thousand research questions in that book . . . You are clearly articulated, making it possible to test the
can take any one statement we make and ask a concepts. The theorists have provided an outline
research question about it . . . Modeling and Role- for collecting, analyzing, and synthesizing data
Modeling has only begun” (H. Erickson, personal and guidelines for implementing the theory. These
communication, November 1984). explicit guidelines increase empirical precision, allow-
ing any practitioner to test the theory using these
Critique tools.
Midrange theories are identified, supported, and
Clarity substantiated. Data obtained through critical analy-
Erickson, Tomlin, and Swain present their theory ses and testing provides evidence for and validation
clearly. Definitions in the theory are denotative, of the theory. Modeling and Role-Modeling Theory
with the concepts explicitly defined. They use every- gains greater empirical precision with new and
day language and offer many examples to illustrate ongoing studies. The need for practicing nurses to
their meaning. Their definitions and assumptions continue research with the theory is recognized and
are consistent, and there is a logical progression welcomed.
from assumptions to assertions.
Importance
Simplicity One of the challenges facing the profession of nursing
The theory appears simple at first. However, on is the development of its unique, scientific knowledge
closer inspection, its complexity appears. It is based base and the use of nursing theory as a basis for pro-
on biological and psychological theories and on fessional practice. The Modeling and Role-Modeling
several of the theorists’ own assumptions. The inter- Theory contributes to steady progress toward this goal.
actions among the major concepts, assumptions, Although relatively young, the theory has gained
and assertions add depth to the theory and increase recognition in the nursing community. Interest has
its complexity. grown, and research supporting its theoretical state-
ments has been generated. Numerous nurses have
Generality engaged in research based on this theory. Publications
The Modeling and Role-Modeling Theory is general- of findings lend more and more credence to the
izable to all aspects and most settings of professional theoretical propositions.
nursing practice. Major assumptions that deal with Chinn and Kramer (2011) propose that the impor-
developmental tasks, basic needs satisfaction, object tance of a theory is relative to how it addresses nurs-
attachment and loss, and adaptive potential are broad ing practice, education, and administration goals.
enough to be applicable in diverse nursing situations. Modeling and Role-Modeling Theory guides research,
Numerous examples of the applicability of the theory directs practice, and generates new ideas, thus this
and their concepts in the educational, clinical prac- theory possesses inherent value and importance for
tice, and research settings have been cited. It could be the discipline of nursing (Alligood, 2011).
argued that the theory lacks applicability in nonverbal
or comatose patients, however the theory could be
applied in these situations by creative clinicians. Summary
Nurses have the opportunity to share in important,
Accessibility intimate life experiences with clients. We have the
Accessibility refers to the testability, application of a ability and responsibility to facilitate healing and
theory, and the extent that defined concepts are achievement of clients’ perceived maximal state of

CHAPTER 25 Helen C. Erickson, Evelyn M. Tomlin, and Mary Ann P. Swain 509

health and well-being. The Modeling and Role-
Modeling Theory provides nurses with a practice- him what he needs to feel better and to help him
based theoretical framework to attain these goals, get through the next few weeks (promoting posi-
in any setting and with any population. Numerous tive future orientation). He replies, “I need to be
research studies and ongoing scientific work provide closer to my friends and the hospital. I am so
empirical support for this nursing theory. As the lonely and afraid out there by myself” (unmet love
theory matures, the extent of its merit and worth and belonging and safety and security needs).
will become evident. After a lengthy discussion, they decide together
to implement a plan of care. (The nurse is facilitat-
ing client control, affirming his strengths and his
self-care knowledge that he knows what will make
CASE STUDY
him heal; together they are setting mutual goals.)
Robert, a 75-year-old rancher with a history of Robert calls and speaks to his son, who plans to
chronic obstructive pulmonary disease (COPD), visit (this action facilitates his sense of perceived
is admitted with shortness of breath, angina, and support and AI). His minister is called, and grief
nausea (unmet physiological needs). It is his counseling is arranged (support is perceived,
fourth admission in 6 months (he is having dif- facilitation of grief resolution is initiated, client is
ficulty adapting to stressors in his life). The nurse facilitated in being future-focused).
introduces herself in a quiet, calm voice and tells Robert decides that he will move to town into a
him she will be his primary nurse during his stay senior citizen apartment that provides meals and
(interventions designed to establish trust and a other services, and arrangements are made for
sense of safety and security and to facilitate a him to have help with the moving process. He will
sense of connectedness). She asks him why he be closer to the hospital and other people if he
came in (he is the primary data source). He needs them (this will help him feel safer and more
states, “I can’t breathe, and my chest hurts.” After secure). He can then choose when to visit with
he is stabilized (physiological needs are met, so friends or participate in social activities that are
the nurse can focus on his other needs), she says, offered at the complex (his love and belonging
“I notice that you have had multiple admissions needs can be met, and this facilitates his sense of
in the last few months. Why do you think you are control). He can also receive assistance with basic
here today?” (The nurse seeks information from physiological needs when needed (meals, house-
the client who is the primary data source and keeping services). After he is settled into his new
facilitates a sense of client control.) He replies, home, the nurse provides him with her telephone
“My wife of 49 years died a few months ago; she number, so he can call if he needs anything or if he
took care of me, and my heart is broken. My life just wants to check in (support and love and be-
no longer has meaning.” (He is experiencing longing needs are met). This action facilitates the
unmet needs, is having problems with the devel- client’s trust and AI. His control is maintained,
opmental stage of generativity, and is grieving the and his strengths and self-care knowledge are
loss of his wife.) affirmed (he will know and be able to call when
During her assessment, the nurse discovers that he needs assistance, or will be connected to the
Robert lives on a ranch by himself. His nearest nurse). Finally, the nurse schedules regular tele-
neighbor is 4 miles away, his son lives out of state, phone calls (based on the client’s schedule) to
he has no help with his daily living activities, he is check in and see how he is doing and to address
housebound because he can no longer drive, he any concerns or questions he has. This action
has no support system, and he feels unable to get facilitates trust, his safety and security and love
on with his life without his wife. The nurse asks and belonging, and A-I needs are met.

510 UNIT IV Nursing Theories

CRITICAL THINKING ACTIVITIES
1. Interview a client, and use the theory to interpret outcome based on the proposed nursing plan of
the data. Identify nursing diagnoses based on the care. Predict the client outcome if the care is not
interpretations. given.
2. Propose a nursing plan of care based on the 4. Assess the client from primary, secondary, and
interview and interpretation in question one. tertiary sources. Compare for congruency among
3. Assuming the goal is to promote the client’s the three types of sources.
health and development, predict the client


POINTS FOR FURTHER STUDY
n http://www.mrmnursingtheory.org/ n Erickson, H. C., Tomlin, E. M., & Swain, M. A.
n Research and conceptual references are available (2002). Modeling and role-modeling: A theory and
on the website on mid-range theories, major paradigm for nursing. Cedar Park, (TX): EST Co.
constructs, and philosophical assumptions of (Original work published 1983, Englewood Cliffs,
the Modeling and Role-Modeling Theory. (NJ): Prentice-Hall.)
n Erickson, H. (Ed.) (2006). Modeling and Role-
Modeling: A View from the Client’s World.
Cedar Park, (TX): Unicorns Unlimited.


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Irvin, B. L. (1993). Social support, self-worth and hope Nash, K. (2003). Evaluation of a holistic peer support and ed-
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Kline, N. W. (1988). Psychophysiological processes of stress Raudonis, B., & Acton, G. (1997). Theory based nursing
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Landis, B. J. (1991). Uncertainty, spiritual well-being, and responses of client with actual or potential myocardial
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518 UNIT IV Nursing Theories

Appendix

Assessment Tool Based on Modeling and II. Interpret data for needs status (assets and deficits
Role-Modeling * related to type of need), attachment objects, loss,
I. Description of the situation grief (normal or morbid), life tasks (developmental:
A. Overview of the situation actual and chronological)
B. Etiology Data Analysis Tool Based on Modeling
1. Eustressors and Role-Modeling ‡
2. Stressors
3. Distressors I. Step one
C. Therapeutic needs A. Articulate relationships between stressors and needs
II. Expectations status.
A. Immediate B. Articulate relationships between needs status and
B. Long-term ability to mobilize resources.
III. Resource potential C. Articulate relationships between needs status and
A. External loss of attachment.
1. Social network D. Articulate relationships between loss and type of
2. Support system grief response.
3. Health care system E. Articulate relationships between the type of need
B. Internal assets and deficits and the developmental residual.
1. Strengths F. Articulate relationships between chronological
2. Adaptive potential developmental task and developmental residual.
a. Feeling states II. Step two
b. Physiological parameters A. Articulate relationships among stressors, resource
IV. Goals and life tasks potential, needs status, loss, grief status, develop-
A. Current mental residual, chronological task, and attachment
B. Future potential.
B. Articulate relationships among needs status, poten-
Data Interpretation Tool Based on Modeling and tial resources, developmental residual, and personal
Role-Modeling † goals.
I. Interpret data for ability to mobilize resources (APAM)

AI, Affiliated individuation; APAM, Adaptive Potential Assessment Model.
*Interview questions and thoughts that guide critical thinking are suggested in Erickson, H. C., Tomlin, E. M., & Swain, M. A. (1983). Modeling and
role-modeling: A theory and paradigm for nursing (pp. 116–168). Englewood Cliffs, NJ: Prentice-Hall. Suggestions for interviewing techniques are
found in Erickson, H. C. (1990). Self-care knowledge. In H. C. Erickson & C. Kinney (Eds.), Modeling and role-modeling: Theory, practice and research
(Vol. 1). Austin, TX: Society for the Advancement of Modeling and Role-Modeling.
†Critical thinking guidelines for data interpretation are suggested in Erickson, H. C., Tomlin, E. M., & Swain, M. A. (1983). Modeling and role-
modeling: A theory and paradigm for nursing(pp. 148–166). Englewood Cliffs, NJ: Prentice-Hall; and Erickson, H. C. (1990). Theory based nursing.
In H. C. Erickson & C. Kinney (Eds.), Modeling and role-modeling: Theory, practice and research(Vol. 1). Austin, TX: Society for the Advancement
of Modeling and Role-Modeling.
‡Critical thinking guidelines for data analysis are suggested in Erickson, H. C., Tomlin, E. M., & Swain, M. A. (1983). Modeling and role-modeling:
A theory and paradigm for nursing (pp. 148–166). Englewood Cliffs, NJ: Prentice-Hall; and Erickson, H. C. (1990). Theory-based nursing. In
H. C. Erickson & C. Kinney (Eds.), Modeling and role-modeling: Theory, practice and research (Vol. 1). Austin, TX: Society for the Advancement
of Modeling and Role-Modeling.

CHAPTER 25 Helen C. Erickson, Evelyn M. Tomlin, and Mary Ann P. Swain 519

Appendix—cont’d

Planning Tool Based on Modeling B. Facilitate a self-projection that is futuristic and
and Role-Modeling § positive.
I. Aims of interventions C. Promote AI with the minimal degree of ambivalence
A. Build trust possible.
B. Promote positive orientation D. Promote a dynamic, adaptive, and holistic state of
C. Promote client control health.
D. Promote strengths E. Promote and nurture a coping mechanism that
E. Set health-directed goals satisfies basic needs and permits growth-need
II. Intervention goals satisfaction.
A. Develop a trusting and functional relationship F. Facilitate congruent actual and chronological
between yourself and your client. developmental stages.
§Critical thinking guidelines for planning are suggested in Erickson, H. C., Tomlin, E. M., & Swain, M. A. (1983). Modeling and role-modeling:
A theory and paradigm for nursing (pp. 169–220). Englewood Cliffs, NJ: Prentice-Hall; and Erickson, H. C. (1990). Theory-based nursing. In
H. C. Erickson & C. Kinney (Eds.), Modeling and role-modeling: Theory, practice and research (Vol. 1). Austin, TX: Society for the Advancement
of Modeling and Role-Modeling.

26

CHAP TER



















Gladys L. Husted James H. Husted
1941 to present 1931 to present


Symphonological Bioethical Theory


Carrie Scotto



“Symphonology (from ‘symphonia,’ a Greek word meaning agreement) is a
system of ethics based on the terms and preconditions of an agreement”
(Husted & Husted).



she was awarded the title of School of Nursing Distin-
Credentials and Background guished Professor. She continues to teach part time and
of the Theorists direct dissertations. The school has also recognized her
Gladys Husted was born in Pittsburgh, where her life, teaching excellence at all levels of the curriculum
practice, education, and teaching continue to influence through the Duquesne University School of Nursing
the nursing profession. Husted received a Bachelor Recognition Award for Excellence 1990/1991 and the
of Science in Nursing degree from the University of Faculty Award for Excellence in Teaching 1994/1995.
Pittsburgh in 1962 and began practice in public health The Medical College of Ohio chose Husted as Distin-
and acute inpatient medical-surgical care. Observa- guished Lecturer in 2000. She is a member of Sigma
tions of interactions between nurses and patients initi- Theta Tau International, Phi Kappa Phi, and the
ated her interest in ethical issues. In 1968, she earned a National League for Nursing.
master’s degree in nursing education while teaching at G. Husted served as consultant for Western
the Louise Suyden School of Nursing at St. Margaret’s Pennsylvania Hospital Nursing Division regarding
Memorial Hospital in Pittsburgh. Her love of teaching the development of an ethics committee, including
prompted doctoral study that resulted in a terminal educating staff and management, and providing
degree from the University of Pittsburgh Department guidance for the newly formed committee. She also
of Curriculum and Supervision. provided consultation for the Allegheny General
G. Husted is currently professor emeritus at Medical Center for staff development and the National
Duquesne University School of Nursing, where in 1998 Nursing Ethics Advisory Group for the Department of

5200
52

CHAPTER 26 Gladys L. Husted and James H. Husted 521

Veterans Affairs. G. Husted served as curriculum con- professionals and patients. The name of the theory is
sultant for several schools of nursing. In addition, she derived from the Greek word symphonia, which means
has presented at many national-level conferences. “agreement.”
James Husted was born in Kingston, Pennsylvania, Ethics is “a system of standards to motivate, deter-
and has had a lifelong interest in philosophy. While in mine, and justify actions directed to the pursuit of
the army in Germany, he became interested in ethics vital and fundamental goals” (Husted & Husted, 2008,
through conversations with a former ethics professor, p. 8). Ethics examines what ought to be done, within
particularly the work of Benedict Spinoza. the realm of what can be done, to preserve and en-
J. Husted’s post-Army career focused on sales and hance human life. The Husteds, therefore, described
on hiring and training agents for health insurance ethics as the science of living well.
companies. However, he continued to read and de- Bioethics is concerned with the ethics of interac-
velop his philosophical and ethical ideas. During the tions between a patient and a health care professional,
1980s, he joined the high-IQ societies, Mensa and what ought to be done to preserve and enhance hu-
Intertel, serving as a philosophy expert for Mensa and man life within the health care arena. Within the past
a regional director for Intertel. century, the expanding knowledge base and growth of
The theorists met and were married in 1974, estab- technology altered existing health care practice and
lishing and cultivating a dialogue that brought about created threatening and confusing circumstances not
the theory of Symphonology. They are coauthors of previously encountered. Increasing numbers and
several editions of Ethical Decision Making in Nursing. types of treatment options allowed patients to survive
Their book was selected as one of Nursing and Health conditions they would not have in the past. However,
Care’s Notable Books of 1991, 1995, and 2001. It also the morbidity of the survivors brought new questions:
won the Nursing Society Award in 2001. Their regular Who should receive treatment? What is the appropri-
column, “A Practice Based Bioethic,” appeared in Ad- ateness of treatments under particular circumstances?
vanced Practice Nursing Quarterly from 1997 to 1998. Who should decide what treatments are appropriate?
In addition to publishing books, book chapters, and In this way, bioethics became a central issue in what
journal articles, they have presented their ethical the- previously had been a prescriptive environment. It
ory at conferences and workshops. became essential to consider ethical concerns, as well
The Husteds reside in Pittsburgh and continue to as scientific solutions, to questions of health (Jecker,
develop and disseminate their work through teaching, Jonsen, & Pearlman, 1997). Through personal experi-
writing, presenting at conferences and workshops, and ence and observation of nurses, the Husteds recog-
serving as consultants for ethics committees. nized the increasingly complex nature of bioethical
dilemmas and the failure of the health care system to
adequately address the problem.
Theoretical Sources To clarify the reasons for the deficiency of the
The authors define Symphonology as “the study of health care system in addressing the issue of deliver-
agreements and the elements necessary to forming ing ethical care, the Husteds examined traditional
agreements,” (Husted & Husted, 2008, p. xv). In ideas and concepts used to guide ethical behavior.
health care, it is the study of agreements between These ideas include deontology, utilitarianism, emo-
health care professionals and patients. An agreement tivism, and social relativism. Deontology is a duty-
is based on the nature of the relationship between the based ethic in which the consequences of one’s
parties involved. In its ethical dimensions, it outlines actions are irrelevant. One acts in accordance with
the commitments and obligations of each. Although preset standards regardless of the outcome. The inap-
the theory developed from the observation of nurses propriateness of this type of guideline is obvious in
and nursing practice, it later expanded to include all relation to health care professionals, because they are
health care professionals. The development of this responsible for foreseeing the effects of their actions
theory has led to the construction of a practice-based and acting only in ways that benefit a patient. Utilitar-
decision-making model that assists in determining ian thought would have health care professionals act-
when and what actions are appropriate for health care ing to bring about the greatest good for the greatest

522 UNIT IV Nursing Theories

number of people. This is inconsistent with the prac- understanding phenomena than simple rationality.
tice of health care professionals who act as agents for He believed that one must develop insight and per-
individual patients. Emotivism promotes ethical ception to recognize how principles can be applied
actions in accordance with the emotions of those to each situation (McKeon, 1941).
involved. Rational thought has no place in emotive The Dutch philosopher, Spinoza, examined the
choices, making this type of decision-making pro- nature of humans and human knowledge. He recog-
cess inappropriate in the health care arena. Social nized that, although the process and outcomes of rea-
relativism imposes the beliefs of a society onto the soning may be comparable for each person, intuitive
individual. This approach is incongruous with the and discerning thought is unique to each. Spinoza
increasing diversity of our emerging global society. believed that reason must be coupled with intuitive
The authors recognized that the inappropriateness thought for true understanding (Lloyd, 1996). Spinoza
of traditional methods of ethical reasoning brought was noted for taking well-worn philosophical con-
about the failure of the health care system to suc- cepts and transforming them into new and engaging
cessfully address bioethical issues. ideas. This is true of the Husteds’ development of Sym-
Because traditional models proved inadequate to phonology, particularly in the evolution of the mean-
guide ethical behavior for health care professionals, ing of the bioethical standards.
the Husteds began to conceive and develop a Polanyi proposed that understanding is derived
method by which health care professionals might from awareness of the entirety of a phenomenon, that
determine appropriate ethical actions. The theory the lived experience is greater than separate, observ-
was based on logical thinking, emphasizing the pro- able parts. Tacit knowledge, that which is implied, is
vision of holistic, individualized care. They drew necessary to understand and interpret that which is
from the work of Aristotle, Benedict Spinoza, and explicit (Polanyi, 1964). These concepts, the unique-
Michael Polanyi. These philosophers adhere to ra- ness of the individual and the extension of reason and
tional thought and value persons as individuals. rationality with insight and discernment to create
Aristotle was a student of Plato who advanced his true understanding, are the foundations of the sym-
teacher’s work by recognizing that there is more to phonological method.




MAJOR CONCEPTS & DEFINITIONS
Agency first two contexts are interwoven. It is an agent’s
Agency is the capacity of an agent to initiate action present awareness of all the relevant aspects (knowl-
toward a chosen goal. The shared goal of a nurse and edge and circumstances) of the situation that are
patient is to restore the patient’s agency (Husted & necessary to understand and act effectively within it
Husted, 2008). (Husted & Husted, 2008).

Context Environment-Agreement
The “context is the interweaving of the relevant facts The environment established by Symphonology is
of a situation” (Husted & Husted, 2008, p. 84). There formed by agreement within a context. Agreement is
are three interrelated elements of context: the con- a shared state of awareness on the basis of which
text of the situation, the context of knowledge, and interaction occurs (Husted & Husted, 2008). Agree-
the context of an agent’s awareness. The context of ment creates the realm in which nursing and all
the situation includes all aspects of the situation that other human interactions occur. Every agreement is
provide understanding of the situation and promote aimed toward a final value to be attained through
the ability to act effectively within it. The context of interactions made possible by understanding.
knowledge is an agent’s preexisting knowledge, The health care professional–patient agreement
which includes factors usually found within the sit- is formed by a meeting of the professional’s and the
uation. In the context of an agent’s awareness, the patient’s needs. Their agreement is one in which the

CHAPTER 26 Gladys L. Husted and James H. Husted 523

MAJOR CONCEPTS & DEFINITIONS—cont’d
needs and desires of the patient are central. The well-being through their interaction (Fedorka &
professional’s commitment is defined in terms of the Husted, 2004).
patient’s needs. Without this agreement, there would
be no context for interaction between the two; the Person-Patient
relationship would be unintelligible to both (Husted A person is an individual with a unique character
& Husted, 1999). structure, possessing the right to pursue vital goals
as he chooses (Husted & Husted, 2001). These char-
Health acteristics are unique to an individual and also may
Health is a concept applicable to every potential of a be shared by others (Husted & Husted, 2008). Vital
person’s life. Health involves not only thriving of the goals are related to survival and the enhancement of
physical body, but also happiness. Happiness is real- life. A person takes on the role of patient when he
ized as individuals pursue and progress toward the has a loss or a decrease in agency resulting in an in-
goals of their chosen life plan (Husted & Husted, ability to take the actions required for survival or
2001). Health is evident when individuals experi- happiness (Husted & Husted, 1998).
ence, express, and engage in the fundamental bio-
ethical standards. Rights
The product of an implicit agreement among rational
Nursing beings, by virtue of their rationality, not to obtain ac-
A nurse acts as the agent of the patient, doing for her tions or the product of actions from others except
patient what he would do for himself if he were able through voluntary consent, objectively gained (Husted
(Husted & Husted, 2008). The nurse’s ethical re- & Husted, 2001). The term rights is a singular term that
sponsibility is to encourage and strengthen those represents the critical agreement of nonaggression
qualities in the patient that serve life, health, and among rational people (Husted & Husted, 1997b).



Use of Empirical Evidence Beginning in 1990, Duquesne University offered a
Study and dialogue between the two theorists, coupled course devoted to this bioethical theory. The authors
with experience of the overall evolution of health care continued to seek critique and examples about their
and observation of individual nurse-patient relation- work from students, practitioners, and other experts.
ships, provided the impetus to develop Symphonology The third edition of the book, Ethical Decision Making
Theory. G. Husted’s dissertation focused on the effect in Nursing and Healthcare: The Symphonological Ap-
of teaching ethical principles on a student’s ability proach (Husted & Husted, 2001), offered a clarified
to use these in practical ways through case studies. description of the theory, with advanced concepts
J. Husted was very instrumental in the selection of the separated from the basic concepts. In addition, the
dissertation topic and was used as a consultant during model was redrawn to better represent the nonlinear
the process. Development of G. Husted’s doctoral nature of the theory in practice. The fourth edition
work led to numerous publications and presentations offers further clarification of concepts and the inte-
before the first edition of the book Ethical Decision gration of concepts in the theory as a whole. In addi-
Making in Nursing was published in 1991. This first tion, the text is rearranged to present the concepts
edition presented their work as a conceptual model from simple to more complex.
only. As they continued to develop their ideas, incor- As the theory emerged, the need for an emphasis
porating feedback from graduate students, the Sym- on the individual became apparent and essential. In
phonological theory emerged. Before publication of recent years, it has become accepted practice in the
the second edition, the Husteds (1995a) continued to literature to designate patients and nurses as “he/she,”
clarify the theoretical concepts and developed the or simply use the plural form, referring to nurses
model for practice. and their patients. The authors recognized that these

524 UNIT IV Nursing Theories

awkward and anonymous terms distract readers from
thinking in terms of real people within the context of Health
a particular situation. Therefore, they chose to refer to The authors do not address or define health directly.
individuals as he, in the case of patients, and she, in The entire theory is driven by the concept of health in
the case of health care professionals in particular situ- the broadest, most holistic sense. Health is a concept
ations and examples. This chapter will continue with applicable to every potential of a person’s life. Health
this practice. involves not only thriving of the physical body, but
also happiness. Happiness is realized as individuals
pursue and progress toward the goals of their chosen
Major Assumptions life plan (Husted & Husted, 2001). Health is evident
The assumptions from this theory arise from the when individuals experience, express, and engage in
practical reasoning. The model is meant to provide the fundamental bioethical standards.
nurses and other health care professionals with a
logical method of determining appropriate ethical ac- Environment or Agreement
tions. Although many of the terms are familiar to The environment established by Symphonology is
nurses and health care professionals, some have been formed by agreement. “Agreement is a shared state of
redefined to support the reality of human interaction awareness on the basis of which interaction occurs”
and ethical delivery of health care. (Husted & Husted, 2001, p. 61). Agreement creates
the realm in which nursing and all other human in-
Nursing teractions occur. Every agreement is aimed toward a
Symphonology holds that a nurse or any other health final value to be attained through interactions made
care professional acts as the agent of the patient. Using possible by understanding.
her education and experience, a nurse does for her The health care professional–patient agreement
patient what he would do for himself if he were able. is formed by a meeting of the professional’s and the
Nursing cannot occur without both nurse and patient. patient’s needs. Their agreement is one in which the
“A nurse takes no actions that are not interactions” needs and desires of the patient are central. The pro-
(Husted & Husted, 2001, p. 37). The nurse’s ethical fessional’s commitment is defined in terms of the
responsibility is to encourage and strengthen those qual- patient’s needs. Without this agreement, there would
ities in the patient that serve life, health, and well-being be no context for interaction between the two. The
through their interaction (Fedorka & Husted, 2004). relationship would be unintelligible to both (Husted
Agency is the capacity of an agent to take action & Husted, 1999).
toward a chosen goal. A nurse as agent takes action Symphonology Theory is not a compilation of tra-
for a patient, one who cannot act on his own behalf. ditional cultural platitudes. It is a method of deter-
The shared goal of a nurse and a patient is to restore mining what is practical and justifiable in the ethical
the patient’s agency. The nurse acts with and for the dimensions of professional practice. Symphonology
patient toward this end. recognizes that what is possible and desirable in the
agreement is dependent on the context.
Person or Patient The context is the interweaving of the relevant facts
The Husteds define a person as an individual with a of a situation—the facts that are necessary to act upon
unique character structure possessing the right to pur- to bring about a desired result (Husted & Husted,
sue vital goals as he chooses (Husted & Husted, 2001). 2001). There are three interrelated elements of context:
Vital goals are concerned with survival and the en- the context of the situation, the context of knowledge,
hancement of life. A person takes on the role of patient and the context of awareness. The context of the situa-
when he has lost or experienced a decrease in agency tion includes all facts relevant to the situation that
resulting in his inability to take the actions required for provide understanding of the situation and promote
survival or happiness. The inability to take action may the ability to act effectively within it. The context of
result from physical or mental problems, or from a lack knowledge is an agent’s preexisting knowledge of the
of knowledge or experience (Husted & Husted, 1998). relevant facts of the situation. The context of awareness

CHAPTER 26 Gladys L. Husted and James H. Husted 525

represents an integration of the agent’s awareness of the This understanding makes negotiation and cooperation
facts of the situation and her preexisting knowledge among individuals possible.
about how to most effectively deal with these facts
(Husted & Husted, 2008). Ethical Standards
Ethical standards have been the benchmarks of ethical
behavior. The standards include terms familiar to health
Theoretical Assertions care professionals such as beneficence, veracity, and
Symphonology is classified as a grand theory because confidentiality. However, the authors have conceived
of its broad scope. Grand theories structure goals new meanings for ethical standards that correspond to
related to a specific view of the discipline (Walker & the foundational concepts of Symphonology: the per-
Avant, 2011). Grand theories are broader than con- son as a unique individual, and the use of insight and
ceptual models and may be used as a model to guide discernment in addition to reason and rationality in
practice and research (Fawcett & Garity, 2009). The order to achieve a deeper understanding.
authors developed Symphonology Theory not from Traditionally, bioethical concepts have been used to
natural progression of other work, but from the rec- guide ethical action by mandating concrete directives
ognition of a need for theoretical guidelines related to for action. For instance, the concept of beneficence
the ethical delivery of health care. The understanding conventionally maintains that one must see that no
and use of this theory are based on a fundamental harm comes to a patient. However, it is not always pos-
ethical element that describes the rational relation- sible to predict how and when harm will occur, mak-
ship between human beings: human rights. ing adherence to this directive an unrealistic goal. The
concept of beneficence, viewed as a mandate, could
Rights also imply that defending yourself against a physical
The Husteds describe rights as the fundamental ethical attack is unethical. Similarly, veracity, or truth telling,
element. Traditionally, rights are viewed as a list of holds that one must always speak the truth regardless
options to which one is entitled, such as a list of items of the consequences. Therefore, it is unethical to with-
or actions to which one has a just claim. Symphonology hold potentially harmful information, regardless of
holds rights as a singular concept. It is the implicit, the consequences. Adhering to veracity may interfere
species-wide agreement that one will not force another with one’s commitment to beneficence. Clearly, ethical
to act, or take by force the products of another’s actions. standards taken as concrete directives do not allow for
Rights are viewed as the critical agreement among ratio- the consideration of context.
nal people, the agreement of nonaggression (Husted & The authors have redefined the ethical standards,
Husted, 1997a). This agreement emerged as humans not as concrete rules, but as human qualities or char-
became rational and developed a civilized social struc- acter structures that can and must be recognized and
ture. A nonaggression agreement is preconditional to all respected in the individual (Husted & Husted, 1995b).
human interaction. It serves as a foundation on which For example, in Symphonological terms, beneficence
all other agreements rest. The formal definition is as includes the idea of acting in the patient’s best inter-
follows: “the product of an implicit agreement among est, but it begins with the patient’s evaluation of what
rational beings, held by virtue of their rationality, not to is beneficial. In this way, ethical standards are presup-
obtain actions or the products of actions from others positions in the health care professional–patient
except through voluntary consent, objectively gained” agreement and ethical guides to decision making. The
(Husted & Husted, 2001, p. 4). The operation of this is participants work together with the implicit under-
evident in human interaction. standing that each is possessed of human characteris-
According to the Husteds, Symphonology Theory tics. The description and names of the bioethical
can ensure ethical action in the provision of health care. standards have changed over time based on feedback
Agreement is the foundation of Symphonology. Agree- from practitioners. Symphonological theory holds
ments can occur based on the implicit understanding of that patients have a right to receive the benefits speci-
human rights. The understanding of nonaggression that fied in the bioethical standards. Box 26–1 provides
exists among rational persons constitutes human rights. definitions and examples of bioethical standards.

526 UNIT IV Nursing Theories

BOX 26-1 Bioethical Standards the individual (J. Husted, personal communication,
March 5, 2004). As stated earlier, recognition of these
Autonomy standards is preconditional to the implicit patient–
Autonomy is the uniqueness of the individual, the health care professional agreement. When recognized
singular character structure of the individual. Every and respected in each individual, these human quali-
person has the right to act on his or her unique and ties and capabilities form the basis for ethical interac-
independent purposes. tion. When they are disregarded, the context of the
situation is lost. Interaction is then based on whatever
Beneficence is served by concrete directives or on the whim of the
Beneficence is the capability to act to acquire desired participants.
benefits and necessary life requirements. Each person
may act to obtain the things he or she needs and Certainty
prefers. There are circumstances in health care when a pa-
tient is unable to communicate his unique character
Fidelity structure, as in the case of an infant or a comatose
Fidelity is an individual’s faithfulness to his or her patient. health care professionals also interact with
own uniqueness. Each person manages, maintains, individuals from different cultures for whom a com-
and sustains his or her unique life. For the health mon language is lacking. In these cases, the bioethi-
care professional, fidelity in agreement means cal standards can provide a measure of certainty
commitment to the obligations accepted in the when knowledge of an individual’s unique character
professional role. is unobtainable.
If you know nothing whatever about an individu-
Freedom al’s uniqueness, then you are justified in acting on the
Freedom is the capability and right to take action basis that, as a member of the human species, he
based on the agent’s own evaluation of the situa- shares much in common with every other individual
tion. Every person may choose his or her course of (Fedorka & Husted, 2004, p. 58).
action. These commonalities are the bioethical standards.
Each person needs the power to sustain his unique
Objectivity nature, the power to be objectively aware of his sur-
Objectivity is the right to achieve and sustain the roundings, and the power to control his time and effort,
exercise of objective awareness. Every person has to pursue benefit, and to avoid harm. Lacking other
an awareness and understanding of the universe information, nurses and health care professionals are
outside himself or herself. Every person has the justified to do all they can to restore these powers to the
right to manage, maintain, and sustain this under- individual.
standing as he or she chooses.
Decision-Making Model
Self-Assertion Figure 26–1 demonstrates the way the concepts of
Self-assertion is the right and capability to con- the theory interact with direct decision making. The
trol one’s time and effort. Each person has the elements of ethical decision making interact in the
right to pursue chosen courses of action without following way:
interference. • A person is a rational being with a unique char-
acter structure. Each person has the right to
choose and pursue, without interference, a course
Just as the bioethical standards are not to be con- of action in accordance with his needs and
sidered as concrete directives, so too, they are not desires.
distinct entities. Each standard blends with the others • Agreements between individuals are demonstrated
as representative of the unique character structure of by a shared state of awareness directed toward a goal.

CHAPTER 26 Gladys L. Husted and James H. Husted 527




Context of Awareness



Healthcare professional/
patient agreement



AUTONOMY



Context of knowledge Beneficence Self-assertion Context of the situation
Objectivity
Freedom











FIDELITY




Decision








FIGURE 26-1 Bioethical Decision-Making Model. (Husted, J. H., & Husted, G. L. [2008]. Ethical decision
making in nursing and health care: The symphonological approach [4th ed.]. New York: Springer.)



• The health care professional–patient agreement is an agent has of how to deal most effectively with
directed toward preserving and enhancing the life these facts” (Husted & Husted, 2008, p. 84). In this
of the patient. way, there are no universal ethical principles.
• Context is the basis for determining what actions are • Ethical decisions are the result of reasoning from
ethical within the health care professional–patient the context to a decision rather than applying a
agreement. “Context is the interweaving of the rele- decision or principle to a situation without regard
vant facts of the situation—the facts that are neces- for the context.
sary to act upon to bring about a desired result, an The Husteds described the ultimate application and
agent’s awareness of these facts, and the knowledge practice of these assumptions by health care professionals

528 UNIT IV Nursing Theories

in the following way. The professional will come to of how to achieve ethical action in health care could
understand and work from the philosophy that: not be more critical.
Since the initial development of Symphonology,
My patient’s virtues (autonomy) are such that he inductive reasoning based on observation and feed-
is moving (self-assertion) toward his goal (free- back from practitioners has provided for refinement
dom) in these circumstances (objectivity) for this of the concepts and clarification of the relationships
reason (beneficence). My virtues (autonomy) are among concepts.
such that I must act with him (interactive self-
assertion) to assist him (his freedom) within the
possibilities (of beneficence) in his circumstances Acceptance by the Nursing Community
to achieve every possible benefit that can be Practice
discovered (by objective awareness) The Husted Symphonological model for ethical deci-
(Husted & Husted, 2001, p. 154).
sion making (Husted & Husted, 2001, p. 201) was
An interactive model can be found at: http://www. developed as a practice model for applying the con-
nursing.duq.edu/faculty/husted/index.html cepts of Symphonology. This model, stressing the
centrality of the individual and the necessity of reason
directed by context, is vital in existing and emerging
Logical Form health care systems. The model provides a philo-
Abductive reasoning, like induction and deduction, sophical framework to ensure ethical care delivery by
follows a pattern: nurses and all other disciplines of health care. Unlike
• A is a collection of data (the process of discerning traditional models, the Symphonological model pro-
ethical action). vides for logically justifiable ethical decision making.
• B (if true) explains A (Symphonology). The North Memorial Medical Center in Robbinsdale,
• No other hypothesis explains A as well as B does Minnesota, has adopted the model for use by their
(traditional methods). nursing ethics committee.
• Therefore B is probably correct. The call to care in nursing is central to the profes-
The strength of an abductive conclusion depends on sion. Hartman (1998) asserted that caring is demon-
how solidly B can stand by itself, how clearly B exceeds strated when nurses recognize that the bioethical
alternatives, how comprehensive was the search for standards are so intertwined with caring that together
alternatives, the cost of B being wrong and the benefits they provide a perfect circle of ethical justification.
of being right, and how strong the need is to come to a Enns and Gregory (2006) proposed that nursing
conclusion at all (Josephson & Josephson, 1994). is losing the essence and practice of caring because
The abductive method is evident in the inception of the changing health care environment. Sympho-
and evolution of Symphonology. The strength of this nology offers a practice-based approach to care, as
theory is evident as well. The concepts of Symphonol- follows:
ogy clearly can be observed not only in health care A practice-based approach is derived from, and
but also in other walks of life. It is clear that ethical therefore is intended to be appropriate to the situ-
action based on the context of an individual’s particu- ation of a patient, the purpose of the health care
lar circumstances is far superior to the imposition of setting, and the role of the nurse. The more an
concrete directives that often contradict each other or ethical system restricts practice based on abstract
have little relationship to the situation at hand. The principles the more nurse and patient become
authors’ extensive study of the philosophy of knowl- alienated from each other
edge, science, and the human condition attests to the (Husted & Husted, 1997b, p. 14).
comprehensive search for alternative answers. The
benefit to patients and health care professionals of Many nurses practice within systems bound by pro-
receiving practice-based ethical care would be im- tocols and critical pathways. Using a Symphonological
measurable. Finally, the need to address the problem approach can ensure that nursing practice remains

CHAPTER 26 Gladys L. Husted and James H. Husted 529

ethical and does not become prescriptive. This is par- students. The broad applicability for Symphonology
ticularly important when considering making deci- makes it an excellent framework for nursing curri-
sions for those who can no longer make decision for cula. Beginning students can easily grasp and apply
themselves (Gropelli, 2005). Often clinical emergency the theoretical concepts. Using this theory as a basis
patients are unable to participate in decision making. for nursing interactions directs the student in ethical
Symphonology offers a method of ensuring that ethical practice from the beginning of learning nursing prac-
conclusion and actions are based on the best interests tice. The concept of context can be used as the basis
of the individual (Fedorka & Husted, 2004). for assessment. The bioethical standards direct the
Offering culturally sensitive care is increasingly im- student in choosing appropriate approaches, timing,
portant as our health care systems change in response to and type of interventions for each patient. Because
a global society (Wehbe-Alamah, 2008; Zoucha & of the holistic approach and central concern for the
Broome, 2008; Chenowethm, Jeon, Goff, et al., 2006). patient, Symphonology can be incorporated easily
Although cultural factors can be helpful in directing into existing nursing curricula.
care for a patient, nurses must also consider the indi- Brown (2001a) addressed the importance of ethi-
vidual’s personal commitment to the traditions and cal interaction between nurse educator and student.
beliefs of his culture. In this way, the nurse provides The agreement in this case is more explicit, because
care for the patient rather than the culture (Zoucha & both parties are more aware of the commitments and
Husted, 2000). Using the Husted model, care is directed responsibilities. Recognizing the bioethical standards
within the context of the individual’s circumstances. in both the educator and the student serves to direct
Imposition of a false context, cultural or otherwise, is ethical actions between them. Above all, the educator
avoided. and student recall that the educator-student-patient
Brown (2001b) advocated the use of Symphonology agreement is central to the learning process.
Theory to direct discussion and education of patients Steckler (1998) agreed with Brown’s application
regarding advance directives. Bioethical standards are of Symphonology in the educational process and rec-
used to guide discussion about what types of treatment ommended incorporating the theory in continuing
an individual would or would not want, given particu- education. The Husted model not only identifies and
lar circumstances. Hardt (2004) has proposed an inter- organizes professional values and ethical principles for
vention for nurses in ethical dilemmas. learners, but it helps the educator to develop a consis-
The emergence of health care teams as a method of tent professional ethical orientation. Cutilli (2009)
delivering comprehensive care brings many disciplines utilized case study applications with the Symphonologi-
together to serve patients’ needs. Overlapping roles and cal Theory approach to patient and family education.
disparate goals can cause confusion among team mem-
bers. Symphonological theory, with its patient-centered Administration
focus, can serve as common ground to initiate and Health care administrators make decisions at several
promote collaboration among health care professionals levels. They have a responsibility to the community at
of all disciplines. large and the financial viability of the institution within
Symphonology can be applied to all caring disci- the community, the employees, and those receiving
plines. Khechane (2008) developed a model for pastoral care. Hardt (2004) described how administrators use
care practice based on Symphonology. Using the deci- the principles of Symphonology to guide their decision
sion-making model, pastoral care practitioners provide making to produce ethically justifiable outcomes.
for the relief of suffering using the bioethical standards. With regard to issues at the community and insti-
tutional levels, one considers the needed services
Education provided by the institution. In cases in which the ser-
As Symphonology is disseminated, it is easy to inte- vices needed would not be feasible for the institution,
grate it into nursing education. More and more ethics resources within the community can be shared
is addressed throughout nursing curricula rather than and supported by the institution so that needed ser-
as a separate topic, particularly for advanced nursing vices are available with the least amount of loss to the

530 UNIT IV Nursing Theories

institution. At the employee level, the administrators decision making for health care issues (Husted, 2001).
are concerned with care delivery as well as interper- The themes that emerged from this study were used to
sonal relations. Symphonology guides decision mak- develop visual analog tools to measure these feelings
ing into equitable rather than equal solutions. For in nurses and patients. In the second phase, a pilot
example, an employer may choose to forego the use study to test the tool was completed. The Cronbach
of a harsh sanction for absenteeism when the alpha was reported as 0.74 for the nurse’s tool and
employee is able to show extenuating circumstances 0.82 for the patient’s tool (Husted, 2004).
that prevented his attendance. This is also true for the Irwin (2004) used a sample of 30 participants in-
development of policy regarding employees’ behavior. volved in a variety of decisions about health care and
Ethical policy provides guidelines for examining situ- treatment during hospitalization in an acute care set-
ations rather than prescribed rules with concrete di- ting. The study included a decision support interven-
rectives for action. With regard to individual patients, tion for patients to determine the following: (1) whether
administrators act as role models and consultants key concepts of Symphonological Theory describe the
when addressing ethical issues. experience of individuals making health care decisions,
Hardt and Hopey (2001) described the problematic and (2) whether application of the decision-making
situations that occur within managed care systems. framework will enable nurses and patients to make
Difficulties that have been identified include the refusal ethically justifiable decisions. Results confirmed that
of the organization to provide care deemed appropriate patients expressed all the concepts of Symphonology
by health care professionals and the inappropriate de- when discussing their experiences with health care
mands of patients and families. Using the principles of decision making. Statistical analysis of pretest and post-
Symphonology, health care professionals can examine test scores on the Bioethical Decision Making Prefer-
the context and determine appropriate ethical actions ence Scale for Patients demonstrated that subjects had a
within the implicit and explicit agreements. more positive experience of being involved in decision
Nurse administrators and managers can also use making (p 5 0.02) and felt more sufficiency of knowl-
Symphonology to mediate inappropriate situations be- edge (p 5 0.013), less frustration (p 5 0.014), and more
tween patients and nurses (Bavier, 2007). For example, sense of power (p 5 0.009) after the intervention. These
cases in which patients wish to give an inappropriate findings support the validity of Symphonology Theory.
gift as a sign of appreciation to a particular nurse., The theory can be used to describe the experience of
being involved in decision making, and Symphonology
Research has utility as a model for assisting patients through the
Symphonology in research is useful in relation to the decision-making process.
researcher-subject agreement. The health care profes- A graduate student used the nursing visual analog
sional–patient relationship is to some extent implicit, tool to discover how nurses felt when dealing with
but the relationship between a researcher and a subject disclosure issues with patients. The Cronbach alpha
must be thoroughly explicit. Brown (2001c) suggested for this study was 0.82 (Bavier, 2003). Further testing
using the bioethical standards to develop an ethical of the theory is underway as a doctoral student is
informed consent protocol. Particularly when the analyzing data from a study designed to determine
research involves vulnerable populations, the consent the effect of a Symphonology-based educational in-
of surrogates is made more acceptable and is obtained tervention on the ethical decision-making perfor-
more easily if the good of the individual is made central mance of advanced-level nursing students, and to
by using the bioethical standards. compare how students understand the application of
Symphonology and other theories (Mraz, 2012).

Further Development
Initial testing of Symphonological Theory included Critique
two phases. First, a qualitative study examined the Clarity
perceptions and satisfaction of nurses and patients In Ethical Decision Making in Nursing (Husted & Husted,
and their significant others as they engaged in ethical 1995a), the authors presented the emerging concepts

CHAPTER 26 Gladys L. Husted and James H. Husted 531

of Symphonology and the relationships among the Accessibility
concepts. The book may be difficult for beginning nurses Symphonology is a theory grounded in ethical principles
to read because deeper concepts meant for advanced and based in reality. Evidence has demonstrated support
practitioners are included along with basic ideas. The of the theory in nursing practice decision research, and
third edition, Ethical Decision Making in Nursing and the reality of the usefulness of the theory in practice is
Healthcare: The Symphonological Approach, begins with evident. Nurses and other health care professionals can
the basic concepts for understanding and using the easily understand the concepts and apply them in all situ-
theory and then moves to more advanced concepts in ations. The result of using the Symphonological model is
later sections (Husted & Husted, 2001). Along with this a patient-centered, ethically justifiable decision.
improved organization, the third edition shows the
emergence of increasing clarity for all concepts, the Importance
bioethical standards in particular. The fourth edition Being able to identify ethical actions in health care is
provides yet further clarity using tables and figures and of vital importance to patients, health care profession-
includes a user-friendly teacher manual. als, and the health care industry itself. Understanding
This work challenges traditional methods of thought the ethical dilemmas of nursing practice is an impor-
and requires the reader to develop a new understand- tant issue for nursing education, research, and prac-
ing of familiar concepts. Storytelling and examples tice. Before a nurse or any health care professional
provide the opportunity to recognize and understand takes action (regardless of how effective the action has
the importance of alternative and extended meanings been in the past), the action must be justified as ethical
for familiar terms. The conversational tone of the writ- with regard to the particular patient at hand. Reliance
ing is appealing and creates a comfortable atmosphere on concrete directives to guide action serves the direc-
for a complex subject. tives, but only by chance serves the patient. Therefore,
the pursuit of a practice-based ethical theory is essen-
Simplicity tial for nursing practice and health care.
The authors first challenge the truth and efficacy of
traditional ideas about ethical behavior and decision
making. This is a simple matter if the reader is open- Summary
minded to a different view of nursing events. As the The Husteds recognized that the traditional methods
reader accepts the challenge, the simplicity of the of decision making were insufficient to address the
theory is evident. There are few concepts, and the re- bioethical problems emerging in the evolving health
lational statements flow logically from the definitions. care system. They developed a theory of ethics and a
The model clearly demonstrates the elements of the decision-making model based on rational thought
process of ethical reasoning and the manner in which combined with ethical principles, insight, and under-
these elements interact. standing. Their theory is founded on the singular
concept of human rights, the essential agreement of
Generality nonaggression among rational people that forms the
Symphonology is applicable at all levels of nursing foundation of all human interaction. Upon this foun-
practice and in all areas of health care. The princi- dation, health care professionals and patients enter
ples can be applied between nurse and patient, re- into an agreement to act to achieve the patient’s goals.
searcher and subject, manager and employee, and Preconditional to this agreement are recognition
educator and student. Health care professionals of and respect for each person’s unique character struc-
all types can use this method to determine appropri- ture and the attendant properties of that structure:
ate ethical behaviors in practice. This theory can also freedom, objectivity, beneficence, self-assertion, and
be applied to the process of establishing health care fidelity. Ethical decisions are established within the
policy that is ethical in nature. Indeed, these princi- context of a particular situation, using knowledge
ples can be applied in all walks of life, depending pertaining to the situation. Symphonological theory
on the nature of the agreement between the parties and the model for practice ensure ethically justifiable,
involved. individualized decisions.