alligood 8th edition_Neat

682 UNIT V Middle Range Nursing Theories

been found valid and reliable in studies (Beck, 2002b; The theory was influenced by various theoretical and
Hanna, Jarman, Savage, et al., 2004; Oppo, Mauri, philosophical stances, adding breadth and texture.
Ramacciotti, et al., 2009). An important feature of Maternity nurses are able to read the theory and under-
Beck’s theory is its immediate accessibility and dy- stand how to apply it in their practice. Beck and others
namic potential to impact women’s lives. continue to expand the theory by exploring its applica-
bility to different cultures and exploring ways of reach-
Importance ing women who have potential for its benefit.
The value of Beck’s work is of growing importance Increasingly, nurses and the wider society are rec-
within nursing and other disciplines. Perinatal mood ognizing that issues of postpartum depression have
disorders are obviously more than transient inconve- not been adequately understood or acknowledged.
niences for women and their families. The sequence Nursing, like other health care professions, has been
of events in the life of women (Meier, 2002) points to shocked by unanticipated events when postpartum
the extraordinary need for greater awareness and use depression leads to untoward outcomes that appear in
of Beck’s Postpartum Depression Theory for preven- the evening news. Even among nurses and other
tion, identification, early intervention, and treatment. health professionals, their knowledge does not miti-
There is a growing awareness that the responsibility gate the effects of this illness. These events point out
for identification and early intervention of postpar- the importance of this theory. Dr. Cheryl Tatano
tum depression belongs to more than those who are Beck’s work has demonstrated that nursing research
primarily responsible for caring for women during provides evidence to understand and prevent postpar-
pregnancy and immediately after birth (Beck, 2003; tum depression. Her research and instruments facili-
Kennedy, Beck, & Driscoll, 2002). Because of consis- tate detection, early intervention, and treatment.
tent interactions with mothers, pediatric and neonatal
nurses can make valuable contributions to successful
interventions for mothers suffering from postpartum CASE STUDY
depression. Psychiatric nurses might also be able to At the tender age of 11 years, Kim was “sold” by her
identify problems in women (or their children) that do mother to three adult men for an evening of sex
not immediately indicate postpartum depression. and drugs. Kim related that as her mother went out
However, knowledge about postpartum depres-
sion is developing in a way that sheds light on less the door, she advised her to “do what they tell you
and I’ll be back in the morning.” Kim was never
obvious consequences. Recently, postpartum depres- okay again. Although she did relatively well during
sion has been linked to adverse effects on children’s the sporadic times she went to school, her life was
cognitive and emotional development and behavior a series of drug and sex binges. At 17, Kim was in
problems of older children in school. Postpartum jail and pregnant. She had been arrested several
depression could have a negative effect upon situa- times and released, but the judge insisted that this
tions such as substance use, traffic accidents, criminal time she stay incarcerated until after the baby was
behaviors, domestic violence, progress in school, em- born to guarantee the baby would be crack-free at
ployment and income, and many others. A growing birth. Kim’s prenatal records, however, did not in-
awareness within nursing, other health care profes- dicate drug or alcohol use, and neither did her
sionals, and the public will allow greater identification jail records. She adamantly insisted that she never
of postpartum depression in the many contexts within used drugs or alcohol once she found out she was
which people live their lives.
pregnant (late in the first trimester). Through a
series of misunderstandings, she was released
Summary 2 weeks before the baby’s birth. However, Kim did
The development of Beck’s Postpartum Depression well, continued to stay drug-free, refused medica-
tion during labor, and delivered a beautiful healthy
Theory is the quintessential example of how creative baby—a baby whose blood test results were nega-
nursing knowledge is developed from nursing observa- tive for drugs.
tions, utilizing multiple methods and rigorous testing.

CHAPTER 34 Cheryl Tatano Beck 683


Kim recalls that she began motherhood believ- Kim once remarked that she loved being preg-
ing this would be the event that would turn her life nant, loved giving birth, and loved the idea of
around. It did for several weeks, but slowly Kim being a mother. She said, “It would be great in
became involved in her old life. She received the beginning, but after a couple of months I’d
money to buy clothes and food for her baby. In start feeling bad. It seems like with both my babies
spite of that help, however, Kim had no place to that around 6 or 7 months, I just couldn’t handle
live and no money to support herself. She never anything.”
held a legal job in her life. She qualified for post- Although Kim took the baby to a pediatrician
partum medical care for 6 weeks, but after that she for follow-up care, none of those care providers
was on her own. knew her or knew her history—they were pri-
When the baby was 7 months old, Kim called a marily concerned with her son’s health. Kim’s
nurse who had once cared for her during her preg- affect is usually very upbeat; she smiles easily.
nancy and asked for help to give her daughter up It is not likely that anyone ever asked her any
for adoption. She believed she would simply never important questions about her life or her experi-
be able to give her baby the life she knew all babies ence of being a mother. Kim was, for all intents
deserved. Kim was using drugs again, and the baby and purposes, “lost to follow-up.”
was being kept by whoever was in the mood to do Kim’s story illustrates the kinds of complexi-
so. Kim absolutely loved this baby, and the choice ties that can make postpartum depression espe-
for adoption came from this love. Kim chose a local cially challenging for women who live amid
Christian adoption agency. Staff there gave her the drugs and chaos. In the midst of this life, women
opportunity to read the profiles of potential fami- still want to be good mothers and have the same
lies, see pictures of them, and actually choose the hopes and same dreams we all have. Drugs, alco-
family who would raise her baby. Though she did hol, crimes, and all the other ways Kim’s life
not know the family’s name or address, the family was chaotic were the only avenues by which she
and the agency committed to regular photographs received services—after-the-fact services.
and updates about her daughter. Interventions by others could have made a
Without resources or support, and without her difference at many points in Kim’s life. One of
baby, Kim returned to the only life she had ever these points was during her prenatal period. She
known among the only people she really knew. clearly evidenced most of the risk factors for
Eighteen months later, Kim gave birth to another postpartum depression, despite her cheerful atti-
baby. This time, she swore things would be differ- tude toward the pregnancy. If you had been a
ent. When this new baby was also about 7 months nurse caring for Kim during her prenatal care
old, Kim found herself deeply involved in crack and identified her to be at risk for postpartum
use, with her baby being passed around from rela- depression, what kind of care plan would you
tive to relative and from friend to friend. Unfortu- have developed before or after her baby’s birth?
nately, Kim was present during the commission of Would you have been willing to intervene on
a violent crime with a predictably tragic outcome. behalf of Kim or her baby, even though their
Although Kim did not actually commit this crime, needs occurred within the community and not in
she was present and was ultimately sent to prison. the confines of a hospital or office?



CRITICAL THINKING ACTIVITIES

1. Interview a friend or family member about her 3. Were any of her experiences suggestive of risk for
prenatal and postnatal experiences. postpartum depression?
2. Did she have feelings that you expected? Did she 4. Explore the resources available in your community
have any that surprised you? for women with postpartum depression.

684 UNIT V Middle Range Nursing Theories

POINTS FOR FURTHER STUDY
n Beck, C. T. (2008). State of the science on post- Beck Instruments
partum depression: What nurse researchers have n Beck, C. T. (1998). Postpartum Depression Pre-
contributed. Part 1. American Journal of Maternal dictors Inventory (PDPI). Available from Journal
Child Nursing, 33, 151–156. of Obstetric, Gynecologic, & Neonatal Nursing,
n Beck, C. T. (2008). State of the science on post- published on behalf of the Association of
partum depression: What nurse researchers have Women’s Health, Obstetrics and Neonatal Nurses,
contributed. Part 2. American Journal of Maternal by Sage Science Press, an imprint of Sage Publica-
Child Nursing, 33, 121–126. tions; Print ISSN: 0884–2175.
n Polit, D., & Beck, C. T. (2007). Nursing research: n Beck, C. T., & Gable, R. K. (2002). Postpartum
Generating and assessing evidence for nursing Depression Screening Scale (PDSS). Available
practice (8th ed.). Philadelphia: Lippincott. through Western Psychological Services, 12031
Wilshire Blvd., Los Angeles, CA 90025–1251.


REFERENCES
Barr, J., & Beck, C. T. (2008). Qualitative study on postpar- Beck, C. T. (2004b). Birth trauma: In the eye of the beholder,
tum depression reveals infanticide secrets. Canadian Nursing Research, 53, 28–35.
Family Physician, 54, 1716–1717, e5. Beck, C. T. (2004c). Post traumatic stress disorder due
Beck, C. T. (1992). The lived experience of postpartum to childbirth: The aftermath, Nursing Research, 53,
depression: A phenomenological study. Nursing 216–224.
Research, 41, 166–170. Beck, C. T. (2005). Benefits of participating in Internet
Beck, C. T. (1993). Teetering on the edge: A substantive interviews: Women helping women. Qualitative Health
theory of postpartum depression. Nursing Research, 42, Research, 15, 411–422.
42–48. Beck, C. T. (2006a). Acculturation: Implications for
Beck, C. T. (1998). Postpartum Depression Predictors perinatal research. Maternal Child Nursing, 31(2),
Inventory (PDPI). Available from Journal of Obstetric, 114–120.
Gynecologic, & Neonatal Nursing, published on behalf Beck, C. T. (2006b). Postpartum depression: It isn’t just the
of the Association of Women’s Health, Obstetrics and blues. American Journal of Nursing, 106(5), 40–50.
Neonatal Nurses, by Sage Science Press, an imprint of Beck, C. T. (2006c). The anniversary of birth trauma: Failure
Sage Publications; Print ISSN: 0884–2175. to rescue. Nursing Research, 55(6), 381–390.
Beck, C. T. (2001). Predictors of postpartum depression: Beck, C. T. (2006d). Postpartum depression: It isn’t just the
An update. Nursing Research, 50, 275–285. blues. American Journal of Nursing, 106, 40–50.
Beck, C. T. (2002a). Mothering multiples: A meta-synthesis Beck, C. T. (2006e). Pentadic cartography: Mapping birth
of the qualitative research.American Journal of Maternal trauma narratives. Qualitative Health Research, 16,
Child Nursing, 27, 214–221. 453–466.
Beck, C.T. (2002b). Revision of the postpartum depression Beck, C. T. (2007). Exemplar: Teetering on the edge: A con-
predictors inventory. Journal of Obstetric, Gynecologic, tinually emerging theory of postpartum depression. In
and Neonatal Nursing, 31, 394–402. P. Munhall (Ed.), Nursing research: A qualitative perspec-
Beck, C. T. (2002c). Postpartum depression: A meta-synthesis tive (4th ed., pp. 273–292). Boston: Jones & Bartlett.
of qualitative research. Qualitative Health Research, 12, Beck, C. T. (2008a). Postpartum mood and anxiety disorders:
453–472. Case studies, research, and nursing care. Washington,
Beck, C. T. (2002d). Postpartum depression screening scale (DC): Association of Women’s Health, Obstetrics, and
(PDSS): Manual. Los Angeles: Western Psychological Neonatal Nursing.
Services. Beck, C. T. (2008b). State of the science on postpartum depres-
Beck, C. T. (2003). Recognizing and screening for postpar- sion: What nurse researchers have contributed. Part 2.
tum depression in mothers of NICU infants. Advances American Journal of Maternal Child Nursing, 33,151–156.
in Neonatal Care, 3, 37–46. quiz 157–158. doi: 10.1097/01.NMC.0000318349.70364.1c.
Beck, C. T. (2004a). Grounded theory research. In J. Fain, Beck, C. T. (2008c). State of the science on postpartum depres-
Reading, Understanding, and F.A. Davis. sion: What nurse researchers have contributed. Part 1.

CHAPTER 34 Cheryl Tatano Beck 685

American Journal of Maternal Child Nursing, 33, 121–126. Beck, C. T., Froman, R., & Bernal, H. (2005). Accultura-
doi: 10.1097/01.NMC.0000313421.97236.cf. tion level and postpartum depression in Hispanic
Beck, C. T. (2008d). The nurses’ vantage point. In S. D. mothers. American Journal of Maternal Child Nursing,
Stone & A. E. Menken (Eds.), Perinatal and Postpartum 30, 299–304.
Mood Disorders: Perspectives and Treatment Guide for Beck, C. T., & Gable, R. K. (2000). Postpartum depression
the HealthCare Practitioner (pp. 203–217). New York: screening scale: Development and psychometric testing.
Springer. Nursing Research, 49, 272–282.
Beck, C. T. (2009a). Critiquing qualitative research. AORN Beck, C. T., & Gable, R. K. (2001a). Further validation of
Journal, 90, 543–554. the Postpartum Depression Screening Scale. Nursing
Beck, C. T. (2009b). Viewing the rich, diverse landscape of Research, 50, 155–164.
qualitative research. Perioperative Nursing Clinics, 4, Beck, C. T., & Gable, R. K. (2001b). Item response theory
217–229. in affective instrument development: An illustration.
Beck, C. T. (2009c). The Arm: There’s no escaping the reality Journal of Nursing Measurement, 9, 5–22.
for mothers caring for their children with obstetric bra- Beck, C. T., & Gable, R. K. (2001c). Comparative analysis
chial plexus injuries. Nursing Research, 58, 237–245. of the performance of the Postpartum Depression
Beck, C. T. (2009d). Birth trauma and its sequelae. Journal Screening Scale with two other depression instruments.
of Trauma and Dissociation, 10, 189–203. Nursing Research, 50, 242–250.
Beck, C. T. (2009e). An Adult Survivor of Childhood Beck, C. T., & Gable, R. K. (2001d). Ensuring content valid-
Sexual Abuse and her Breastfeeding Experience: A ity: An illustration of the process. Journal of Nursing
Case Study. American Journal of Maternal Child Measurement, 9(2), 201–215.
Nursing, 34, 91–97. Beck, C. T., & Gable, R. K. (2003). Postpartum Depression
Beck, C. T. (2011a). Revealing the subtle differences among Screening Scale—Spanish Version. Nursing Research 52,
postpartum mood and anxiety disorders: Phenomenology 296–306.
holds the key (pp. 193–214). In G. Thomson, F. Dykes, Beck, C. T., & Gable, R. K. (2005a). The Postpartum Depres-
& S. Downe (Eds.), Qualitative research in midwifery and sion Screening Scale (PDSS). In C. Henshaw & S. Elliott
childbirth: Phenomenological approaches. New York: (Eds.), Screening for perinatal depression (pp. 133–140).
Routledge. London: Jessica Kingley.
Beck, C. T. (2011b). A metaethnography of traumatic Beck, C. T. & Gable, R. K. (2005b). Screening performance
childbirth and its aftermath: Amplifying causal looping. of the Postpartum Depression Screening Scale—Spanish
Qualitative Health Research, 21, 301–311. Version. Journal of Transcultural Nursing, 16, 331–338.
Beck, C. T. (2011c). Secondary traumatic stress in nurses: Beck, C. T., Gable, R. K., Sakala, C., & Declercq, E. R.
A systematic review. Archives of Psychiatric Nursing, 25, (2011a). Postpartum depression in new mothers:
1–10. Results from a two-stage U.S. national survey. Journal
Beck, C. T. (2011d). Meta-synthesis: Helping qualitative of Midwifery andWomen’s Health, 56, 427–435.
research take its rightful place in the hierarchy of evi- Beck, C. T., Gable, R. K., Sakala, C., & Declercq, E. R.
dence. Japanese Journal of Nursing Research, 44, 352–370. (2011b). Postpartum depressive symptomology:
Beck, C. T. (2011e). Developing a research program using Results from a two-stage U.S. national survey. Journal
qualitative and quantitative approaches. Japanese Jour- of Midwifery & Women’s Health, 56(5), 427–435.
nal of Nursing Research, 44, 371–379. Beck, C. T., Records, K., & Rice, M. (2006). Further validation
Beck, C. T. (2012a). Exemplar: Teetering on the edge: A of the Postpartum Depression Predictors Inventory—
second grounded theory modification (pp. 257–284). Revised. Journal of Obstetric, Gynecologic, and Neonatal
In P.L. Munhall (Ed.), Nursing research: A qualitative Nursing, 35, 735–745.
perspective (5th ed.). Sudbury, (MA): Jones & Bartlett. Beck, C. T., & Watson, S. (2008). The impact of birth trauma
Beck, C. T. (2012b). A metaethnography of traumatic on breastfeeding: A tale of two pathways. Nursing Research,
childbirth and its aftermath: Amplifying causal looping. 57, 228–236.
Qualitative Health Research, 21(3), 301–311. Beck, C. T., & Watson, S. (2010). Subsequent childbirth
Beck, C. T., & Barnes, D. L. (2006). Post-traumatic stress after a previous traumatic birth. Nursing Research, 59,
disorder in pregnancy. Annals ofthe American Psycho- 241–249.
therapy Association, summer, 4–9. Bryanton, J., & Beck, C. T. (2010). Postnatal parental edu-
Beck, C. T. & Driscoll, J. W. (2006). Postpartum mood and cation for optimizing infant general health and parent-
anxiety disorders: A clinician’sguide. Sudbury, (MA): infant relationships. Cochrane Review. The Cochrane
Jones & Bartlett. Library 2010, Issue 1.

686 UNIT V Middle Range Nursing Theories

Cesario, S. K., Beck, C. T., Creehan, P., Watts, N., & Santa- S. C. Couch, & E. Philipson (Eds.), Nutrition and
Donato, A. (2006). Compendium of postpartum care Health: Handbook of Nutrition and Pregnancy. Totowa,
(2nd ed.). Washington, (DC): Association of Women’s (NJ): Humana.
Health, Obstetric, and Neonatal Nursing. Kennedy, H., Beck, C., & Driscoll, J. (2002). A light in the
Chinn, P., & Kramer, M. (2011). Integrated theory and fog: Caring for women with postpartum depression.
knowledge development in nursing (8th ed.). Maryland Journal of Midwifery & Women’s Health, 47(5), 318–330.
Heights, (MO): Mosby-Elsevier. Le, H.-N., Perry, D., & Sheng, X. (2008). Using the Internet
Clemmens, D., Driscoll, J., & Beck, C. T. (2004). Postpartum to screen for postpartum depression. Maternal and Child
depression as profiled through the Postpartum Depression Health Journal, Springer Netherlands: SpringerLink.
Screening Scale. American Journal of Maternal Child Meier, E. (2002). Pediatric ethics, issues & commentary.
Nursing, 29, 180–185. Andrea Yates: where did we go wrong? Pediatric Nursing,
Colaizzi, P. (1978). Psychological research as the phenome- 28(3), 299.
nologist views it. In R. Valle & M. King (Eds.), Existential Oppo, A., Mauri, M., Ramacciotti, D., Borri, C., Rambelli, C.,
phenomenological alternative for psychology (pp. 48–71). Montagnani, M., et al. (2009). Risk factors for postpar-
New York: Oxford University Press. tum depression: The role of the Postpartum Depression
Davidson, M., London, M., & Ladewig, P. (2011). Olds’ Predictors Inventory-Revised (PDPI-R). Archives of
maternal-newborn nursing & women’s health across the Women’s Mental Health, 12, 239–249.
lifespan (9 ed.). Prentice Hall: Upper Saddle River, (NJ). Polit, D., & Beck, C. T. (2011). Nursing research: Generating
th
Freda, M. C., Beck, C. T., Campbell, D. E., Dell, D. L., & and assessing evidence for nursing practice, North American
Ratcliffe, S. (2011). Quality improvement opportunities Edition (9th ed.). Philadelphia: Lippincott.
in postpartum care (pp. 88–100). In March of Dimes. Polit, D., & Beck, C. T. (2003). Nursing research: Generating
Toward improving the outcome of pregnancy III. and assessing evidence for nursing practice, North American
New York: March of Dimes. Edition (7th ed.). Philadelphia: Lippincott.
Gable, R., & Wolf, M. (1993). Instrument development in Rychnovsky, J. D., & Beck, C. T. (2006). Screening for
the affective domain. Boston: Kluwer Academic. postpartum depression in military women using the
Glaser, B. (1978). Theoretical sensitivity: Advances in the Postpartum Depression Screening Scale. Military
methodology of grounded theory. Mill Valley, (CA): Medicine, 171, 1100–1104.
Sociology Press. Segre, L., O’Hara, M., & Beck, C. T. (2010a). Nursing care
Glaser, B., & Strauss, A. (1967). The discovery of grounded for postpartum depression. Part I: Do nurses think
theory. Chicago: Aldine. they should offer both screening and counseling?
Hanna, B., Jarman, H., Savage, S., & Layton, K. (2004). The AmericanJournal of Maternal Child Health Nursing,
early detection of postpartum depression: Midwives 35, 220–225.
and nurses trial a checklist. Journal of Obstetric, Gyne- Segre, L., O’Hara, M., & Beck, C. T. (2010b). Screening and
cologic, & Neonatal Nursing, 33, 191–197. counseling for postpartum depression by nurses Part II:
Hutchinson, S. (1986). Grounded theory: The method. Women’s views. American Journal of Maternal Child
In P. Munhall & C. Oiler (Eds.), Nursing research: A Health Nursing, 35, 280–285.
qualitative perspective (pp. 111–130). Norwalk, (CT): Sichel, D., & Driscoll, J. (1999). Women’s moods. New York:
Appleton-Century-Crofts. HarperCollins.
Judge, M. P., & Beck, C. T. (2008). Postpartum depression
and the role of nutritional factors. In C. J. Lammi-Keefe,

Bibliography of Research Using the Screening Scale
Baker, L. & Oswalt, K. (2008). Screening for postpartum Neonatal Nursing, 40, 440–449. doi: 10.1111/j.1552–6909.
depression in a rural community. Community Mental 2011.01254.x.
Health Journal, 44, 171–180. Cantilino, A., Carvalho, J. A., Maia, A., Albuquerque, C.,
Boyd, R. C., & Worley, H. (2007). Utility of the Postpartum Cantilino, G., & Sougey, E. B. (2007). Translation, vali-
Depression Screening Scale among low-income ethnic dation and cultural aspects of Postpartum Depression
minority women. In A. I. Rosenfield (Ed.), New research Screening scale in Brazilian Portuguese. Transcultural
on postpartum depression (pp. 151–166). Nova Science. Psychiatry, 44(4), 672–684.
Callister, L., Beckstrand, R. L., & Corbett, C. (2011). Postpar- Clarke, P. (2008). Validation of two postpartum depression
tum depression and help-seeking behaviors in immigrant scales with a sample of First Nations and Metis women.
Hispanic women. Journal of Obstetric, Gynecologic, & Canadian Journal of Nursing Research, 40, 113–125.

CHAPTER 34 Cheryl Tatano Beck 687

Davis, S., Cross, J., & Link, B. K. (2008). Exploring the depression? Archives of Women’s Mental Health, 14, 227–238.
Postpartum Adjustment Questionnaires a predictor doi: 10.1007/s00737–010–0178-y.
of postpartum depression. Journal of Obstetric, Postmontier, B. (2008). Sleep quality with and without post-
Gynecologic & Neonatal Nursing, 37, 622–630. partum depression. Journal of Obstetric, Gynecologic, and
De Alencar, A. E., Arraes, L. C., de Albuquerque, E. C., & Neonatal Nursing, 37, 722–737.
Alves. J.G. (2008). Effect of kangaroo mother care on Quelopana, A. M., & Champion, J. D. (2010). Validation
postpartum depression. Journal of Tropical Pediatrics, of the Postpartum Depression Screening Scale Spanish
55(1), 36–38. doi: 10.1093/tropej/fmn083. Version in women from Arica, Child. Ciencia y
Karacam, Z., & Kitiis, Y. (2008). The Postpartum Depression Enfermeria 16,37–47.
Screening Scale: Its reliability and validity for the Turkish Zubaran, C., Foresti, K., Schumacher, M. V., Amoretti, A.
population. Turkish Journal of Psychiatry, 19(2), 187–196. L., Müller, L. C., Thorell, M. R., et al. (2009).Validation
Le, H. N., Perry, D. F., & Sheng, X. (2009). Using the internet of a screening instrument for postpartum depression in
to screen for postpartum depression. Maternal Child Southern Brazil. Journal of Psychosomatic Obstetrics &
Health Journal, 13, 213–221. Gynecology, 30, 244–254.
Le, H. N., Perry D. F., & Ortiz G. (2010). The Postpartum Zubaran, C., Schumacher M. V., Foresti K., Thorell M. R.,
Depression Screening Scale-Spanish Version: Examining Amoretti A., & Müller L. (2010a). The Portuguese version
the psychometric properties and prevalence of risk for of the Postpartum Depression Screening Scale-Short
postpartum depression. Journal of Immigrant Minority Form. Journal of Obstetrics and Gynaecology Research, 36,
Health, 12, 249–258. doi: 10.1007/s10903–009–9260–9. 950–957. doi: 10.1111/j.1447–0756.2010.01282.x.
Li, L., Liu, F., Zhang, H., Wang, L., & Chen X. (2011). Zubaran, C., Schumacher, M., Roxo, M. R., & Foresti, K.
Chinese version of the Postpartum Depression Screening (2010b). Screening tools for postpartum depression:
Scale: Translation and validation. Nursing Research, 60, Validity and cultural dimensions. African J. of Psychia-
231–239. doi: 10.1097/NNR.0b013e3182227a72. try, 13, 357–366.
Pereira, A. T., Bos, S., Marques, M., Maia, B. R., Soares, M. J., Zubaran, C., Foresti, K., Schumacher, M. V., Amoretti, A. L.,
Valente J., et al. (2010). The Portuguese version of the post- Thorell, M. R., & Müller, L. C. (2010c). The correlation
partum Depression Screening Scale. J. of Psychosomatic between postpartum depression and health status.
Obstetrics & Gynecology, 31, 90–100. doi: 10.3109/ Maternal Child Health Journal, 14, 751–757. doi: 10.1007/
0167482X.2010.481736. s10995–009–0512-z.
Pereira, A. T., Bos, S. C., Marques, M., Maia, B. R., Soares, M. Zubaran, C., & Foresti, K. (2011). Investigating quality of
J., Valente, J., et al. (2011). The Postpartum Depression life and depressive symptoms in the postpartum period.
Screening Scale: Is it valid to screen for antenatal Women and Birth, 24, 10–16.

35

CHAP TER



















Kristen M. Swanson
1953 to present


Theory of Caring


Danuta M. Wojnar



“Caring is a nurturing way of relating to a valued other toward
whom one feels a personal sense of commitment and responsibility”
(Swanson, 1991, p. 162).



master’s degree in nursing in 1978, she worked
Credentials and Background briefly as clinical instructor of medical-surgical
of the Theorist nursing at the University of Pennsylvania School of
Kristen M. Swanson, RN, PhD, FAAN, was born in Nursing and subsequently enrolled in the Ph.D. in
Providence, Rhode Island. She earned her baccalaure- nursing program at the University of Colorado in
ate degree (magna cum laude) from the University of Denver. There she studied psychosocial nursing
Rhode Island, College of Nursing in 1975. She began with an emphasis on the concepts of loss, stress,
her career as a registered nurse at the University of coping, interpersonal relationships, person and per-
Massachusetts Medical Center in Worcester, because sonhood, environments, and caring.
the founding nursing administration clearly articu- While a doctoral student, as part of a hands-on
lated a vision for professional nursing practice and experience with a self-selected health promotion
actively worked with nurses to apply these ideals activity, Swanson participated in a cesarean birth sup-
while working with clients (Swanson, 2001). port group focused on miscarriage. The guest speaker,
As a novice nurse, more than anything Swanson a physician, focused on pathophysiology and health
wanted to become a knowledgeable and technically problems prevalent after miscarriage, but women
skillful practitioner with a goal of teaching others. attending the meeting were more interested in talking
Hence, she pursued graduate studies in Adult about their personal experiences with pregnancy loss.
Health and Illness Nursing at the University of That day Swanson decided to learn more about the
Pennsylvania in Philadelphia. After receiving a human experience and responses to miscarrying.

688

CHAPTER 35 Kristen M. Swanson 689

Caring and miscarriage became the focus of her doc- Theoretical Sources
toral dissertation and subsequently her program of Swanson has drawn on various theoretical sources
research. while developing her Theory of Caring. She recalls
Swanson received an individually awarded National that from the beginning of her nursing career, her
Research Service postdoctoral fellowship from the education and clinical experience made her acutely
National Center for Nursing Research, which she aware of the profound difference caring made in the
completed under the direction of Dr. Kathryn E. lives of people she served:
Barnard at the University of Washington in Seattle. Watching patients move into a space of total depen-
She joined the faculty at the University of Washington dency and come out the other side restored was like
School of Nursing and continued her scholarly work witnessing miracles unfold. Sitting with spouses in
as professor and chairperson of the Department of the waiting room while they entrusted the heart
Family Child Nursing until summer 2009. In addi- (and lives) of their partner to the surgical team was
tion to teaching and administrative responsibilities awe inspiring. It was encouraging to observe the
at the University of Washington, She conducted re- inner reserves family members could call upon in
search funded by the National Institutes of Nursing order to hand over that which they could not con-
Research; published, mentored faculty and students, trol. It warmed my heart to be so privileged as to be
and served as a consultant at national and interna- invited into the spaces that patients and families
tional levels. She has been an invited speaker or created in order to endure their transitions through
visiting professor on multiple occasions, including illness, recovery, and, in some instances, death
Karolinska Institute in Sweden, IWK (Isaac Walton (Swanson, 2001, p. 412).
Killam) Health Centre, a tertiary care hospital for
women, children, and families in Halifax, Nova Scotia, Swanson credits several nursing scholars for insights
Canada, and, most recently, the National Cheng that shaped her beliefs about the nursing discipline and
Kung University in Taiwan, Taiwan. While at the influenced her program of research. She acknowledges
University of Washington in 2009, Swanson also Dr. Jacqueline Fawcett’s course on the conceptual basis
held the University of Washington Medical Center of nursing practice, which led her to understand the
Term Professorship in Nursing Leadership. differences between the goals of nursing and other
In 2009, Swanson was appointed Dean and health disciplines, and to realize that caring for others as
Alumni Distinguished Professor at the University of they go through life transitions of health, illness, heal-
North Carolina (UNC) School of Nursing at Chapel ing, and dying was congruent with her personal values
Hill and Associate Chief Nursing Officer for Aca- (Swanson, 2001). Swanson chose Dr. Jean Watson as
demic Affairs at UNC Hospitals. Dr. Swanson con- mentor during her doctoral studies. She attributes the
tinues her scholarship, which in recent years shifted emphasis on exploring the concept of caring in her doc-
to translational research and consulting with vari- toral dissertation to Dr. Watson’s influence. However,
ous organizations to enact the Theory of Caring in despite the close working relationship and emphasis on
clinical practice, education, and research. Her ser- caring in Swanson’s dissertation, Swanson’s program of
vice contributions include service on the editorial research on caring and miscarriage is not an application
board or reviewer for Journal of Nursing Scholarship, of Watson’s Theory of Human Caring (Watson, 1979,
Nursing Outlook, Research in Nursing and Health,and 1988, 1999). Instead, both Swanson and Watson assert
the International Journal of Human Caring. In recog- that compatibility of findings on caring in their indi-
nition of many outstanding contributions to the vidual programs of research adds credibility to their
nursing discipline, among other honors, Swanson theoretical assertions (Swanson, 2001). Swanson ac-
was inducted as a fellow in the American Academy of knowledges Dr. Kathryn E. Barnard for encouraging
Nursing in 1991, received a Distinguished Alumnus her transition from the interpretive to a contemporary
Award from the University of Rhode Island in 2002, empiricist paradigm and for transferring caring
and was selected as a fellow for the Robert Wood knowledge from her phenomenological investigations
Johnson Foundation Nurse Executive Fellows pro- to intervention research and clinical practice with
gram in 2004. women who have miscarried.

690 UNIT V Middle Range Nursing Theories

MAJOR CONCEPTS & DEFINITIONS
Caring comforting, performing skillfully and competently,
Caring is a nurturing way of relating to a valued and protecting the one cared for while preserving his
other toward whom one feels a personal sense of or her dignity (Swanson, 1991).
commitment and responsibility (Swanson, 1991).
Enabling
Knowing Enablingis facilitating the other’s passage through
Knowing is striving to understand the meaning of an life transitions and unfamiliar events by focusing
event in the life of the other, avoiding assumptions, on the event, informing, explaining, supporting,
focusing on the person cared for, seeking cues, as- validating feelings, generating alternatives, think-
sessing meticulously, and engaging both the one ing things through, and giving feedback (Swanson,
caring and the one cared for in the process of know- 1991).
ing (Swanson, 1991).
Maintaining Belief
Being With Maintaining belief is sustaining faith in the other’s
Being with means being emotionally present to the capacity to get through an event or transition and
other. It includes being there in person, conveying face a future with meaning, believing in other’s ca-
availability, and sharing feelings without burdening pacity and holding him or her in high esteem,
the one cared for (Swanson, 1991). maintaining a hope-filled attitude, offering realistic
optimism, helping to find meaning, and standing
Doing For by the one cared for no matter what the situation
Doing for means to do for others what one would do (Swanson, 1991).
for self if at all possible, including anticipating needs,




Use of Empirical Evidence mothers, fathers, physicians, and nurses who were
Swanson formulated her Theory of Caring induc- responsible for care of infants in the NICU. Hence,
tively, as a result of several investigations. For her she retained the wording that described the acts of
doctoral dissertation, using descriptive phenomenol- caring and proposed that all-inclusive care in a com-
ogy, she analyzed data from in-depth interviews with plex environment embraces balance among caring
20 women who had recently miscarried. As a result of (for the self and the one cared for), attaching (to oth-
this phenomenological investigation, Swanson pro- ers and roles), managing responsibilities (assigned by
posed two models: (1) The Caring Model, and (2) The self, others, and society), and avoiding bad outcomes
Human Experience of Miscarriage Model. The Caring (Swanson, 1990).
Model proposed five basic processes (knowing, being In a subsequent phenomenological investigation
with, doing for, enabling, and maintaining belief) that conducted with socially at-risk mothers, Swanson
give meaning to acts labeled as caring (Swanson- (1991) explored what it had been like for these
Kauffman, 1985, 1986, 1988a, 1988b). This was foun- mothers to receive an intense, long-term nursing
dational for Swanson’s (1991) middle-range Theory of intervention. Swanson recalls that after this study
Caring. she was finally able to define caring and refine the
While a postdoctoral fellow, Swanson conducted understanding of caring processes. Collectively,
a phenomenological study, exploring what it was like phenomenological inquiries with women who mis-
to be a provider of care to vulnerable infants in the carried, caregivers in the NICU, and socially at-risk
neonatal intensive care unit (NICU). Swanson (1990) mothers formed a basis for expansion of the Caring
discovered that the caring processes she identified Model into the middle-range Theory of Caring
with women who miscarried were also applicable to (Swanson, 1991, 1993).

CHAPTER 35 Kristen M. Swanson 691

Swanson tested her Theory of Caring with women • The fourth domain refers to actions of caring.
who miscarried in investigations funded by the National • The fifth domain refers to the consequences or the
Institutes of Nursing Research and other funding intentional and unintentional outcomes of caring
sources. Swanson’s (1999a, 1999b) intervention research for both the client and the provider (Swanson,
(N 5 242) examined the effects of caring-based coun- 1999c).
seling sessions on women coming to terms with loss Conducting the literary metaanalysis clarified the
and emotional well-being during the first year after meaning of the concept of caring as it is used in the
miscarrying. Additional aims were examination of the nursing discipline and validated the transferability of
effects of passage of time on healing during that first Swanson’s middle-range Theory of Caring beyond
year and development of strategies to monitor caring perinatal context.
interventions. This study established that passing of Subsequently, Swanson authored or coauthored
time had positive effects on women’s healing after mis- numerous scholarly articles and book chapters on
carriage, however, caring interventions had a positive application of caring-healing relationships in clinical
impact on decreasing the overall disturbed mood, an- practice and education or tested the theory of caring.
ger, and level of depression. The second aim was to Swanson coauthored an article on nursing’s historical
monitor the caring variable and determine if caring was legacy as a caring—healing profession, and the mean-
delivered as intended. To do so, caring was monitored ing, significance, and consequences of optimal healing
in the following three ways: environments for modern nursing practice, education,
1. Approximately 10% of counseling sessions were and research (Swanson & Wojnar, 2004).
transcribed and data were analyzed using inductive The article presented the core foci of nursing as a
and deductive content analysis. discipline: what it means to be a person and experi-
2. Before each caring session, the counselor com- ence personhood; the meaning of health at the indi-
pleted McNair, Lorr, and Droppleman’s (1981) vidual, family, and societal levels; how environments
Profile of Mood States to monitor whether the create or diminish the potential for the promotion,
counselor’s mood was associated with women’s maintenance, or restoration of well-being; and the
ratings of caring after each session, using an inves- caring-healing therapeutics of nursing. A book
tigator-developed Caring Professional Scale. chapter followed toenhance nurses’ capacity for com-
3. After each session, the counselor completed an passionate caring (Swanson, 2007). In it, Swanson
investigator-developed Counselor Rating Scale and explored how caring matters to well-being of every
took narrative notes about her own counseling. person and described conditions that impact quality
The most noteworthy finding of monitoring caring of nurse caring ranging from the interpersonal rela-
was that clients were highly satisfied with caring re- tionships through physical environments, to execu-
ceived during counseling sessions, suggesting caring tive/managerial leadership. Swanson’s coauthored
was delivered and received as intended. works focused on social and economic factors that
Swanson’s (1999c) subsequent investigation was a affect nursing shortage and quality of care (Grant &
literary metaanalysis on caring. An in-depth review of Swanson, 2006) and consumer satisfaction with
130 investigations on caring led Swanson to propose health care (Mowinski-Jennings, Heiner, Loan, et al.,
that knowledge about caring may be categorized into 2005). Swanson and colleagues also explored comple-
five hierarchical domains (levels), and research con- mentary and alternative medicine (CAM) attitudes
ducted in any one domain assumes the presence of all and competencies of nursing students and faculty and
previous domains (Swanson, 1999c). the results of integrating CAM into the nursing cur-
• The first domain refers to the persons’ capacities to riculum as a holistic approach to nursing (Booth-
deliver caring. Laforce, Scott, Heitkemper, et al., 2010).
• The second domain refers to individuals’ concerns In her own program of research, Swanson tested
and commitments that lead to caring actions. the usability of the Theory of Caring. In 2003, Swanson
• The third domain refers to the conditions (nurse, and colleagues published results from an investiga-
client, organizational) that enhance or diminish tion on the miscarriage effects on interpersonal and
the likelihood of delivering caring. sexual relationships during the first year after loss

692 UNIT V Middle Range Nursing Theories

from women’s perspective and investigated the context Researchers concluded that applying the Theory of
and evolution of women’s responses to miscarriage Caring in clinical practice is an effective strategy to
during the first year after loss (Swanson, Connor, promote healing after unexpected pregnancy loss for
Jolley, et al., 2007). In 2009, Swanson and her women and men as individuals and as couples.
research team published results of a funded inter- Swanson continues to contribute to research of
vention study called Couples Miscarriage Healing other scholars. In 2006, Wojnar and Swanson ex-
Project. The purpose was to better understand the plored why lesbian mothers should deserve special
effects of miscarriage on men and women as indi- consideration when it comes to healing after miscar-
viduals and as couples, to explore the effects of mis- riage. As a result, Wojnar, Swanson, and Adolfsson
carriage on couple relationships, and to identify best (2011) offered a revised conceptual model of miscar-
ways of helping men and women heal as individuals riage inclusive of lesbian population for clinical
and as couples after unexpected pregnancy loss. practice and research. Swanson coauthored findings
Study participants (341 heterosexual couples) were from an investigation that explored soldiers’ experi-
randomly assigned to control or one of the follow- ences with military health care (Jennings, Loan,
ing three treatment groups: (1) nurse caring, which Heiner, et al., 2005). Findings suggest that quality of
entailed attending three counseling sessions with a care for soldiers is improved by narrowing the gap
nurse, (2) self-caring, which involved completing between what is offered for them as consumers and
three videos and workbooks, or (3) combined caring, what they experience when they seek care. Most
which involved attending one nurse caring session recently, Swanson coauthored results from a study
and completion of three videos and workbooks, that explored the experiences of parents following
to determine the most effective way of supporting moderate to severe traumatic brain injury of their
couples after miscarriage. Interventions, based on child (Roscigno & Swanson, 2011) as well as the
Swanson’s Theory of Caring and Meaning of Miscar- quality of life for children following traumatic brain
riage Model, were offered at 1, 5, and 11 weeks after injury (Roscigno, Swanson, Solchany, et al., 2011),
enrollment. Outcomes included depression (CES-D) where participants described health and cultural
and grief, pure grief (PG), and grief-related emo- barriers leading to misunderstandings that could be
tions (GRE). Differences in rates of recovery were easily avoided.
estimated via multilevel modeling conducted in a Swanson’s Theory of Caring has been validated for
Bayesian framework. Bayesian odds (BO) ranging a wide range of usage in research, education, and
from 3.0 to 7.9 showed that nurse caring was most clinical practice.
effective for accelerating women’s resolution of de-
pression. BO of 3.2 to 6.6 favored nurse caring inter-
vention and no treatment over self, and combined Major Assumptions
caring for resolving men’s depression. BO of 3.1 to In 1993, Swanson further developed her theory of
7.0 favored all three interventions over no treatment informed caring by making her major assumptions
for accelerating women’s grief resolution, and BO of explicit about the four main phenomena of concern
18.7 to 22.6 favored nurse caring and combined car- to the nursing discipline: nursing, person/client, health,
ing over self-caring or no treatment for resolving and environment.
men’s grief. BO ranging from 2.4 to 6.1 favored
nurse-caring and self caring over combined caring Nursing
or no treatment for promoting women’s resolution of Swanson (1991, 1993) defines nursing as informed
grief-related emotions. BO from 3.5 to 17.9 favored caring for the well-being of others. She asserts that the
nurse caring, combined caring, and control over nursing discipline is informed by empirical knowledge
self-caring for resolving men’s grief emotions. Nurse- from nursing and other related disciplines, as well as
caring had the overall most positive impact on cou- “ethical, personal and aesthetic knowledge derived
ples’ resolution of grief and depression. In addition, from the humanities, clinical experience, and personal
grief resolution was accelerated by self-caring for and societal values and expectations” (Swanson, 1993,
women and combined caring intervention for men. p. 352).

CHAPTER 35 Kristen M. Swanson 693
Person creativity, relatedness, femininity, masculinity,
Swanson (1993) defines persons as “unique beings and sexuality, to name just a few” (p. 353).
who are in the midst of becoming and whose whole-
ness is made manifest in thoughts, feelings, and be- Thus, Swanson sees reestablishing well-being as a
haviors” (p. 352). She posits that the life experiences of complex process of curing and healing that includes
each individual are influenced by a complex interplay “releasing inner pain, establishing new meanings, re-
of “a genetic heritage, spiritual endowment and the storing integration, and emerging into a sense of re-
capacity to exercise free will” (Swanson, 1993, p. 352). newed wholeness” (Swanson, 1993, p. 353).
Hence, persons both shape and are shaped by the
environment in which they live. Environment
Swanson (1993) views persons as dynamic, grow- Swanson (1993) defines environment by situation. She
ing, self-reflecting, yearning to be connected with maintains that for nursing it is “any context that influ-
others, and spiritual beings. She suggests the follow- ences or is influenced by the designated client” (p. 353).
ing: “ . . . spiritual endowment connects each being to Swanson states that there are many kinds of influences
an eternal and universal source of goodness, mystery, on environment, such as the cultural, social, biophysi-
life, creativity, and serenity. The spiritual endowment cal, political, and economic realms, to name only a few.
may be a soul, higher power/Holy Spirit, positive According to Swanson (1993), the terms environment
energy, or, simply grace. Free will equates with choice and person-client in nursing may be viewed inter-
and the capacity to decide how to act when confronted changeably. For example, Swanson posits, “for heuristic
with a range of possibilities” (p. 352). Swanson (1993) purposes the lens on environment/designated client
noted, however, that limitations set by race, class, may be specified to the intra-individual level, wherein
gender, or access to care might prevent individuals the ‘client’ may be at the cellular level and the environ-
from exercising free will. Hence, acknowledging ment may be the organs, tissues or body of which the
free will mandates nursing discipline to honor indi- cell is a component” (p. 353). Therefore, what is consid-
viduality and consider a whole range of possibilities ered an environment in one situation may be consid-
that are acceptable or desirable to those whom the ered a client in another.
nurses attend.
Moreover, Swanson posits that the other, whose
personhood nursing discipline serves, refers to fam- Theoretical Assertions
ilies, groups, and societies. Thus, with this under- Swanson’s Theory of Caring (Swanson, 1991, 1993,
standing of personhood, nurses are mandated to 1999b) was empirically derived through phenomeno-
take on leadership roles in fighting for human rights, logical inquiry. It offers a clear explanation of what it
equal access to health care, and other humanitarian means for nurses to practice in a caring manner and
causes. Lastly, when nurses think about the other to emphasizes that the goal of nursing is promotion of
whom they direct their caring, they also need to well-being. Swanson (1991) defines caring as “a nur-
think of self and other nurses and their care as that turing way of relating to a valued other toward whom
cared-for other. one feels a personal sense of commitment and respon-
sibility” (p. 162).
Health According to Swanson, a fundamental and univer-
According to Swanson (1993), to experience health sal component of good nursing is caring for the
and well-being is: client’s biopsychosocial and spiritual well-being.
Swanson (1993) asserts that caring is grounded
“ . . . to live the subjective, meaning-filled experi- in maintenance of a basic belief in human beings,
ence of wholeness. Wholeness involves a sense of supported by knowing the client’s reality, conveyed
integration and becoming wherein all facets of by being emotionally and physically present, and
being are free to be expressed. The facets of being enacted by doing for and enabling the client. The car-
include the many selves that make us a human: ing processes overlap and may not exist in separation.
our spirituality, thoughts, feelings, intelligence, Each is an integral component of the overarching

694 UNIT V Middle Range Nursing Theories

The Structure of Caring

( )

Client
Maintaining Knowing Being Doing Enabling well-
belief with for being




Philosophical attitudes Informed understanding Message Therapeutic Intended
towards persons (in of the clinical condition (in conveyed actions outcome
general) and the desig- general) and the situation to client
nated client (in specific) and client (in specific)
FIGURE 35-1 The structure of caring as linked to the nurse’s philosophical attitude, informed under-
standings, message conveyed, therapeutic actions, and intended outcome. (From Swanson, K. M. [1993].
Nursing as informed caring for the well-being of others. Image: The Journal of Nursing Scholarship, 25[4],
352–357.)





structure of caring (Figure 35–1). Swanson (1993) who received long-term care from master’s-prepared
has noted that the repertoire of caring therapeutics nurses. Swanson claims that her in-depth meta-
of novice nurses might be limited and restricted by analysis of research on caring has supported the
inexperience. Conversely, the techniques and knowl- generality of her theory beyond a perinatal context
edge imbedded in caring of experienced nurses are (Swanson, 1999c).
elaborate and subtle, so caring might go unnoticed
by an uninformed observer. Yet, Swanson (1993) Acceptance by the Nursing Community
asserts that, regardless of the years of nursing experi-
ence, caring is delivered as a set of sequential pro- Practice
cesses (subconcepts) created by the nurse’s own The usefulness of Swanson’s Theory of Caring has
philosophical attitude (maintaining belief), under- been demonstrated in research, education, and clini-
standing (knowing), verbal and nonverbal messages cal practice. The proposition that caring is central to
conveyed to the client (being with), therapeutic ac- nursing practice had its beginning in the theorist’s
tions (doing for and enabling), and the consequences own insights into the importance of caring in profes-
of caring (intended client outcome). sional nursing practice and in findings from Swanson’s
phenomenological investigations. Her subsequent in-
vestigations demonstrated applicability of the Theory
Logical Form of Caring in clinical nursing practice, education, and
Swanson’s middle-range Theory of Caring was devel- research. Swanson’s theory has been embraced as a
oped empirically using an inductive approach. Chinn framework for professional nursing practice in the
and Kramer (2011) note, “With induction people United States, Canada, and Sweden. An example is the
induce hypotheses and relationships by observing or Dalhousie University School of Nursing in Halifax,
experiencing an empiric reality and reaching some Nova Scotia, Canada, which selected Swanson’s
conclusion” (p. 182). Swanson’s theory was generated Theory of Caring to guide the development of future
from phenomenological investigations with women generations of nurses as caring professionals. Likewise,
who experienced unexpected pregnancy loss, caregiv- nurses at IWK (Isaac Walton Killam) Health Centre,
ers of premature and ill babies in the newborn inten- a tertiary care hospital for women, children, and
sive care unit (NICU), and socially at-risk mothers families in Halifax, Nova Scotia, have recognized the

CHAPTER 35 Kristen M. Swanson 695

traditional legacy of nursing as a caring-healing who have experienced unexpected pregnancy loss.
discipline and the concepts in Swanson’s theory Recent review of computerized databases (MEDLINE,
as applicable in practice. Since 1998, the Nursing CINHAL, and Digital Dissertations) indicated that
Practice Council at IWK used Swanson’s Theory of Swanson’s work on caring and miscarriage has been
Caring as their framework for professional nursing cited or otherwise utilized in over 160 data-based pub-
practice. lications. Examples of applications of Swanson’s The-
Nurse caring is manifested in different ways and ory of Caring in clinical research include exploring
practice contexts. For example, in a postpartum con- clinical scholarship in practice (Kish & Holder, 1996);
text, demonstration of a baby bath to new parents guidelines for nurses working with patients diagnosed
incorporates all five caring processes. The act involves with multiple sclerosis (Yorkston, Klasner, & Swanson,
being with by demonstrating bathing the newborn to 2001); assessing the impact of caring in work with
the parents. The unrushed timing of the bath so the vulnerable populations (Kavanaugh, Moro, Savage,
infant is awake and parents are present conveys will- et al., 2006); the importance of creating a caring envi-
ingness (doing for or enabling); and the observing, ronment for older adults (Sikma, 2006); Wojnar’s (2007)
querying, and involving parents in the task engages study of lesbian couples who miscarried; and Roscigno’s
them in their own infant’s care (intended outcome) research of children who sustained traumatic brain
while acknowledging that they are perfectly capable injury (Roscigno & Swanson, 2011; Roscigno, Swanson,
of caring for their new child and that their preferences Solchany, et al., 2011).
matter (knowing and maintaining belief). In carrying
out this seemingly simple act, the nurse creates an
optimal environment for learning that enables new Further Development
parents to make decisions about infant care, while Swanson is interested in further development by test-
leveraging the task as an opportunity to engage in a ing and applying her theory in clinical practice. There
meaningful social encounter and developing a trust- is much potential for further development by testing
ing relationship. Swanson’s Theory of Caring in various contexts of
health and illness. Also, her processes of caring suggest
Education that the theory is applicable in other helping disciplines
Humane and altruistic caring occurs when the theory such as teaching, social work, and medicine as well as
is used in various practice areas such as feeding or other life situations for nursing.
grooming an incapacitated older adult, monitoring
and managing the recovery of a patient who suffered Critique
a stroke, or enhancing infant care skills of new par-
ents. Nurse caring, as demonstrated by Swanson in Clarity
research with women who miscarried, caregivers in The concept of caring and caring processes (knowing,
the NICU, and socially at-risk mothers, recognizes being with, doing for, enabling, and maintaining belief)
the importance for nurses to attend to the wholeness that are central to the theory are clearly defined and
of humans in their everyday lives. Thus Swanson’s arranged in a logical sequence that describes the pro-
theory offers nurse educators a simple way of initiat- cesses of caring delivery. Swanson’s theory offers clear
ing students into the profession by immersing them definitions and contextual linkages with the concepts
in the language of what it means to be caring and of the nursing discipline (person, nurse, environment,
cared for in order to promote, restore, or maintain the and health) in nurse-client interactions, thus further
optimal wellness of individuals. explicating the definitions.

Research Simplicity
Swanson has persisted in the development of her the- A simple theory has a minimal number of concepts.
ory, describing and defining the concept of caring and Swanson’s Theory of Caring is simple yet elegant. It
basic caring processes, instrument development, and brings the importance of caring to the forefront and
testing in intervention research with women and men exemplifies the discipline’s values. The main purpose

696 UNIT V Middle Range Nursing Theories

of the theory is to foster delivery of nursing care fo- beyond nurse-client encounters. Recent applications
cused on the needs of the individuals while fostering in clinical nursing practice show tangible positive re-
their dignity, respect, and empowerment. Simplicity sults. For example, since coming to the UNC School
and consistent language used to define the concepts of Nursing at Chapel Hill as Dean, Swanson has
and processes allows students and nurses to under- focused on intensifying the linkages among nursing
stand and apply Swanson’s theory in their practice. education, research, and practice. In partnership with
Clinical Professor Dr. Mary Tonges, Chief Nursing
Generality Officer and Senior Vice President for Patient Care
Swanson’s Theory of Caring may be applied in re- Services at UNC Hospital, Swanson has worked on
search and clinical work with diverse populations. strengthening the scholarship that supports nursing
The conditions essential for delivering caring that practice and enhances the relevance of nursing educa-
promotes individuals’ wholeness across the life span tion and research to clinical practice through quality
have been described clearly (Swanson, 1999c). Hence, improvement projects. This research partnership has
the theory is generalizable to nurse-client relation- already resulted in positive outcomes on nursing
ships in many clinical settings. workplace satisfaction and patient safety. Likewise,
Swanson’s Theory of Caring has been applied in clini-
Accessibility cal practice and evaluated on selected variables at
Swanson’s Theory of Caring concepts and assump- Virginia Mason Medical Center in Seattle, Washing-
tions are grounded in clinical nursing practice and ton, resulting in positive outcomes for patients and
research using an empirical approach. The com- nurses.
pleteness and simplicity of operational definitions
strengthen empirical precision of this theory. Swan-
son and others have successfully applied her theory CASE STUDY
in numerous studies. Swanson and her research 1. The birth of a child is one of the most memo-
team tested the Theory of Caring in a clinical trial rable experiences in a woman’s life. You are a
with women and men who experienced miscar- birth unit nurse, and at the change of a shift
riage and demonstrated that caring intervention you are assigned to care for a teen mother
resulted in decreased depressive mood and facili- who came to hospital alone and is now in
tated healthy grieving for both genders. Swanson active labor. When you arrive in her room,
has published research guidelines with colleagues you notice that she is teary and appears
for assessing the impact of caring healing relation- frightened. Describe how you would apply
ships in clinical nursing (Quinn, Smith, Ritenbaugh, Swanson’s theory to connect emotionally and
et al., 2003) and developed self-report instruments deliver caring in your practice with this
to measure caring as delivered by health care pro- young mother.
fessionals and by couples to each other (Swanson, 2. A 56 year old obese man presents in the out-
2002). The template for delivering caring-based in- patient clinic. He is experiencing polydipsia
terventions and the research-based instruments and polyuria for over a week. He also reports
open possibilities for use and further testing with a weight loss of 5 kg in the past few weeks.
other populations.
He delayed his clinic visit for as long as
Importance possible because he feared he may have
Swanson’s Theory of Caring describes nurse-client diabetes like his father and was afraid to face
the reality. You check his sugar level and it is
relationships that promote wholeness and healing. The 430. The man bursts into tears. Describe how
theory offers a framework for enhancing contempo- you would apply Swanson’s theory to help the
rary nursing practice, education, and research while client face the diagnosis of chronic disease,
bringing the discipline to its traditional values and cope with the disease process, and promote
caring-healing roots. Swanson’s Theory of Caring has well-being?
been applied to interdisciplinary caring relationships

CHAPTER 35 Kristen M. Swanson 697

CRITICAL THINKING ACTIVITIES
1. Consider Swanson’s Theory of Caring as a frame- 3. Think about an interaction with a client-family
work for your own nursing practice and research. in your clinical practice that you wish you could
How is it applicable? change or improve. Use the processes of the
2. Think about a time when you felt that someone Theory of Caring to critically assess about where
cared about you deeply. Remember what it felt like you might have made more appropriate actions. If
to experience caring. Now reflect on that experi- it were possible to improve this interaction, what
ence and review your experience in the context of would you change and why?
the processes of caring in Swanson’s theory.

POINTS FOR FURTHER STUDY
n Swanson, K. M. (1998). Caring made visible. nursing research (pp. 31–60). Thousand Oaks, (CA):
Creative Nursing, 4(4), 8–11, 16. Sage.
n Swanson, K. M. (1999a). Research-based practice n Swanson, K. M., & Wojnar, D. (2004). Optimal
with women who have had miscarriages. Image: healing environments in nursing. Journal of
The Journal of Nursing Scholarship, 31(4), Alternative and Complementary Medicine,
339–345. 10(1), 43–48.
n Swanson, K. M. (1999b). The effects of caring, n Swanson, K. M., Chen, H. T., Graham, J. C.,
measurement, and time on miscarriage impact Wojnar, D. M., & Petras, A. (2009). Resolution
and women’s well-being in the first year subse- of depression and grief during the first year after
quent to loss. Nursing Research, 48(6), 288–298. miscarriage: A randomized controlled clinical
n Swanson, K. M. (1999c). What’s known about caring trial of couples-focused interventions. Journal
in nursing: A literary meta-analysis. In A. S. Hinshaw, of Women’s Health and Gender-based Medicine,
J. Shaver, & S. Feetham (Eds.), Handbook of clinical 18(8), 1245–1257.

REFERENCES
Booth-Laforce C., Scott C. S., Heitkemper M. M., Kish, C. P., & Holder, L. M. (1996). Helping to say good-
Cornman B. J., Bond E. F., & Swanson K. M. bye: Merging clinical scholarship with community
(2010). Complementary and alternative medicine service. Holistic Nursing Practice, 10(3), 74–82.
(CAM) attitudes and competencies of nursing McNair, D. M., Lorr, M., & Droppleman, L. F. (1981).
students and faculty: Results of integrating CAM Profile of mood states: Manual. San Diego: Educational
into nursing curriculum. Journal of Professional and Industrial Testing Service.
Nursing, 26(5), 293–300. doi:10.1016/j.profnurs.2010. Mowinski-Jennings, B. M., Heiner, S. L., Loan, L. A.,
03.003. Hemman, E. A., & Swanson, K. M. (2005). What really
Chinn, P. L., & Kramer, M. (2011). Integrated knowledge matters to health care consumers. Journal of Nursing
development in nursing (8th ed.). Maryland Heights, Administration, 35(4), 173–180.
(MO): Mosby-Elsevier. Quinn, J., Smith, M., Ritenbaugh, C., & Swanson, K. M.
Grant, S., & Swanson, K. M. (2006). Steaming the tide of (2003). Research guidelines for assessing the impact of
the nursing shortage. The CERNER Quarterly, 2(2), the healing relationship in clinical nursing. Alternative
34–35. Therapies, 9(31), 69–79.
Jennings, B. M., Loan, L. A., Heiner, S. L., Hemman, E. A., Roscigno C. I., & Swanson K. M. (2011). Parent’s experi-
& Swanson, K. M. (2005). Soldiers’ experiences with ences following children’s moderate to severe traumatic
military health care. Military Medicine, 170(12), brain injury: A clash of cultures. Qualitative Health
999–1004. Research, 21(10), 1413–1426.
Kavanaugh, K., Moro, T. T., Savage, T., & Mehendale, R. Roscigno C. I., Swanson K. M., Solchany J., & Vavilala M.
(2006). Enacting a theory of caring to recruit and (2011). Children’s longing for everydayness: Life fol-
retain vulnerable populations for sensitive research. lowing traumatic brain injury in the USA. Brain Injury,
Research in Nursing and Health, 29(3), 244–252. 25(9), 882–894.

698 UNIT V Middle Range Nursing Theories

Sikma, S. (2006). Staff perceptions of caring. The importance responses to miscarriage during the first year after loss.
of a supportive environment. Journal of Gerontological Research in Nursing and Health, 30(1), 2–16.
Nursing, 32(6), 22–29. Swanson, K. M., & Wojnar, D. (2004). Optimal healing
Swanson, K. M. (1990). Providing care in the NICU: environments in nursing. Journal of Alternative and
Sometimes an act of love. Advances in Nursing Science, Complementary Medicine, 10(1), 43–48.
13(1), 60–73. Swanson-Kauffman, K. M. (1985). Miscarriage: A new
Swanson, K. M. (1991). Empirical development of a mid- understanding of the mother’s experience. Proceedings
dle range theory of caring. Nursing Research, 40(3), of the 50th Anniversary Celebration of the University of
161–166. Pennsylvania School of Nursing, 63–78.
Swanson, K. M. (1993). Nursing as informed caring for the Swanson-Kauffman, K. M. (1986). Caring in the instance
well-being of others. Image: The Journal of Nursing of unexpected early pregnancy loss. Topics in Clinical
Scholarship, 25(4), 352–357. Nursing, 8(2), 37–46.
Swanson, K. M. (1999a). Research-based practice with Swanson-Kauffman, K. M. (1988a). The caring needs of
women who have had miscarriages. Image: The Journal women who miscarry. In M. M. Leininger (Ed.), Care,
of Nursing Scholarship, 31(4), 339–345. discovery and uses in clinical and community nursing
Swanson, K. M. (1999b). The effects of caring, measure- (pp. 55–71). Detroit: Wayne State University Press.
ment, and time on miscarriage impact and women’s Swanson-Kauffman, K. M. (1988b). There should have
well-being in the first year subsequent to loss. Nursing been two: Nursing care of parents experiencing the
Research, 48(6), 288–298. perinatal death of a twin. Journal of Perinatal and
Swanson, K. M. (1999c). What’s known about caring in Neonatal Nursing, 2(2), 78–86.
nursing: A literary meta-analysis. In A. S. Hinshaw, J. Watson, J. (1979). Nursing: The philosophy and science
Shaver, & S. Feetham (Eds.), Handbook of clinical nurs- of caring. Boston: Little, Brown.
ing research (pp. 31–60). Thousand Oaks, (CA): Sage. Watson, J. (1988). New dimensions of human caring
Swanson, K. M. (2001). A program of research on caring. theory. Nursing Science Quarterly, 1, 175–181.
In M. E. Parker (Ed.), Nursing theories and nursing Watson, J. (1999). Nursing: Human science and human
practice (pp. 411–420). Philadelphia: F. A. Davis. care: A theory of nursing. Sudbury, (MA): Jones &
Swanson, K. M. (2002). Caring Professional Scale. In Bartlett.
J. Watson (Ed.), Assessing and measuring caring in nursing Wojnar, D. M. (2007). Miscarriage experiences of lesbian
and health science (pp. 203–206). New York: Springer. birth and social mothers: Couples’ perspective: Journal
Swanson, K. M. (2007). Enhancing nurses’ capacity for of Midwifery and Women’s Health, 52(5), 479–485.
compassionate caring. In M. Koloroutis, J. Felgen, Wojnar, D., & Swanson, K. M.(2006). Why shouldn’t
C. Person, & S. Wessel (Eds), Relationship-Based Care lesbian women who miscarry receive equal consider-
Field Guide (pp. 502–507). Minneapolis: Creative Help ation? A viewpoint. Journal of GLBT Family Studies,
Care Management. 2(1), 1–12.
Swanson, K. M., Chen, H. T., Graham, J. C., Wojnar, D. M., Wojnar, D., Swanson, K. M., & Aldofsson, A. (2011).
& Petras, A. (2009). Resolution of depression and grief Confronting the inevitable: A conceptual model of
during the first year after miscarriage: A randomized miscarriage for use in clinical practice and research.
controlled clinical trial of couples-focused interven- Death Studies, 35(6), 536–558.
tions. Journal of Women’s Health and Gender-based Yorkston, K. M., Klasner, E. R., & Swanson, K. M. (2001).
Medicine, 18(8),1245–1257. Communication in multiple sclerosis: Understanding
Swanson, K. M., Connor, S., Jolley, S., Pettinato, M., & the insider’s perspective. American Journal of Speech
Wang, T. J. (2007). Context and evolution of women’s Language Pathology, 10, 126–137.


BIBLIOGRAPHY
Primary Sources balancing act: Having it all. Health Care of Women
Book Chapters International, 8[2–3], 101–108.)
Swanson-Kauffman, K. M. (1987). Overview of the balancing Swanson-Kauffman, K. M. (1988). The caring needs of
act: Having it all. In K. Swanson-Kauffman (Ed.), Women’s women who miscarry. In M. M. Leininger (Ed.), Care,
work, families and health. New Yark: Hemisphere. (Reprint discovery and uses in clinical and community nursing
of Swanson-Kauffman, K. M. [1987]. Overview of the (pp. 55–71). Detroit: Wayne State University Press.

CHAPTER 35 Kristen M. Swanson 699

Swanson-Kauffman, K. M., & Roberts, J. (1990). Caring following traumatic brain injury in the USA. Brain
in parent and child nursing. In Knowledge about care Injury, 25(9), 882–894.
and caring: State of the art and future development. Swanson-Kauffman, K. M. (1981). Echocardiography: An
Washington, DC: American Academy of Nursing. access route to the heart. Critical Care Nurse, 1(6),
Swanson-Kauffman, K. M., & Schonwald, E. (1988). 20–26.
Phenomenology. In B. Sarter (Ed.), Paths to knowledge: Swanson-Kauffman, K. M. (1986). A combined qualitative
Innovative research methods for nursing (pp. 97–105). methodology for nursing research. Advances in Nursing
New York: National League for Nursing. Science, 8(3), 58–69.
Swanson, K. M. (1992). Foreword. In S. Wheeler & M. Pike Swanson-Kauffman, K. M. (1986). Caring in the instance
(Eds.), Grief ltd. manual. Covington, (IN): Grief Limited. of unexpected early pregnancy loss. Topics in Clinical
Swanson, K. M. (1999c). What’s known about caring in nurs- Nursing, 8(2), 37–46.
ing: A literary meta-analysis. In A. S. Hinshaw, J. Shaver, Swanson-Kauffman, K. M. (1987). Overview of the balancing
& S. Feetham (Eds.), Handbook of clinical nursing research act: Having it all. Health Care for Women International,
(pp. 31–60). Thousand Oaks, (CA): Sage. 8(2–3), 1–8.
Swanson, K. M. (2001). A program of research on caring. Swanson-Kauffman, K. M. (1988). There should have been
In M. E. Parker (Ed.), Nursing theories and nursing two: Nursing care of parents experiencing the perinatal
practice (pp. 411–420). Philadelphia: F. A. Davis. death of a twin. Journal of Perinatal and Neonatal
Swanson, K. M. (2002). Caring Professional Scale. In J. Watson Nursing, 2(2), 78–86.
(Ed.), Assessing and measuring caring in nursing and health Swanson, K. M. (1990). Providing care in the NICU:
science (pp. 203–206). New York: Springer. Sometimes an act of love. Advances in Nursing Science,
Swanson, K. M. (2007). Enhancing nurses’ capacity for 13(1), 60–73.
compassionate caring. In M. Koloroutis, J. Felgen, C. Swanson, K. M. (1991). Empirical development of a middle
Person, & S. Wessel (Eds). Relationship-based care field range theory of caring. Nursing Research, 40(3), 161–166.
guide. Minneapolis: Creative Help Care Management, Swanson, K. M. (1993). Commentary: The phenomena of
pp. 502–507. doing well in people with AIDS. Western Journal of
Nursing Research, 15(1), 56.
Journal Articles Swanson, K. M. (1993). Nursing as informed caring for the
Booth-Laforce C., Scott C. S., Heitkemper M. M., Cornman B. J., well-being of others. Image: The Journal of Nursing
Bond E. F., & Swanson K. M. (2010). Complementary and Scholarship, 25(4), 352–357.
alternative medicine (CAM) attitudes and competencies of Swanson, K. M. (1995). Commentary, the power of human
nursing students and faculty. Results of integrating CAM caring: Early recognition of patient problems. Scholarly
into nursing curriculum. Journal of Professional Nursing, Inquiry for Nursing Practice, 9(4), 319–321.
26(5), 293–300. doi:10.1016/j.profnurs.2010.03.003. Swanson, K. M. (1998). Caring made visible. Creative Nursing,
Grant, S., & Swanson, K. M. (2006). Steaming the tide of the 4(4), 8–11, 16.
nursing shortage. The CERNER Quarterly, 2(2), 34–35. Swanson, K. M. (1999). Research-based practice with
Jennings, B. M., Loan, L. A., Heiner, S. L., Hemman, E. A., & women who have had miscarriages. Image: The Journal
Swanson, K. M. (2005). Soldiers’ experiences with military of Nursing Scholarship, 31(4) 339–345.
health care. Military Medicine, 170(12), 999–1004. Swanson, K. M. (1999). The effects of caring, measure-
Mowinski-Jennings, B. M., Heiner, S. L., Loan, L. A., ment, and time on miscarriage impact and women’s
Hemman, E. A., & Swanson, K. M (2005). What really well-being in the first year subsequent to loss. Nursing
matters to health care consumers. Journal of Nursing Research, 48(6), 288–298.
Administration, 35(4), 173–180. Swanson, K. M. (2000). Predicting depressive symptoms
Quinn, J., Smith, M., Ritenbaugh, C., & Swanson, K. M. after miscarriage: A path analysis based on Lazarus’
(2003). Research guidelines for assessing the impact of paradigm. Journal of Women’s Health & Gender-Based
the healing relationship in clinical nursing. Alternative Medicine, 9(2), 191–206.
Therapies, 9(31), 69–79. Swanson, K. M., Chen, H. T., Graham, J. C., Wojnar, D. M.,
Roscigno C. I., & Swanson K. M. (2011). Parent’s experiences & Petras, A. (2009). Resolution of depression and grief
following children’s moderate to severe traumatic brain during the first year after miscarriage: A randomized
injury: A clash of cultures. Qualitative Health Research, controlled clinical trial of couples-focused interven-
21(10), 1413–1426. tions. Journal of Women’s Health and Gender-based
Roscigno C. I., Swanson K. M., Solchany J., & Vavilala M. Medicine, 18(8), 1245–1257.
(2011). Children’s longing for everydayness: Life

700 UNIT V Middle Range Nursing Theories

Swanson, K.M., Connor, S., Jolley, S., Pettinato, M., & Swanson, K. M. (1993). Caring theory: Structure and
Wang, T.J. (2007). Context and evolution of women’s assumptions (Abstract). Communicating Nursing
responses to miscarriage during the first year after loss. Research, 26, 255.
Research in Nursing and Health, 30(1), 2–16. Swanson, K. M. (1995). Effects of caring on healing post
Swanson, K. M., Karmali, Z., Powell, S., & Pulvermakher, miscarriage (Abstract). Communicating Nursing
F. (2003). Miscarriage effects on couples’ interpersonal Research, 28, 281.
and sexual relationships during the first year after loss: Swanson, K. M., Kieckhefer, G., Henderson, D., Powers, P.,
Women’s perceptions. Psychosomatic Medicine, 65(5), Leppa, C., & Carr, K. (1991). Miscarriage: Patterns of
902–910. meaning (Abstract). Communicating Nursing Research,
Swanson, K. M., & Wojnar, D. (2004). Optimal healing 24, 110.
environments in nursing. Journal of Alternative and Swanson, K. M., Kieckhefer, G., Powers, P., & Carr, K.
Complementary Medicine, 10(1), 43–48. (1990). Meaning of miscarriage scale: Establishment of
Wojnar, D. M., & Swanson, K. M. (2006). Why shouldn’t psychometric properties (Abstract). Communicating
lesbian miscarriage receive special consideration? A Nursing Research, 23, 89.
viewpoint. Journal of GLTB Family Studies, 2(1), 1–12. Swanson, K. M., Klaich, K., & Leppa, C. (1992). A caring inter-
Wojnar, D. M., & Swanson, K. M. (2007). Phenomenology: An vention to promote well-being in women who miscarry
exploration. Journal of Holistic Nursing, 25(3), 172–180; (Abstract). Communicating Nursing Research, 25, 365.
discussion 181–182, quiz 183–185. Swanson, K. M., Pulvermakher, F., Karmali, Z., & Powell,
Wojnar, D., & Swanson, K. M.(2006). Why shouldn’t lesbian S. (2001). Effects of miscarriage on couple relationships
women who miscarry receive equal consideration? A (Abstract). Communicating Nursing Research, 34, 339.
viewpoint. Journal of GLBT Family Studies, 2(1), 1–12. Swanson, K. M., Taylor, G., Shipman, L., Spoor K., & Zillyet, K.
Wojnar, D., Swanson, K. M., & Aldofsson, A. (2011). Confront- (2002). Miscarriage and healing amongst the Shoalwater
ing the inevitable: A conceptual model of miscarriage for (Abstract). Communicating Nursing Research, 35, 135.
use in clinical practice and research. Death Studies, 35(6), Swanson, K. M., Wojnar, D. M., Petras, A., Chen, H., &
536–558. Graham, C. (2008). Effects of caring on couples’ grief after
Yorkston, K. M., Klasner, E. R., & Swanson, K. M. (2001). miscarriage. Communicating Nursing Research, 40,162.
Communication in multiple sclerosis: Understanding Swanson-Kauffman, K. M. (1984). A profile of the human
the insider’s perspective. American Journal of Speech experience of miscarriage (Abstract). Communicating
Language Pathology, 10, 126–137. Nursing Research, 6(3), 46.
Swanson-Kauffman, K. M. (1985). A combined qualitative
Dissertation methodology for nursing research (Abstract). Commu-
Swanson-Kauffman, K. M. (1983). The unborn one: A profile nicating Nursing Research, 18, 57.
of the human experience of miscarriage. Unpublished Swanson-Kauffman, K. M. (1985). Miscarriage: A new
doctoral dissertation, University of Colorado, Denver. understanding of the mother’s experience. Proceedings
Newsletters and Reprints of the 50th anniversary celebration of the University of
Swanson-Kauffman, K. M. (1984, Spring). A methodology Pennsylvania School of Nursing, 63–78.
for the study of nursing as a human science. Alpha Swanson-Kauffman, K. M. (1986). Work and family: The
Kappa Chapter at Large News, 3. delicate balance. Symposium (Abstract). Communicating
Swanson-Kauffman, K. M. (1987). Caring in the instance of Nursing Research, 19, 153–156.
unexpected early pregnancy loss. Counselor Connection, Swanson-Kauffman, K. M. (1988). Empirical development
3(2), 2–5. (Reprint of Swanson-Kauffman, K. M. [1986]. and refinement of a model of caring (Abstract). Commu-
Caring in the instance of unexpected early pregnancy nicating Nursing Research, 21, 80.
loss. Topics in Clinical Nursing, 8[2], 37–46.) Swanson-Kauffman, K. M. (1989). From phenomenological
Swanson-Kauffman, K. M. (1988). Miscarriage: An often- to experimental design: Qualitative inquiry as a frame-
overlooked maternal loss. Perinatal Newsletter, 2(3), 1. work for the intervention (Abstract). Communicating
Nursing Research, 22, 147.
Published Abstracts Swanson-Kauffman, K. M., Powers, P., Klaich, K., Lethbridge,
Swanson, K. M. (1993). Caring as intervention (Abstract). D. & Jarrett, M. (1990). Success: As women view it
Communicating Nursing Research, 26, 299. (Abstract). Communicating Nursing Research, 23, 59.

36

CHAP TER



















Cornelia M. Ruland Shirley M. Moore
1954 to present 1948 to present


Peaceful End-of-Life Theory


Patricia A. Higgins and Dana M. Hansen



“Standards of care offer a promising approach for the development of middle-range
prescriptive theories because of their empirical base in clinical practice
and their focus on linkages between interventions and outcomes”
(Ruland & Moore, 1998, p. 169).




Credentials and Background evaluation of information systems to support it. She
of the Theorists focuses on aspects of and tools for shared decision
making in clinically challenging situations: (1) for pa-
Cornelia M. Ruland tients confronted with difficult treatment or screening
Cornelia M. Ruland received her Ph.D. in nursing in decisions for which they need help to understand the
1998 from Case Western Reserve University in potential benefits and harms of alternative options and
Cleveland, Ohio. She is Director of the Center for to elicit their values and preferences, and (2) prefer-
Shared Decision Making and Nursing Research at ence-adjusted management of chronic or serious long-
Rikshospitalet University Hospital in Oslo, Norway, term illness over time. As primary investigator on a
and holds an adjunct faculty appointment in the number of research projects, she has received awards
Department of Biomedical Informatics at Columbia for her work.
University in New York. Ruland has established a
research program on improving shared decision Shirley M. Moore
making and patient-provider partnerships in health Shirley M. Moore is Associate Dean for Research and
care, and the development, implementation, and Professor, School of Nursing, Case Western Reserve


The authors wish to express their appreciation to Cornelia Ruland and Shirley Moore for their contributions to the chapter.

701

702 UNIT V Middle Range Nursing Theories

University. She received her diploma in nursing from philosophers to explain and define quality of life
the Youngstown Hospital Association School of Nurs- (Sandoe, 1999), a concept that is significant in end-
ing (1969) and her bachelor’s degree in nursing from of-life research and practice. In preference theory,
Kent State University (1974). She earned a master’s the good life is defined as getting what one wants, an
degree in psychiatric and mental health nursing approach that seems particularly appropriate in end-
(1990) as well as a Ph.D. in nursing science (1993) at of-life care. It can be applied to both sentient per-
Case Western Reserve University. She has taught sons and incapacitated persons who have previously
nursing theory and nursing science to all levels of provided documentation related to end-of-life deci-
nursing students and conducts a program of research sion making. Quality of life, therefore, is defined and
and theory development that addresses recovery after evaluated as a manifestation of satisfaction through
cardiac events. Early in her doctoral study, Moore was empirical assessment of such outcomes as symptom
encouraged by nurse theorists Joyce J. Fitzpatrick, relief and satisfaction with interpersonal relation-
Jean Johnson, and Elizabeth Lenz to not only use ships. Incorporating patient preferences into health
theory but to develop it as well. The Rosemary Ellis care decisions is considered appropriate (Ruland &
Theory Conference, held annually for several years at Bakken, 2001; Ruland, Kresevic, & Lorensen, 1997)
Case Western Reserve University, offered Moore an and necessary for successful processes and outcomes
opportunity to explore theory as a practical tool for (Ruland & Moore, 2001).
practitioners, researchers, and teachers. Influenced This theory was derived in a doctoral theory course
by these experiences, Moore has assisted in the devel- in which Ruland was a student and Moore was fac-
opment and publication of several theories (Good ulty. Middle-range theories were just emerging, and
& Moore, 1996; Huth & Moore, 1998; Ruland & there were few good definitions or examples. The class
Moore, 1998). Moore considers theory construction was challenged to think about the future use and de-
an essential skill for doctoral students. velopment of middle range theory for nursing science
and practice. The students discussed knowledge
sources from which they could derive middle range
Theoretical Sources theory, such as empirical knowledge, clinical practice
The Peaceful End-of-Life Theory is informed by a knowledge, and synthesized knowledge. Each student
number of theoretical frameworks (Ruland & Moore, was asked to derive a middle range theory from a
1998). It is based primarily on Donabedian’s model of knowledge source of choice. Ruland had just com-
structure, process, and outcomes, which in part was pleted a major project to develop a clinical practice
developed from general system theory. General sys- standard for peaceful end of life with a group of can-
tem theory is pervasive in other types of nursing cer nurses in Norway. The standard was synthesized
theory, from conceptual models to middle-range and into the theory of peaceful end of life by Ruland
micro-range theories—an indicator of its usefulness and later was refined with Moore’s assistance. This
in explaining the complexity of health care interac- is an example of middle range theory developed by
tions and organizations. In the Peaceful End-of-Life doctoral nursing students as they study knowledge
Theory, the structure-setting is the family system development methods. This theory is also an example
(terminally ill patient and all significant others) that of middle range theory development using a standard
is receiving care from professionals on an acute care of practice as a source.
hospital unit, and process is defined as those actions
(nursing interventions) designed to promote the
positive outcomes of the following: (1) being free Use of Empirical Evidence
from pain, (2) experiencing comfort, (3) experienc- The Peaceful End-of-Life Theory is based on empiri-
ing dignity and respect, (4) being at peace, and cal evidence from direct experience of expert nurses
(5) experiencing a closeness to significant others and review of the literature addressing components of
and those who care. the theory. The group of expert practitioners who
A second theoretical underpinning is preference developed the standard of care for peaceful end of life
theory (Brandt, 1979), which has been used by had at least 5 years of clinical experience caring for

CHAPTER 36 Cornelia M. Ruland and Shirley M. Moore 703

MAJOR CONCEPTS & DEFINITIONS can be derived from these relational statements to be
tested their usefulness. The authors of the standard
Not Being in Pain of care and authors of the theory attempted to incor-
Being free of the suffering or symptom distress is the porate clearly described, observable concepts and
central part of many patients’ end-of-life experience. relationships that expressed the notion of caring.
Pain is considered an unpleasant sensory or emo-
tional experience associated with actual or potential Major Assumptions
tissue damage (Lenz, Suppe, Gift, et al., 1995; Pain
terms, 1979). Nursing, Person, Health and Environment
As in other middle-range theories the focus of the
Experience of Comfort theory of peaceful end of life does not address each
Comfort is defined inclusively, using Kolcaba and metaparadigm concept. The theory was derived from
Kolcaba’s (1991) work as “relief from discomfort, standards of care written by a team of expert nurses
the state of ease and peaceful contentment, and who were addressing a practice problem, therefore,
whatever makes life easy or pleasurable” (Ruland the metaparadigm concepts explicitly addressed were
& Moore, 1998, p. 172). nursing and person. The theory addresses the nursing
phenomena of complex, holistic care to support per-
Experience of Dignity and Respect sons’ peaceful end of life.
Each terminally ill patient is “respected and valued Two assumptions of Ruland and Moore’s (1998)
as a human being” (Ruland & Moore, 1998, p. 172). theory are identified as follows:
This concept incorporates the idea of personal 1. The occurrences and feelings at the end-of-life
worth, as expressed by the ethical principle of experience are personal and individualized.
autonomy or respect for persons, which states that 2. Nursing care is crucial for creating a peaceful end-
individuals should be treated as autonomous of-life experience. Nurses assess and interpret cues
agents, and persons with diminished autonomy are that reflect the person’s end-of-life experience and
entitled to protection (United States, 1978). intervene appropriately to attain or maintain a
peaceful experience, even when the dying person
Being at Peace cannot communicate verbally.
Peace is a “feeling of calmness, harmony, and con- Two additional assumptions are implicit:
tentment, (free of) anxiety, restlessness, worries, 1. Family, a term that includes all significant others,
and fear” (Ruland & Moore, 1998, p. 172). A is an important part of end-of-life care.
peaceful state includes physical, psychological, and 2. The goal of end-of-life care is not to optimize care,
spiritual dimensions. in the sense that it must be the best, most techno-
logically advanced treatment, a type of care that
Closeness to Significant Others frequently results in overtreatment. Rather, the
Closeness is “the feeling of connectedness to other goal in end-of-life care is to maximize treatment,
human beings who care” (Ruland & Moore, 1998, that is, the best possible care will be provided
p. 172). It involves a physical or emotional near- through the judicious use of technology and com-
ness that is expressed through warm, intimate fort measures, in order to enhance quality of life
relationships. and achieve a peaceful death.



terminally ill patients. The standard of care consisted Theoretical Assertions
of best practices based on research-derived evidence Six explicit relational statements were identified
in the areas of pain management, comfort, nutrition, (Ruland and Moore, 1998) as theoretical assertions
and relaxation. This prescriptive theory comprises for the theory, as follows:
several proposed relational statements for which 1. Monitoring and administering pain relief and
more empirical evidence is needed. Explicit hypotheses applying pharmacologic and nonpharmacologic

704 UNIT V Middle Range Nursing Theories

interventions contribute to the patient’s experience care was an interim step that effectively linked clinical
of not being in pain. practice and theory.
2. Preventing, monitoring, and relieving physical dis- Ruland and Moore (2001) detailed the steps they
comfort, facilitating rest, relaxation, and content- followed in the development of the standard for
ment, and preventing complications contribute to peaceful end of life, which included review of relevant
the patient’s experience of comfort. literature, clarification of important concepts, and
3. Including the patient and significant others in de- incorporation of clinical practice knowledge. Each
cision making regarding patient care, treating the step is analogous to those used in theory develop-
patient with dignity, empathy and respect, and ment. Thus, the logic for the development of this
being attentive to the patient’s expressed needs, theory is straightforward, and the process used is
wishes, and preferences contribute to the patient’s clearly stated.
experience of dignity and respect.
4. Providing emotional support, monitoring and Acceptance by the Nursing Community
meeting the patient’s expressed needs for anti-
anxiety medications, inspiring trust, providing the Practice
patient and significant others with guidance in A small but growing number of articles cite the Peace-
practical issues, and providing physical presence of ful End-of-Life Theory. It is included on the Clayton
another caring person if desired contribute to the State University School of Nursing Theory Link page
patient’s experience of being at peace. with a link to American Journal of Critical Care,
5. Facilitating participation of significant others in End-of-Life Care (Kirchhoff, Spuhler, Walker, et al.,
patient care; attending to significant others’ grief, 2000). Liehr and Smith (1999) refer to the theory’s
worries, and questions; and facilitating opportuni- development of a practice standard as a foundation
ties for family closeness contribute to the patient’s for developing theory, Kehl (2006) cites it in her con-
experience of closeness to significant others or cept analysis of a “good death,” and Baggs and Schmitt
persons who care. (2000) discuss the potential usefulness of the theory
6. The patient’s experiences of not being in pain, as a means to improve end-of-life decision making
comfort, dignity, and respect, being at peace, and for critically ill adults. Kirchoff (2002) continued
closeness to significant others or persons who care the discussion on creating an environment of care
contribute to the peaceful end of life (p. 174). in the intensive care unit that promotes a peaceful
death by synthesizing information from three sources
(the Peaceful End-of-Life Theory [Ruland & Moore,
Logical Form 1998], the Institute of Medicine’s definition of peace-
The Peaceful End-of-Life Theory was developed using ful death [Field & Cassell, 1997], and precepts from
inductive and deductive logic. A unique feature of the the American Association Colleges of Nursing’s
theory is its development from a standard of care. The “Peaceful Death: Recommended Competencies and
peaceful end-of-life standard was created by expert Curricular Guidelines for End of Life Nursing Care,”
nurses in response to a lack of direction for managing 1997). The Peaceful End-of-Life Theory was one of
the complex care of terminally ill patients. The stan- the theories used to develop a model for holistic
dard was developed for the surgical gastroenterologi- palliative care for sickle cell patients (Wilkie, Johnson,
cal care unit in a university hospital in Norway. Thus, Mack, et al., 2010). In Taiwan, Lee and colleagues
the standard served as a logical intermediary step (2009) cite Peaceful End-of-Life Theory as important
linking practice and theory. Standards of care serve to establish a framework to identify the major barriers
as credible, authoritative statements that describe of good end-of-life care in an ICU.
a practitioner’s roles and responsibilities and an
expected performance level of nursing care by which Education
the quality of practice can be evaluated (American Peaceful end of life has been integrated into nursing
Association of Critical Care Nurses, 1998). In this courses for generations with a focus on care of the
instance of knowledge development, the standard of patient and family. End-of-life content has become

CHAPTER 36 Cornelia M. Ruland and Shirley M. Moore 705

more standardized in the form of theory, competen- and relieving physical discomfort) and the peace pro-
cies, and curricular guidelines. Ruland and Moore cess criterion (monitoring and meeting patient’s
(1998) are an example of an early end-of-life theory as needs for antianxiety medication). Nonpharmaco-
attention to hospice and palliative care has developed. logical interventions (e.g., music, humor, relaxation)
Ruland and Moore (1998) were cited by Kirchoff and that serve to distract a dying patient are useful for
colleagues (2000) when End of Life was a featured the relief of pain, anxiety, and general physical
topic of a CE (continuing education) offering for discomfort. Future studies are suggested to explore
critical care nurses in their online journal. linkages of the Peaceful End-of-Life Theory to other
middle-range theories such as one for acute pain
Research based on practice guidelines (Good and Moore,
The Peaceful End-of-Life Theory has gained interna- 1996), pain management (Good, 1998), and unpleas-
tional recognition as containing key components of a ant symptoms (Lenz, Pugh, Milligan, et al., 1997;
peaceful death. Kongsuwan and colleagues created a Lenz, Suppe, Gift, et al., 1995).
conceptual model (Kongsuwan & Touhy, 2009) and
conducted qualitative (Kongsuwan & Locsin, 2009) Critique
and quantitative research (Kongsuwan, Keller, Touhy
et al., 2010) on peaceful death in adult patients in Clarity
Thailand. Ruland and Moore’s (1998) Peaceful End- All elements of the theory are stated clearly, including
of-Life Theory served as a comparison model for the setting, assumptions, concepts, and relational
Kongsuwan and colleagues’ work and was cited as statements. These concepts vary considerably in their
possessing qualities essential for a peaceful death that level of abstraction, from more concrete (pain and
have been identified in many cultures. comfort) to more abstract (dignity).
In Quebec, an ethnographic study was conducted
to identify key components of a good death for rural Simplicity
residents, and the authors identified The Peaceful Despite uncomplicated terms and clear expression of
End-of-Life Theory as important to developing an ideas, the theory has been described as one of a
understanding of the concept of a good death (Wilkie, higher-level middle-range theories (Higgins & Moore,
Johnson, Mack, et al., 2010). 2000), primarily because of the level of abstraction
of the outcome criteria and the multidimensional
complexity expressed in its relational statements.
Further Development
Ruland and Moore acknowledge the need for contin- Generality
ued refinement and development of the theory. There The Peaceful End-of-Life Theory has specific bound-
are a number of potential ideas to advance its devel- aries related to time, setting, and patient population.
opment, and testing the theory is in the planning It was developed for use with terminally ill adults and
stage; for example, testing the relationships among their families who are receiving care in an acute care
the five major concepts is a possibility. Another idea setting. The concept of peaceful end of life came from
is merging some of the process criteria from the three a Norwegian context and may not be appropriate for
concepts of pain, comfort, and peace to explore out- all cultures; however it has been noted for practice by
comes related to physical-psychological symptom nurses in other cultures. Its concepts and relation-
management. Concept analysis or mapping could be ships resonate with many nurses, and it comprehen-
used to determine if the process criteria associated sively addresses the multidimensional aspects of
with the three concepts are different or sufficiently end-of-life care. For example, the outcome indicators
alike to allow merging. For the concept of pain, two associated with the five concepts address the techni-
process criteria (monitoring and administering pain cal aspect of care (providing both pharmacological
relief and applying pharmacological and nonpharma- and nonpharmacological interventions for the relief
cological interventions) are closely related to the of symptoms), communication (decision making),
comfort process criterion (preventing, monitoring, the psychological aspect (emotional support), and

706 UNIT V Middle Range Nursing Theories

dignity and respect (treating the patient with dignity, identified need for a comprehensive middle-range
empathy, and respect) (Figure 36–1). theory to guide care of patients in the end-of-life
experience, Ruland and Moore’s (2001) work clearly
Accessibility illustrates the richness of practice and standards as a
The deductive and inductive logic used to develop this source for the development of theory.
theory provides a solid basis for developing testable All of the outcome indicators are measurable, us-
hypotheses among the five concepts of the theory. ing qualitative, quantitative or both methodology
Theoretical congruency is demonstrated through the (see Figure 36–1). Unlike some middle-range theories
outcome indicators, all of which are conceptualized that have a specific instrument to measure a particu-
from the perspective of the patients and their families. lar concept, no instrument has been developed for
Peaceful End-of-Life Theory. For future studies
Importance among the five concepts, instruments need to be
As a successful synthesis of clinical practice and identified to measure hypothesized relationships.
scholarly theory development, the Peaceful End-of- Mixed methods (Tashakkori & Teddlie, 2003) was
Life Theory illustrates a way to bridge the theory- described as an appropriate approach for investigat-
practice-research continuum. Besides addressing an ing the concepts. For example, a phenomenological




Peaceful End of Life




Closeness to
Not being Experience of Experience of
in pain comfort dignity/respect Being at peace significant others/
persons who care
Monitoring and Preventing, Including patient Providing Facilitating participation
administering monitoring, and and significant emotional support of significant others
pain relief relieving physical others in in patient care
discomfort decision making Monitoring and
Applying meeting patient’s Attending to significant
pharmacological Facilitating rest, Treating patient needs for others’ grief, worries
and nonpharma- relaxation, and with dignity, antianxiety and, questions
cological contentment empathy, and medications
interventions respect Facilitating
Preventing Inspiring trust opportunities for
complications Being attentive family closeness
to patient’s
expressed needs, Providing patient/
wishes, and significant others
preferences with guidance
in practical issues

Providing physical
assistance of
another caring
person, if desired

FIGURE 36-1 Relationships among the concepts of the Peaceful End-of-Life Theory. (From Ruland, C. M.,
& Moore, S. M. [1998]. Theory construction based on standards of care: A proposed theory of the peaceful
end of life. Nursing Outlook, 46[4], 174.)

CHAPTER 36 Cornelia M. Ruland and Shirley M. Moore 707

approach could be used to investigate patient and
family perceptions of their opportunities for and sat- breathing, even though her mother has a Do Not
isfaction with family closeness, decision making, or Resuscitate (DNR) order.
both. Also with attention to linkages, a number of The physician has ordered home hospice care.
existing instruments could be considered to measure The daughter greets the social worker and nurse at
outcome indicators associated with the five concepts the door and insists the word hospice is not men-
(see Figure 36–1) such as perception of symptoms tioned to her mother, as it would “kill” her. During
with the Memorial Symptom Assessment Scale the hospice admission, it became clear that Becky
(Portenoy, Thaler, Kornblith, et al., 1994) or the Gen- understands she is dying and sees how much her
eral Comfort Questionnaire (Kolcaba, 2003). children are grieving over the thought of losing
another parent. After several weeks on the hospice
program, Becky continues to report discomfort,
high pain levels, shortness of breath, and difficulty
CASE STUDY
in communicating with her children about her
Becky is a 66-year-old woman who was diag- wishes. She is not ready to say good-bye to her
nosed with stage IV congestive heart failure children or grandchildren and is afraid to die.
(CHF). She is recently widowed (approximately Despite prescribed medication and team-focused
6 months ago) and the mother of four devoted care (social worker, nurse, nursing assistant, and
young adult children and the grandmother of clergy), Becky continues to rate her pain level at
two. Her youngest daughter (Sue) lives with her severe (8 to 10) and talks about her suffering, fear of
mother and is a student at a local University. Sue death, and concern over what will happen to her
has taken leave from the University to care for family when she is gone. During a team meeting, it
her mother. Becky has completed her advance was decided to ask Becky to describe three different
directives, and is adamant that she not receive kinds of pain (physical, emotional, and spiritual).
extraordinary measures to sustain her life. This Becky had a physical pain rating of 3 to 4, and both
has been a difficult issue for her children, as they emotional and spiritual pains were rated as severe
cannot fathom the loss of another parent. Sue is (8 to 10). The adult children continue to ask about
the durable power of attorney (DPOA) and states treatments that are more aggressive; however, they
she will call 911 in the event her mother stops also state that they do not like to see her suffer.




CRITICAL THINKING ACTIVITIES
The end of life is filled with complex physiological, to suffering (e.g., emotional, spiritual, and psy-
psychological, spiritual, and family relationship chological) in a case from your clinical practice?
problems that affect the patient’s comfort and ability In the case of Becky?
to achieve peaceful end of life. In addition, unre- 2. Use the concepts of “closeness to significant others”
solved issues in family relationships can lead to and “experience of dignity and respect” from the
complicated grieving for family members before Peaceful End-of-Life Theory to assist you in devel-
and after the death. Suffering outside of physical oping a nursing practice strategy to address the
discomfort is not readily understood, but the relief relationship issues for Becky and her family.
of suffering is a fundamental goal of end-of-life care 3. With the professional ethical standards for nursing
and is necessary to achieve comfort and a peaceful practice (such as ANA), evaluate the correspon-
end of life. dence with the “experience of dignity and respect”
1. Explore the Peaceful End-of-Life Theory in in this theory. Discuss the similarity, difference,
relation to your practice. How does it assist relevance, significance, scope, usefulness, and
you in identifying and addressing issues related adequacy.

708 UNIT V Middle Range Nursing Theories

4. Describe how the concepts of the Peaceful End- nursing interventions? What limitations of the
of-Life Theory apply to patients with diagnoses theory did you find in these considerations?
other than congestive heart failure, such as 5. Identify signs of anticipatory grieving that exist
Alzheimer’s disease, amyotrophic lateral sclerosis for Becky and her family, and then describe use
(ALS), or chronic obstructive pulmonary disease of the Peaceful End-of-Life Theory to address
(COPD). Does the theory help you identify issues these issues and how to achieve a peaceful end
and develop, implement, and evaluate appropriate of life.

POINTS FOR FURTHER STUDY
n Higgins, P. A., & Moore, S. M. (2000). Levels of care unit nurses’ perspective of a peaceful
theoretical thinking in nursing. Nursing Outlook, death: An empirical study. International
48(4), 179–183. Journal of Palliative Nursing, 16(5), 241–247.
n Kirchoff, K. T. (2002). Promoting a peaceful death n Ruland, C. M., & Moore, S. M. (1998). Theory
in the ICU. Critical Care Nursing Clinics of North construction based on standards of care: A pro-
America, 14(2), 201–206. posed theory of the peaceful end of life. Nursing
n Kongsuwan, W., Keller, K., Touhy, T., & Outlook, 46(4), 169–175.
Schoenhofer, S. (2010). Thai Buddhist intensive


REFERENCES
American Association of Critical Care Nurses. (1998). Kehl, K. A. (2006). Moving toward a peace: An analysis
Standards for acute and critical care nursing practice. of the concept of the good death. American Journal of
Aliso Viejo, CA: AACN. Retrieved from http://www. Hospice and Palliative Medicine, 23(4), 277–286.
aacn.org/AACN/practice.nsf/ad0ca3b3bdb4f332882569 Kirchoff, K. T. (2002). Promoting a peaceful death in the
81006fa692/5e3c9805e57b3b0888256a6b00791f35. ICU. Critical Care Nursing Clinics of North America,
Baggs, J. G., & Schmitt, M. H. (2000). End-of-life decisions 14(2), 201–206.
in adult intensive care: Current research base 158 and Kirchhoff, K. T., Spuhler, V., Walker, L., Hutton, A., Cole,
directions for the future. Nursing Outlook, 48(4), 158–164. B., & Clemmer, T. (2000). End-of-life care: Intensive
Beckstrand, R. L., Callister, L. C., & Kirchoff, K. T. (2006). care nurses’ experiences with end-of-life care. American
Providing a “Good Death”: Critical care nurses’ sugges- Journal of Critical Care, 9(1), 36–42.
tions for improving end-of-life care. American Journal Kolcaba, K. (2003). Comfort theory and practice: A vision
of Critical Care, 15(1), 38–45. for holistic health care and research. New York:
Brandt, R. B. (1979). A theory of the good and the right. Springer.
Oxford: Clarendon Press. Kolcaba, K. Y., & Kolcaba, R. J. (1991). An analysis of the
Field, M. J., Cassell, C. K. (1997). Approaching death: concept of comfort. Journal of Advanced Nursing,
Improving care at the end of life (IOM report). 16(11), 1301–1310.
Washington, (DC): National Academy Press. Kongsuwan, W., Keller, K., Touhy, T., & Schoenhofer, S. (2010).
Good, M. (1998). A middle-range theory of acute pain Thai Buddhist intensive care unit nurses’ perspective of a
management: Use in research. Nursing Outlook, 46(3), peaceful death: An empirical study. International Journal of
120–124. Palliative Nursing, 16(5), 241–247.
Good, M., & Moore, S. M. (1996). Clinical practice guide- Kongsuwan, W., & Locsin, R. C. (2009). Promoting peaceful
lines as a new source of middle-range theory: Focus on death in the intensive care unit in Thailand. International
acute pain. Nursing Outlook, 44(2), 74–79. Nursing Review, 56, 116–122.
Higgins, P. A., & Moore, S. M. (2000). Levels of theoretical Kongsuwan, W., Touhy, T. (2009). Promoting peaceful
thinking in nursing. Nursing Outlook, 48(4), 179–183. death for Thai Buddhists; implications for a holistic end
Huth, M. M., & Moore, S. M. (1998). Prescriptive the- of life care. Holistic Nursing Practice, 23(5), 289–296.
ory of acute pain management in infants and chil- Lee, S. Y., Hung, C. L., Lee, J. H., Shih, S. C., Weng, Y. L.,
dren. Journal of the Society of Pediatric Nurses, 3(1), Chang, W. H., et al. (2009). Attaining good end of life
23–32. care in intensive care units in Taiwan—The dilemma

CHAPTER 36 Cornelia M. Ruland and Shirley M. Moore 709

and the strategy. International Journal of Gerontology, Ruland, C. M., & Moore, S. M. (1998). Theory construc-
3(1), 26–30. tion based on standards of care: A proposed theory
Lenz, E. R., Pugh, L. C., Milligan, R. A., Gift, A., & Suppe, F. of the peaceful end of life. Nursing Outlook, 46(4),
(1997). The middle-range theory of unpleasant symp- 169–175.
toms: An update. Advances in Nursing Science, 19(3), Ruland, C. M., & Moore, S. M. (2001). Eliciting exercise
14–27. preferences in cardiac rehabilitation: Initial evaluation of
Lenz, E. R., Suppe, F., Gift, A. G., Pugh, L. C., & Milligan, a new strategy. Patient Education and Counseling, 44(3),
R. A. (1995). Collaborative development of middle- 283–291.
range nursing theories: Toward a theory of unpleasant Sandoe, P. (1999). Quality of life—Three competing views.
symptoms. Advances in Nursing Science, 17(3), 1–13. Ethical Theory and Moral Practice, 2(1), 11–23.
Liehr, P., & Smith, M. J. (1999). Middle range theory: Tashakkori, A., & Teddlie, C., (2003). Handbook of mixed
Spinning research and practice to create knowledge methods in social & behavioral research. Thousand
for the new millennium. Advances in Nursing Science, Oaks, (CA): Sage.
21(4), 81–91. United States, National Commission for the Protection of
Pain terms: A list with definitions and notes on usage. Rec- Human Subjects of Biomedical and Behavioral Re-
ommended by the IASP Subcommittee on Taxonomy. search. (1978). The Belmont report: Ethical principles
(1979). Pain, 6(3), 249. and guidelines for the protection of human subjects of re-
Portenoy, R. K., Thaler, H. T., Kornblith, A. B., Lepore, J. M., search (Bethesda, MD), Washington, (DC): For Sale by
Friedlander-Klar, H., Kiyasu, E., et al. (1994). The Memo- the Commission. Superintendent of Documents, U.S.
rial Symptom Assessment Scale: An instrument for the Government Printing Office.
evaluation of symptom prevalence, characteristics and Veillette, A. M., Fillion, L., Wilson, D. M., Thomas, R., &
distress. European Journal of Cancer, 30A(9), 1326–1336. Dumont, S. (2010). La Belle mort en milieu rural: A
Ruland, C. M., & Bakken, S. (2001). Representing patient report of an ethnographic study of the good death for
preference-related concepts for inclusion in electronic Quebec rural francophones. Journal of Palliative Care,
health records. Journal of Biomedical Informatics, 34(6), 26(3), 159–166.
415–422. Wilkie, D. J., Johnson, B., Mack, A. K., Labotka, R., &
Ruland, C. M., Kresevic, D., & Lorensen, M. (1997). Includ- Molokie, R. E. (2010). Sickle cell disease: An opportunity
ing patient preferences in nurses’ assessment of older for palliative care across the life span. Nursing Clinics of
patients. Journal of Clinical Nursing, 6(6), 495–504. North America, 45(3), 375–397.

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VI

UNIT













The Future of Nursing Theory





n Nursing theoretical systems actively give direction and create understanding
in practice, research, administration, and education.

n Theoretical works of a discipline address pertinent questions, offer frame-
works to answer the questions, and develop knowledgeable evidence for
practice.

n Nursing models and theories exhibit normal science, that is, global communi-
ties of scholars whose research and practice contribute scientific achievements.

n Expansion of the philosophy of nursing science, qualitative approaches, and
quantitative methods has greatly increased the development and use of middle
range theories in nursing research and practice.

n Internet communication continues to greatly expand global sharing among
professional communities of nurse scholars.

37

CHAP TER










State of the Art and Science

of Nursing Theory


Martha Raile Alligood



“Nursing theoretical knowledge has demonstrated powerful contributions to education,
research, administration and professional practice for guiding nursing thought and action.
That knowledge has shifted the primary focus of the nurse from nursing functions to the
person. Theoretical views of the person raise new questions, create new approaches and
instruments for nursing research, and expand nursing scholarship throughout the world.”
Alligood, M. R. (2011). Nursing Science Quarterly, 24(4), p. 304.




t becomes obvious from studying texts such as this integrity of each work and keeping the size of the text
Ione that understanding and use of nursing theoreti- workable. Unit I content was updated and restructured,
cal works is active and growing globally, pointing the and a new Chapter 4 was added on knowledge struc-
way to new knowledge through research, education, ture and the role of analysis in theory development.
administration, and practice applications. Reviews of Units II to VI were updated, and the uniform outline
the seventh edition of this text by consumers identified of each chapter was maintained. The philosophies, nurs-
by the publisher as well as published reviews in schol- ing models, and theories in Units II to IV address each
arly nursing journals recognize its contribution to metaparadigm concept (person, environment, health,
professional nursing. Suggestions that are given receive and nursing). Since middle-range nursing theories
careful consideration for each new edition (Dickson & (Unit V) are limited in scope and specific to practice, care
Wright, 2012; Smith, 2012; Paley, 2006). Smith (2012) was given to clarifying this and specifying the metapara-
points out, “The text is significant in that it provides digm concepts addressed. Rodgers (2005) notes that
nursing students with an accurate and scholarly refer- “middle-range theories currently have the most emphasis
ence to identify significant philosophies, models and in nursing” (p. 191). Similarly, Im & Chang (2012) con-
theories that are pertinent to their own nursing prac- clude that “ . . . middle range [theory] will play an essen-
tice” (p. 201). Similarly, Dickson and Wright (2012) tial role in nursing research . . . ” (p. 162).
conclude, the text “simply and elegantly describes the As in previous editions, the chapters in this eighth
great progress that nursing as a discipline and profes- edition are written by those who use the various theo-
sion has accomplished guided by the vision of leading retical works in their professional practice and research.
nursing theorists. The scope and depth … may address Nurses around the world are increasingly recognizing
the concerns and critics who argue nursing theory the vital nature of theoretical works and applying them
is outdated or irrelevant to current practice and re- to their practice, research, education, and administra-
search” (p. 204). In this eighth edition, effort was given tion (Alligood & Marriner Tomey, 1997, 2002, 2006;
to updating the chapters while maintaining clarity and Alligood & Tomey, 2010; Butts & Rich, 2011; George,

712

CHAPTER 37 State of the Art and Science of Nursing Theory 713

2011; Marriner, 1986; Marriner Tomey, 1989; Marriner theory continue to grow globally as formally organized
Tomey, 1994; Marriner Tomey & Alligood, 1998; 2002; societies that share knowledge and address questions
2006). from their research and practice on websites and in
As indicated in Chapter 1, this eighth edition con- newsletters and journals. Nursing models and theories
tinues to clarify the relevance of nursing theoretical address the central concepts of the discipline: person,
works, facilitate their recognition as systematic dem- environment, health, and nursing, (Fawcett, 1984b).
onstrations of nursing substance, and inspire their use Nurses generate theory-based scholarship for re-
as frameworks for nursing scholarship in practice, search and practice. Work by the communities of schol-
research, education, and administration. Simply put, ars in the nursing models has led to the development of
the framing of an issue guides to the desired outcome. research instruments or clinical measurement tools
There are many different ways to survey the art and unique to that paradigm (Fawcett, 2005, 2009).
science of nursing theory. This chapter explores the Kuhn (1970) stated, “Paradigms gain their status by
growth of nursing theory from three perspectives. being more successful than their competitors in solving
First, as noted in Chapter 2, the philosophy of sci- a few problems that the group of practitioners have
ence continues to open new ways of developing and come to recognize as acute” (p. 23). Kuhn (1970) defines
using theoretical works (Butts & Rich, 2011; Carper, normal science as “research firmly based upon one or
1978; Chinn & Kramer, 2011; Fawcett & Garity, 2009; more past scientific achievements, achievements that
Kuhn, 1962, 1970). The significance of normal science some particular scientific community acknowledges for
(Chapter 3) to the discipline is considered (Kuhn, a time as supplying the foundation for its further prac-
1962, 1970). Second, nursing theory is viewed in the tice” (p. 10). The characteristics of paradigms that evi-
context of new growth that encourages framing dence their nature and lead to normal science include
knowledge in present day understanding. The phe- the following:
nomenal expansion of middle-range theory develop- • A community of scholars who base their research
ment and use in all areas of nursing is discussed and practice on the paradigm
(Butts & Rich, 2011). Third and finally, the global • The formation of specialized journals
development and use of nursing theoretical works by • The foundation of specialists’ societies
nurse scholars around the world highlights growth • The claim for a special place in curricula (Kuhn,
and reminds the reader of the vital nature of theory 1970)
for the profession, discipline, and science (Johnson & Rodgers (2005) describes normal science as . . . “the
Webber, 2004). highly cumulative process of puzzle solving in which the
paradigm guides scientific activity and the paradigm is,
in turn, articulated and expanded” (p. 100). Rodgers
Nature of Normal Science (2005) cites Kuhn’s premise that research in normal sci-
Many nursing models and theories included in this text ence “is directed to the articulation of those phenomena
exhibit characteristics of Kuhn’s (1970) criteria for nor- and theories that the paradigm supplies” (p.100).
mal science (Wood, 2010). Increasingly over the past The conceptual models of nursing in this text exhibit
30 years, the conceptual models of nursing and nursing these characteristics. Each model is unique with ranges
theories as presented by Alligood (2010a, 2014), of development in these characteristics. Rogers’ Science
Alligood and Marriner Tomey (1997, 2002, 2006), of Unitary Human Beings (Chapter 13) is an excellent
Alligood & Marriner Tomey (2010), Fawcett (1984a, example having generated hundreds of research studies,
1989, 1993, 1995, 2005), Fitzpatrick and Whall (1984, 13 research instruments, and 12 nursing process clinical
1989, 1996), George (1985, 1986, 1989, 1995, 2002, tools for practice (Fawcett, 2005; Fawcett & Alligood,
2011), Marriner Tomey (1986, 1989, 1994), Marriner 2001). The Society of Rogerian Scholars, founded in
Tomey and Alligood (1998, 2002, 2006), McEwen and 1988, publishes a refereed journal, Visions: The Journal
Wills (2002, 2006), Meleis (1985, 1991, 1997, 2005, of Rogerian Nursing Science, with issues available on the
2007, 2012), and Parker (2001, 2006) have led to theory- Society of Rogerian Scholars website to foster develop-
based education, administration, research, and practice. ment of the science among the community of scholars.
Communities of scholars associated with a model or Rogerian science is the basis of award winning texts

714 UNIT VI The Future of Nursing Theory

and curricula for undergraduate and graduate nursing from inquiry and guides practice” (Parse, 2008, p. 101).
programs (Fawcett, 2005). In 2008, the Society of The growth of middle-range theory accentuates the
Rogerian Scholars celebrated 25 years of Rogerian practice-theory connection opening new insights and
conferences, the 20th anniversary of the society and vistas for theory development. The literature demon-
15 years of Visions: The Journal of Rogerian Nursing strates numerous ways for scholars to classify nursing
Science. Similarly, the International Orem Society for theoretical works. Classifications vary based on the
Orem’s Self-Care Deficit Theory (Chapter 14). King framework used for the classification. Of importance is
International Nursing Group for King’s Conceptual that nurses: know the individual works, recognize
System (Chapter 15), the Neuman Trustee Group for them as evidence on which to base practice, teach them
Neuman’s Systems Model (Chapter 16), and the Boston- to students, and select one for a professional style of
based Adaptation Research in Nursing Society for Roy’s practice and improved quality of care.
Adaptation Model (Chapter 17) are well developed and Nurses eagerly embraced qualitative research ap-
productive communities of scholars. proaches to explore questions that quantitative research
Nursing theories that have developed normal sci- methods could not answer, and this expanded theory
ence include: Boykin & Schoenhofer’s Theory of Nurs- development led to new qualitative middle-range theo-
ing as Caring (Chapter 19). Meleis’s Transitions Theory ries (Alligood & May, 2000; Peterson & Bredow, 2009;
(Chapter 20), Pender’s Health Promotion Model Sieloff & Frey, 2007; Smith & Liehr, 2008; Thorne,
(Chapter 21), Leininger’s Theory of Culture Care Kirkham, & O’Flynn-Magee, 2004). New theories
(Chapter 22), Margaret Newman’s Theory of Health as expand the volume of middle-range or practice theory
Expanding Consciousness (Chapter 23), Parse’s Theory applications. Examples include new theories in Orem
of Human Becoming (Chapter 24), and Erickson, (Biggs, 2008; Reigel, Jaarsma, & Stromberg, 2012), in
Tomlin, and Swain’s Theory of Modeling and Role- Neuman (Bigbee & Issel, 2012; Casalenuovo, 2002;
Modeling (Chapter 25). Many of these have founded Gigliotti, 2003; Shamsudin, 2002), in Roy (DeSanto-
consortia or societies for development of research, pre- Madeya, 2007; Dobratz, 2011; Dunn, 2005; Hamilton &
sentations, publications, and practice applications. Bowers, 2007; Roy, 2011), in Rogers (Kim, Kim, Park,
et al., 2008; Malinski, 2012; Willis & Grace, 2011), in
Newman (Brown, 2011; MacNeil, 2012; Pharris &
Expansion of Theory Development Endo, 2007), in King (Alligood, 2010e; Sieloff & Frey,
Theoretical works provide ways to think about nurs- 2007), and in Parse (Smith, 2012; Wang, 2008). This
ing. Johnson and Webber (2001, 2004) addressed the exciting development closes the gap between research
future of nursing in questions about the importance and practice (Alligood, 2010c) coming from quantita-
of theory development for recognition of nursing as a tive and qualitative methods.
profession, as a discipline, and as a science. They Considering nursing knowledge in a generic
identify three significant areas affected by nursing structure as presented in Figure 37–1 is a view of
knowledge and dependent on its continued develop- knowledge based on the nature of the content within
ment. Theory affects recognition of nursing as 1) a nursing science rather than focusing on the research
profession, 2) a discipline, and 3) a science. Substan- method. Middle-range theories vary in range and
tive knowledge is the heart of nursing for recognition level of abstraction as the name of the classification
but most importantly for quality care of patients indicates. Actually, this is true for theoretical works
whom we serve. Moving nurses beyond functional in other classifications (philosophies, models, and
practice to a style of practice with a professional deliv- theories) as they also have similarities and differ-
ery model requires transposing from emphasis on ences in their levels of abstraction (Fawcett, 2005).
what the nurse does to emphasis on the patient. This Middle-range theories are recognizable as they include
requires practice based on a systematic presentation details that are specific to practice, such as the situation
and focus on persons. As knowledge is transferred to or health condition involved, client population or age
those coming into the profession, a style of practice is group, location or area of nursing practice, and action
also related. As nurses shift to a professional style of of the nurse or the nursing intervention (Alligood,
nursing, most agree that, “nursing knowledge arises 2010a, p. 482).

CHAPTER 37 State of the Art and Science of Nursing Theory 715

conferences alternate between the United States
Person Environment Health Nursing and other countries. The 2010, the conference was held
in Thailand. Parse’s Institute of Humanbecoming
Conceptual models of nursing and Watson’s Consortium on Caring Science draw
international applicants each year. The 12th Interna-
Grand theories, theories
tional Biennial Neuman Systems Model Symposium
was titled Enhancing Global Health with Nursing
Theories—NSM. This may be attributed to global
communication, increased world travel, and transla-
Middle range theories tion of nursing theory textbooks into other lan-
guages. Nurses around the world are embracing
nursing theory as they experience its utility in their
practice. Numerous nursing journals publish articles
by international scholars such as: Journal of Nursing
Themes
Scholarship, Nursing Science Quarterly, Journal of Ad-
Qualitative interpretation vanced Nursing, Visions: The Journal of Rogerian
Nursing Science,and International Journal for Human
Text Caring, to name a few.
Various editions of Nursing Theorists and Their
FIGURE 37-1 Middle-range theory in a generic structure of Work (Marriner Tomey, 1989, 1994; Marriner Tomey
nursing knowledge from quantitative research methods and & Alligood, 1998; 2002; 2006; Alligood & Marriner
qualitative research approaches. (Includes data from Fawcett, J. Tomey, 2010) and Nursing Theory: Utilization and Ap-
[2005]. Contemporary nursing knowledge: Nursing models and plication (Alligood & Marriner Tomey, 1997, 2002,
theories. Philadelphia: F. A. Davis.)
2006; Alligood, 2010a) have been published in classi-
cal Chinese, which is Taiwanese, Finnish, German,
Application of middle-range theories in nursing Italian, Japanese, Korean, Spanish, and Portuguese as
practice is improving nursing practice quality, whether well as international circulation to English-speaking
developed quantitatively or qualitatively. Both approaches countries. Publications demonstrate global interest in
are at the level of practice and develop useful nursing nursing conceptual models and nursing theories. In
knowledge. Consideration of middle-range theory in a addition, the theoretical works of international theo-
generic structure of knowledge reveals that theory from rists are included in this text: Evelyn Adam, Canada
the hypothetical-deductive method and theory from (Chapter 5). Roper, Logan, and Tierney, Scotland
qualitative approaches arrives at a similar level of abstrac- (Chapter 5), Katie Eriksson, Finland (Chapter 11),
tion. In spite of different philosophical bases, methods, Phil Barker, Ireland (Chapter 32), Kari Martinsen,
and approaches, the knowledge is at a similar level of Norway (Chapter 10), and Nightingale, England
abstraction (Figure 37–1). (Chapter 6). A PubMed search of nursing theory pub-
lications in each language possible in PubMed was
conducted on October 23, 2008, and again on August
Global Communities of Nursing 24, 2012, which is evidence of growth. (Table 37–1)
Scholars Current trends indicate that global consciousness has
In addition to the growth stimulated by a broader phi- arrived evidenced by nursing theory articles from
losophy of nursing science and emergence of middle- around the world in nursing journals in the United
range theories, a major contribution to the state of the States and other countries (Hisama, 1999; Im & Chang,
art and science of nursing theory is globalization of 2012; Tanaka, Katsuno, and Towako, et al., 2012). Sigma
communities of nurse scholars with vast communica- Theta Tau International with worldwide membership
tion via the Internet. Most nursing conceptual model and international conferences has contributed along
and theory societies or consortia have international with the Internet. The Journal of Nursing Scholarship
members. The International Orem Society biennial features articles from global members (Palese, Tomietto,

716 UNIT VI The Future of Nursing Theory

TABLE 37-1 Global Nursing Theory Several nursing theory websites provide informa-
Publications* tion such as the Nursing Theory Link Page maintained
by Clayton College and State University Department
Languages with Nursing Theory Nursing Theory of Nursing and the Nursing Theory Page maintained
Nursing Theory Publications Publications by the University of San Diego School of Nursing.
Publications October 23, 2008 August 24, 2012 These websites link to home pages or websites for most
English 10,144 12,629 theorists and their work.
Japanese 409 413 In conclusion, the state of the art and science of
Portuguese 298 376 nursing theory is exciting as we continue to see phe-
German 295 340 nomenal growth. First, nursing theoretical works are
French 214 248 used globally by nurse scholars who collaborate to
Korean 79 102 develop nursing science (Kuhn, 1970). Second, theory
Chinese 59 91 development with qualitative research addresses un-
Dutch 56 56 answered nursing questions. New understanding
Danish 54 55 from middle-range theories improves nursing prac-
Spanish 41 59
Norwegian 41 41 tice (see Figure 37–1). Third, and finally, global nurse
Italian 33 37 scholars are applying nursing theoretical works and
Sweden 28 28 contributing new nursing knowledge. Nurses of the
Finnish 24 24 world share ideas and knowledge with the Internet.
Polish 13 14 This is a crucial time in the history of nursing. I am
Afrikaans 7 7 not speaking about the shortage of nurses, although this
Russian 3 3 is extremely important. Rather, there are important
Greek 2 2 changes in process for nursing. We are moving forward
Thai 1 1 with continued challenges for Quality and Safety Edu-
Turkish 1 1 cation for Nurses (QSEN), as noted in Robert Wood
Hebrew 1 1 Johnson Foundation (2012) reports. Similarly, Benner
Hungarian 1 2
Czeck 1 2 and colleagues (2010) have called for radical transfor-
All other possible 0 0 mation of nursing education, and nurses are responding
languages to the Institute of Medicine (IOM) report, The Future of
examined Nursing: Leading Change (Ellerbe & Regen, 2012). In all
of these efforts, it is vital that nursing knowledge be
*Number of nursing theory publications retrieved when limited by each valued and nursing theory be taught, learned, used, and
language possible in a PubMed search (August 23, 2012).
applied in practice for development of the profession
Suhonen, et al., 2011), and Nursing Science Quar- and that nursing research continue to develop new
terly has a global column in each issue by nurses in nursing knowledge for the discipline. One thing
countries such as Canada, Malawi, Australia, New remains true for the nursing profession: “Theory with-
Zealand, England, Japan, Sweden, Korea, Germany, out practice is empty and practice without theory is
Turkey, Taiwan, Hong Kong, Ireland, and Israel. blind” (Cross, 1981, p. 110).

REFERENCES

Alligood, M. R. (2002). A theory of the art of nursing Nursing theory: Utilization & application (4th ed.,
discovered in Rogers’ science of unitary human pp. 481–493). Maryland Heights, (MO): Mosby Elsevier.
beings. International Journal for Human Caring, 6(2), Alligood, M. R. (2010c). Philosophies, models, and theo-
55–60. ries: Critical thinking structures. In M. Alligood (Ed.),
Alligood, M. R. (2010a). Nursing theory: Utilization & applica- Nursing theory: Utilization & application (4th ed.,
tion (4th ed.). Maryland Heights, (MO): Mosby Elsevier. pp. 47–71). Maryland Heights, (MO): Mosby Elsevier.
Alligood, M. R. (2010b). Areas for further development of Alligood, M. R. (2010d). The nature of knowledge needed
theory-based nursing practice. In M. Alligood (Ed.), for nursing practice. In M. Alligood (Ed.), Nursing

CHAPTER 37 State of the Art and Science of Nursing Theory 717

theory: Utilization & application (4th ed., pp. 3–15). Dickson, V., & Wright, F. (2012). [book review] Nursing
Maryland Heights, (MO): Mosby Elsevier. theorists and their work (7th ed.) by M. R. Alligood
Alligood, M. R. (2010e). Family healthcare with King’s and A. M. Tomey (Eds.) (Maryland Heights, [MO]:
theory of goal attainment. Nursing Science Quarterly, Mosby Elsevier, 2010). Nursing Science Quarterly,
23(2), 99–104. 25(2), 203–204.
Alligood, M. R. (2011). The power of theoretical knowledge. Dobratz, M. C. (2011). Toward development of a middle-
Nursing Science Quarterly, 24(4), 304–305. range theory of psychological adaptation in death and
Alligood, M. R. (2014). Nursing theory: Utilization & applica- dying. Nursing Science Quarterly, 24(4), 370–376.
tion (5th ed.). Maryland Heights, (MO): Mosby Elsevier. Dunn, K. S. (2005). Testing a middle-range theoretical
Alligood, M. R., & Marriner Tomey, A. (1997). Nursing mode of adaptation to chronic pain. Nursing Science
theory: Utilization & application. St. Louis: Mosby. Quarterly, 18, 146–156.
Alligood, M. R., & Marriner Tomey, A. (2002). Nursing Ellerbe, S., & Regen, D. (2012). Responding to health care
theory: Utilization & application (2nd ed.). St. Louis: reform by addressing the institute of medicine report
Mosby. on the future of nursing. Nursing Administration Quar-
Alligood, M. R., & Marriner Tomey, A. (2006). Nursing terly, 36(3), 210–216.
theory: Utilization & application (3rd ed.). St. Louis: Fawcett, J. (1984a). Analysis and evaluation of conceptual
Mosby. models of nursing. Philadelphia: F. A. Davis.
Alligood, M. R., & Marriner Tomey, A. (2010). Nursing Fawcett, J. (1984b). The metaparadigm of nursing: Present
theorists and their work (7th ed.). Maryland Heights, status and future refinements. Image: The Journal of
(MO): Mosby Elsevier. Nursing Scholarship, 16(3), 84–89.
Alligood, M. R., & May, B. A. (2000). A nursing theory of Fawcett, J. (1989). Analysis and evaluation of conceptual
personal system empathy: Interpreting a conceptualiza- models of nursing (2nd ed.). Philadelphia: F. A. Davis.
tion of empathy in King’s interacting systems. Nursing Fawcett, J. (1993). Analysis and evaluation of nursing theo-
Science Quarterly, 13(3), 243–247. ries. Philadelphia: F. A. Davis.
Benner, P., Sutphen, M., Leonard, V., Day, L. (2010). Edu- Fawcett, J. (1995). Analysis and evaluation of conceptual
cating nurses. San Francisco: Jossey-Bass. models of nursing (3rd ed.). Philadelphia: F. A. Davis.
Bigbee, J. L. & Issel, L. M. (2012). Conceptual models for Fawcett, J. (2005). Analysis and evaluation of contemporary
population-focused public health nursing interventions nursing knowledge: Nursing models and theories (2nd ed.)
and outcomes: The state of the art. Public Health Nursing, Philadelphia: F. A. Davis.
29(4), 370–379. Fawcett, J., & Alligood, M. (2001). SUHB INSTRUMENTS:
Biggs, A. (2008). Orem’s self-care deficit nursing theory: An overview of research instruments and clinical tools
Update on the state of the art and the science. Nursing derived from the science of unitary human beings.
Science Quarterly, 21, 200–206. Theoria: Journal of Nursing Theory, 10(2), 5–12.
Brown, J. W. (2011). Health as expanding consciousness: A Fawcett, J., & Garity, J. (2009). Evaluating research for evidence-
nursing perspective for grounded theory research. based nursing practice. Philadelphia: F.A. Davis.
Nursing Science Quarterly, 24(3), 197–201. Fitzpatrick, J. J., & Whall, A. L. (1984). Conceptual models
Butts, J. B., & Rich, K. L. (2011). Philosophies and theories for of nursing: Analysis and application. Norwalk, (CT):
advanced nursing practice. Sudbury, (MA): Jones & Bartlett. Appleton & Lange.
Carper, B. (1978). Fundamental patterns of knowing. Fitzpatrick, J. J., & Whall, A. L. (1989). Conceptual models
Advances in Nursing Science, 1(1), 13–23. of nursing: Analysis and application (2nd ed.). Norwalk,
Casalenuovo, G. A. (2002). Fatigue in diabetes mellitus: (CT): Appleton & Lange.
Testing a middle range theory of optimal client system Fitzpatrick, J. J., & Whall, A. L. (1996). Conceptual models
stability and the Neuman Systems Model. Dissertation of nursing: Analysis and application (3rd ed.). Stamford,
Abstracts International, 63, 2301B. (CT): Appleton & Lange.
Chinn, P., & Kramer, M. (2011). Integrated knowledge devel- George, J. B. (1985). Nursing theories. Norwalk, (CT):
opment in nursing (8th ed.). Maryland Heights, (MO): Appleton & Lange.
Mosby Elsevier. George, J. B. (1986). Nursing theories (2nd ed.). Norwalk,
Cross, P. (1981). Adults as learners. Washington, (DC): (CT): Appleton & Lange.
Jossey-Bass. George, J. B. (1989). Nursing theories (3rd ed.). Norwalk,
DeSanto-Madeya, S. (2007). Using case studies based on a (CT): Appleton & Lange.
nursing conceptual model to teach medical-surgical George, J. B. (1995). Nursing theories (4th ed.). Upper Saddle
nursing, Nursing Science Quarterly, 20, 324–329. River, (NJ): Prentice Hall.

718 UNIT VI The Future of Nursing Theory

George, J. B. (2002). Nursing theories (5th ed.). Upper Saddle Meleis, A. I. (1997). Theoretical nursing: Development and
River, (NJ): Prentice Hall. progress (2nd ed.). Philadelphia: Lippincott.
George, J. B. (2011). Nursing theories (6th ed.). Boston: Meleis, A. I. (2005). Theoretical nursing: Development and
Pearson. progress (3rd ed.). Philadelphia: Lippincott.
Gigliotti, E. (2003). The Neuman Systems Model Institute: Meleis, A. I. (2007). Theoretical nursing: Development and
Testing middle-range theories. Nursing Science Quarterly, progress (4th ed.). Philadelphia: Lippincott.
16, 201–206. Meleis, A.I. (2012). Theoretical nursing: Development and
Hamilton, R. J., & Bowers, B. J. (2007). The theory of genetic progress (5th ed.). Philadelphia: Lippincott.
vulnerability: A Roy model exemplar. Nursing Science Palese, A., Tomietto, M., Suhonen, R., Efstathiou, G.,
Quarterly, 20, 254–264. Tsangaari, H., Merkouris, A., et al. (2011). Surgical
Hisama, K. K. (1999). Towards an international theory of patient satisfaction as an outcome of nurses caring
nursing. Nursing Health Science, 1(2), 77–81. behaviors: A descriptive and correlational study in
Im, E., & Chang, S. (2012). Current trends in nursing the- six European countries. Image: The Journal of Nurs-
ories. Image: The Journal of Nursing Scholarship, 44(2), ing Scholarship, 43(4), 341–350.
156–164. Paley, J. (2006). [book review] Nursing theorists and their
Johnson, B., & Webber, P. (2001). An introduction to theory work. Nursing Philosophy, 7(4), 275–280.
and reasoning in nursing. Philadelphia: Lippincott. Parker, M. (2001). Nursing theories and nursing practice.
Johnson, B., & Webber, P. (2004). An introduction to the- Philadelphia: F. A. Davis.
ory and reasoning in nursing (2nd ed.). Philadelphia: Parker, M. (2006). Nursing theories and nursing practice
Lippincott. (2nd ed.). Philadelphia: F. A. Davis.
Kim, T. S., Kim, C., Park, K. M., Park, Y. C., Lee, B. S. Parse, R. R. (2008). Nursing knowledge development:
(2008). The relation of power and well-being in Korean Who’s to say how? Nursing Science Quarterly, 21,101.
adults. Nursing Science Quarterly, 21, 247–254. Peterson, S., & Bredow, T. (2009). Middle Range Theories.
Kuhn, T. S. (1962). The structure of scientific revolutions. Philadelphia: Lippincott.
Chicago: University of Chicago Press. Pharris, M. D., & Endo, E. (2007). Flying free: The evolv-
Kuhn, T. S. (1970). The structure of scientific revolutions ing nature of nursing practice guided by the theory of
(2nd ed.). Chicago: University of Chicago Press. health as expanding consciousness. Nursing Science
MacNeil, J. M. (2012). The complexity of living with Quarterly, 20,136–143.
hepatitis C: A Newman perspective. Nursing Science Riegel, B., Jaarsma, T, & Stromberg, A. (2012). A middle-
Quarterly, 25(3), 261–266. range theory of self-care of chronic illness. Advances in
Malinski, V. M. (2012). Meditations on the unitary rhythm of Nursing Science, 35(3), 194–204.
dying-grieving. Nursing Science Quarterly, 25(3), 239–244. Robert Wood Johnson Foundation (2012). Passing the Baton:
Marriner Tomey, A. (1986). Nursing theorists and their work. After seven highly successful years, a new start and a new
St. Louis: Mosby. institute for QSEN. Human Capital. Retrieved from http://
Marriner Tomey, A. (1989). Nursing theorists and their work www.rwjf.org/humancapital/product,jsp?id574451&cid5
(2nd ed.). St. Louis: Mosby. XEM_A6052.
Marriner Tomey, A. (1994). Nursing theorists and their work Rodgers, B. L. (2005). Developing nursing knowledge.
(3rd ed.). St. Louis: Mosby. Philadelphia: Lippincott.
Marriner Tomey, A., & Alligood, M. (1998). Nursing theo- Roy, C. (2011). Extending the Roy Adaptation Model to
rists and their work (4th ed.). St. Louis: Mosby. meet changing global needs. Nursing Science Quarterly,
Marriner Tomey, A., & Alligood, M. R. (2002). Nursing 24(4), 345–351.
theorists and their work (5th ed.). St. Louis: Mosby. Shamsudin, N. (2002). Can the Neuman Systems Model be
Marriner Tomey, A., & Alligood, M.R. (2006). Nursing the- adapted to the Malaysian nursing context? International
orists and their work (6th ed.). St. Louis: Mosby-Elsevier. Journal of Nursing Practice, 8(2), 99–105.
McEwen, M., & Wills, E. (2002). Theoretical basis for nursing. Sieloff, C. L., & Frey, M. A. (Eds.) (2007). Middle range theory
Philadelphia: Lippincott. development using King’s conceptual system. New York:
McEwen, M., & Wills, E. (2006). Theoretical basis for nursing Springer.
(2nd ed.). Philadelphia: Lippincott. Smith, J. M. (2012). [book review] Nursing theorists and
Meleis, A. I. (1985). Theoretical nursing: Development and their work (7th ed.) by M. R. Alligood and A. M.
progress. Philadelphia: Lippincott. Tomey (Eds.) (Maryland Heights, [MO]: Mosby
Meleis, A. I. (1991). Theoretical nursing: Development and Elsevier, 2010). Nursing Science Quarterly, 25(2),
progress. Philadelphia: Lippincott. 201–202.

CHAPTER 37 State of the Art and Science of Nursing Theory 719

Smith, M. J., & Liehr, P. (2008). Middle range theory for Willis, D. G., & Grace, P. J. (2011). The applied philosopher-
nursing (2 ed.). New York: Springer. scientist: Intersections among phenomenological research,
nd
Tanaka, J., Katsuno, T., Takahashi, T. (2012). Using Parse’s nursing science, and Theory as a basis for practice aimed
humanbecoming theory in Japan. Nursing Science Quar- at facilitating boys’ healing from being bullied. Advances
terly, 25(1), 99–102. doi: 10.1177/0894318411429065. in Nursing Science, 34(1), 19–28.
Thorne, S., Kirkham, S. R., & O’Flynn-Magee, K. (2004). The Wood, A., (2010). Nursing models: Normal science for
analytic challenge in interpretive description. International nursing practice. In M. R. Alligood (Ed.), Nursing theory:
Journal of Qualitative Methods, 3(1), article 1. Retrieved Utilization & application (4th ed., pp. 17–46). Maryland
fromhttp://www.ualberta.ca/aiiqm/backissues/3_1/pdf/ Heights, (MO): Mosby Elsevier.
thorneetal.pdf
Wang, C. H. (2008). Working with older adults: A nurse
practitioner’s experience from a humanbecoming per-
spective. Nursing Science Quarterly, 21, 218–221.

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Index





Page numbers followed by “f” indicate figures, “t” indicate tables, and “b” indicate boxes.
A
Acquired immunodeficiency syndrome (AIDS), 453, 581
Abdellah, Faye Glenn, 46–47 Actions, 348, 614
accomplishments of, 46 deliberate, 242–243
nursing theory development, contributions to, 47 nursing, 348–349
professional nursing associations, role in, 46 perceived barriers of, 399
Abduction, 180 perceived benefits of, 399
Abductive conclusion, 528 self-care, 502
Abductive reasoning, 23, 528 Activities of living (ALs), 52–54
Abstract concepts, 24 Activity-related affect, 399
Acceptance, 500 Adam, Evelyn, 52, 715
Accessibility Adaptation, 223, 265, 550, 560
in Adaptation Model, 320 in Adaptation Model, 309
in Behavioral System Model, 346 in Conservation Model, 206
in Bureaucratic Caring Theory, 112 equilibrium, 346
in Caring, Theory of, 696 levels of, 305
in Caritative Caring Theory, 184 middle-range theory of, 317–318
in Chronic Sorrow Theory, 618 in Modeling and Role-Modeling Theory, 501
in Comfort Theory, 666 person, difference in characteristics of, 501
in Conservation Model, 211 problems with, 305
in Culture Care Theory of Diversity and Universality, 431 research instruments for, 317
in Goal Attainment Theory, 268 in Uncertainty in Illness Theory, 557
in Health as Expanding Consciousness Theory, 454 Adaptation Model, 303–331
in Health Promotion Model, 405 adaptive modes in, overview of, 321–322t
in Humanbecoming Theory, 479 case study based on, 322b
in Illness Trajectory Theory, 602 critiquing of, 319–320
in Maternal Role Attainment Theory, 551 empirical evidence for, 308
in Modeling and Role-Modeling Theory, 508 further developments of, 318–319
in Nursing as Caring Theory, 370 logical form of, 311–312
in nursing theory, analysis of, 10 major assumptions of, 308–309
in Peaceful End-of-Life Theory, 706 major concepts and definitions in, 305–307b
in Philosophy of Caring Theory, 160 nursing communities acceptance of, 312–318
in Postpartum Depression Theory, 681–682 summary of, 320–323
in Self-Care Deficit Theory of Nursing, 251 theoretical assertions of, 310–311
in Self-Transcendence Theory, 583 theoretical sources for, 304–307
in Symphonological Bioethical Theory, 531 Adaptation to Spinal Cord Injury Interview Schedule (ASCIIS), 317
in Systems Model, 291 Adaptive modes, 321–322t
in Theory of Nursing Practice Expertise, 135 Adaptive Potential Assessment Model (APAM), 500, 501,
in Tidal Model of Mental Health Recovery, 646 502–503, 504–505
in Transitions Theory, 387 Hopkins Clinical Assessment of, 504–505
in Uncertainty in Illness Theory, 564 Adaptive responses, 306
in Unitary Human Beings Theory, 231 ADHD. See Attention-deficit/hyperactivity disorder (ADHD)
Acculturation health assessment enabler, 427 Adjustment, 265
Achievement, 347 Administration
Achievement subsystems, 335, 346–347 in Bureaucratic Caring Theory, 107–108
Achieving Methods of Intraprofessional Consensus, Assessment health care, 529
and Evaluation (AMICAE), 126–127, 132 in Symphonological Bioethical Theory, 529–530
Acquired coping mechanisms, 306 in Transpersonal Caring, 87
721

722 Index

Adolescent empowerment, 317–318 ASCIIS. See Adaptation to Spinal Cord Injury Interview Schedule
Adolescent Lifestyle Profile, 404 (ASCIIS)
Advanced beginner, 124, 134 Aspects of situation, 125
Advance directives, 529 Assessment, 340–341, 347–348
Advance nursing science, 31–33 Attachment, 541
Aesthetic patterns, 371 Attachment-affiliative subsystems, 334, 346–347
Affect, in Health Promotion Model, 399 Attainment, 541, 550
Affiliated individuation (AI), 499–500, 501 Attending-distancing, 469
Affirming, 470 Attending Nurse Caring Model (ANCM), 86–87
Agency, 522, 524 Attention-deficit/hyperactivity disorder (ADHD), 317
dependent-care, 246, 250–251 Attributes of situation, 125
nursing, 246, 250–251 Authority, 557
self-care, 246, 250–251 Autonomy, 504, 532
in Symphonological Bioethical Theory, 522 Awareness, 207, 382, 524–525
Agency for Healthcare Research and Quality, 405 Axiomatic theory, 30
Agent, 242 Axioms, 29–30
Aggressive-protective subsystems, 335, 346–347
Agreement, 522–523, 524–525 B
AI. See Affiliated individuation (AI) Bacon, Francis, 15–16
AIDS. See Acquired immunodeficiency syndrome (AIDS) Balance, 346
Akayama, Tsuyoshi, 640 Bandura, Albert, 398
Alanen, Y., 635 Barker, Phil, 626–656. See also Tidal Model of Mental Health Recovery
All-at-onceness of human experience, 467 background of, 626–627
Allegiance Health, 288–289 credentials of, 626–627
Altruistic values, 83 Barnard, Kathryn E., 51–52, 689
Altschul, Annie, 629, 635 Basic conditioning factors, 247
Alzheimer’s disease, 479 Basic needs, 501
American Academy of Nursing, 46, 51, 121, 205 Basic Needs Satisfaction Inventory, 504–505
American Association Colleges of Nursing, 704 Basic Principles of Nursing Care, 45
American Holistic Nurses’ Certification Corporation (AHNCC), 497 Baumhart, Dr., 205
American Journal of Critical Care, 131–132, 704 Beck, Cheryl Tatano, 672–687. See also Postpartum Depression
American Journal of Health Promotion, 398 Theory
American Journal of Nursing, 8, 131–132 background of, 672–674
American Mental Health Aid to Israel, 205 credentials of, 672–674
American Nurses Association (ANA), 43–44 Becoming, 179, 543, 546–547
AMICAE. See Achieving Methods of Intraprofessional Consensus, Becoming visible–invisible becoming of the emerging, 467
Assessment and Evaluation (AMICAE) Behavior
ANA. See American Nurses Association (ANA) in Behavioral System Model, 334
ANCM. See Attending Nurse Caring Model (ANCM) ethical, 525–526
Anthropology, 420, 425 health-promoting, 400
Anticipatory stage of Maternal Role Attainment Theory, 545 health-seeking, 660
Anxiety prior related, 399
Maternal Role Attainment Theory, 541 Behavioral assessment, 347–348
Postpartum Depression Theory, 677 Behavioral science, 19–20
prenatal, 676 Behavioral system equilibrium, 341
APAM. See Adaptive Potential Assessment Model (APAM) Behavioral System Model, 332–356, 339f
Appraisal, 563 case study based on, 347–349b
Appraisal support, 542 critiquing of, 346
A priori reasoning, 15, 17 empirical evidence for, 336–337
Aristotle, 15, 173, 174, 180, 182, 522 further developments by, 344–345
Art logical form of, 340
clinical nursing, element of, 48 major assumptions of, 337–338
normal science, nature of, 713–714 major concepts & definitions of, 334–336b
nursing scholars, global communities of, 715–716 nursing communities acceptance of, 340–344
of nursing theory, 711–719 summary of, 346–349
theory development, expansion of, 714–715 theoretical assertions of, 338–340
Articulation research, 121–122, 133 theoretical sources for, 333–334

Index 723

Behavior disorders, 346 C
Being, dimension of health, 179
Being ill, 130 Calls for nursing, 363, 365, 445
Being-nonbeing, 470 Canadian Nurse, The, 48
Being situated, 130 Cancer, 600
Being with, 690, 695 Carative factors of Transpersonal Caring, 82t
Belief, 445, 690, 695 Care
Belong to the person, 634 culture, 421
Beneficence, 532 dependent, 244
Benner, Patricia, 120–146. See also Theory of Nursing human, 421
Practice Expertise moral practice, founded on, 155
background of, 120–121 nursing, 178, 422
credentials of, 120–121 people-based, 423
Berdâev, Nikolaj, 174 in Philosophy of Caring Theory, 155
Bereavement, 616 suffering related to, 175–176
Best policies, 660, 664 transformation of, 368
Best practices, 660, 664 universality of, 425
Biennial Neuman Systems Model Symposium, 288, 290 Care continuum, 634–635
Biochemical loading, 674 Caring, 365. See also Bureaucratic Caring Theory; Caring, Theory
Bioethical concepts, 525 of; Caritative Caring Theory; Culture Care Theory of
Bioethical standards, 526b Diversity and Universality; Nursing as Caring Theory;
Bioethics, 521 Theory of Nursing Practice Expertise; Transpersonal Caring
Biographical work, 596 Theory
Biological factors, 399 act of, 175
Biopsychosocial systems, people as, 560 bureaucratic, 106
Birth experience, perception of, 541 in Bureaucratic Caring Theory, 102
Boca Raton Community Hospital, 367, 368 call for nursing as, 365
Body, 152, 596 in Caring, Theory of, 690
Bourdieu, Pierre, 151 culturally based, 424
Boykin, Anne, 357–377. See also Nursing as existential being as, 152
Caring Theory human care and, 421
background of, 358–359 literary metaanalysis on, 691
credentials of, 358–359 meaning of, 106
Brainstorming, 599 moral, 156–157
Bridge-builder, 154–156 natural, 178
Brigham and Women’s Hospital, 506 in nursing practice (See Theory of Nursing Practice Expertise)
British Royal Sanitary Commission, 65 original, 178
Bureaucracy, 101–102 persons as, perspective of, 360
Bureaucratic caring, 106 philosophy of, 20, 147–170
Bureaucratic Caring Theory, 98–119 practical, 156–157
case study based on, 113–114b relational, 156–157
critiquing of, 111–113 spiritual-ethical, 102, 104, 106, 111–112
empirical evidence for, 102–105 Caring, Theory of, 688–700
further developments by, 109–111 case study based on, 696b
Holographic Theory of, 105f critiquing of, 695–696
logical form of, 106 empirical evidence for, 690–692
major assumptions of, 105–106 further developments by, 695
major concepts & definitions of, 102–103b logical form of, 694
nursing communities acceptance of, 107–109 major assumptions of, 692–693
research publications related to, 110–111t major concepts & definitions of, 690b
summary of, 113–114 nursing communities acceptance of, 695
theoretical assertions of, 106 theoretical assertions of, 693–694
theoretical sources for, 100–103 theoretical sources for, 689–690
Burke, Mary Lermann, 609–625. See also Chronic Caring between phenomenon, 363, 365
Sorrow Theory Caring communion, 174–175, 180
background of, 609–612 Caring culture, 176
credentials of, 609–612 Caring from the heart model, 368–369
Burke/Eakes Chronic Sorrow Assessment, 617 Caring Inquiry Dynamics, 108–109

724 Index

Caring relationships, 67, 178 Clarity (Continued)
Caritas, 82, 178 in Behavioral System Model, 346
in Caritative Caring Theory, 174 in Bureaucratic Caring Theory, 111–112
process, 82t in Caring, Theory of, 695
Caritas-based theory, 184 in Caritative Caring Theory, 183
Caritative caring ethics, 174, 175 in Chronic Sorrow Theory, 617
Caritative Caring Theory, 171–202 in Comfort Theory, 666
case study based on, 184–185b in Conservation Model, 211
critiquing of, 183–184 in Goal Attainment Theory, 267
empirical evidence for, 176–177 in Health as Expanding Consciousness Theory, 454
further developments by, 183 in Health Promotion Model, 404
logical form of, 180–181 in Humanbecoming Theory, 478
major assumptions of, 177–179 in Illness Trajectory Theory, 601
major concepts & definitions of, 174–176b in Maternal Role Attainment Theory, 550–551
nursing communities acceptance of, 181–183 in Modeling and Role-Modeling Theory, 508
summary of, 184–185 of Nightingale’s works, 69–70
theoretical assertions of, 179–180 in Nursing as Caring Theory, 370
theoretical sources for, 173–176 in nursing theory, analysis of, 10
Cassandra, 68 in Peaceful End-of-Life Theory, 705
Casual process, 29, 30–31 in Philosophy of Caring Theory, 160
Center for Epidemiological Studies Depression (CES-D) scale, in Postpartum Depression Theory, 681
576–577 in Self-Care Deficit Theory of Nursing, 250
Center for Human Caring, 80 in Self-Transcendence Theory, 582–583
Center on Infant Mental Health and Development, 51 in Symphonological Bioethical Theory, 530–531
Certainty, 470, 526 in Systems Model, 291
CES-D. See Center for Epidemiological Studies Depression in Theory of Nursing Practice Expertise, 134
(CES-D) scale in Tidal Model of Mental Health Recovery, 642–643
Changes, 382–383 in Transitions Theory, 387
Chaos theory, 100–101, 104–105, 560, 629 in Transpersonal Caring, 88
Chaotic sense of reality, 637–638 in Uncertainty in Illness Theory, 563–564
Chardin, Pierre Teilhard De, 284 in Unitary Human Beings Theory, 230
Charity, 178 Classification gaze, 154
Child abuse, 616 Clayton College, 716
Child care stress, 676 Cleanliness, 63–64
Child Health Assessment Interaction Theory, 52 Client system
Child-rearing attitudes, 541 basic structure of, 284
Children’s Hospital of the University of Wisconsin, 506 line of defense, 284
Choice, 348 lines of resistance, 284
Chronic sorrow, 613 in Systems Model, 284
concept of, 612 Clinical forethought, 128
definition of, 613 Clinical grasp, 128
triggers of, 613–614 Clinical judgment, 135
Chronic Sorrow Theory, 609–625 Clinical knowledge, 134–135
case study based on, 619b Clinical nurse specialists (CNSs), 132
critiquing of, 617–619 Clinical Nursing: A Helping Art, 47–48
empirical evidence for, 613–614 Clinical nursing, elements specified by, 48
further developments by, 617 Clinical Nursing Research journal, 33
logical form of, 615 Clinical practice development models (CPDMs), 121
major assumptions of, 614–615 Clinical wisdom in nursing practice. See Theory of Nursing
major concepts & definitions of, 613b Practice Expertise
nursing communities acceptance of, 615–616 Closeness, 703
summary of, 619 CNSs. See Clinical nurse specialists (CNSs)
theoretical assertions of, 615 Coaching for stress reduction, 661
theoretical sources for, 612–613 Coconstitution, 466
Claritas, 178 Coexistence, 466
Clarity Cognator subsystem, 306
in Adaptation Model, 319 Cognitive Adaptation Processing Scale, 315

Index 725

Cognitive capacities, 557 Connecting-separating, 469, 476–477
Cognitive coping mechanisms, 614 Conover, Martin, 241
Cognitive development, 499 Conscience, 359–360
Cognitive schema, 557 Consciousness, 444–445, 448–450
Cognitive stages of lifetime development, 501 concept of, 448
Collectivist humanity, 160 reflection of, 448
Comfort shared, 452
in Comfort Theory, 660 Consensus, 19, 20
defined, 660 Conservation
holistic, 661 in Conservation Model, 207
interventions for, 660 of energy, 207
mental, 658 of personal integrity, 208
in Peaceful End-of-Life Theory, 703 principles of, 207–208
Comfort Daisies, 665–666 of social integrity, 208
Comfort Theory, 657–671 of structural integrity, 207
case study based on, 667b Conservation Model, 203–219
conceptual framework for, 661f case study based on, 211–213b
critiquing of, 666–667 critiquing of, 211
empirical evidence for, 660–662 empirical evidence for, 208
further developments by, 665–666 further developments by, 211
logical form of, 663–664 logical form of, 209
major assumptions of, 662 major assumptions of, 208–209
major concepts & definitions of, 659–660b major concepts & definitions of, 206–208b
nursing communities acceptance of, 664–665 nursing communities acceptance of, 210–211
summary of, 667 summary of, 211–213
theoretical assertions of, 662–663 theoretical assertions of, 209
theoretical sources for, 658–660 theoretical sources for, 205–208
Commitment, 359–360 Consortium on Caring Science, 715
Common Journey Breast Cancer Support Group, 292 Contemporary theories of science, 18–19
Community-based health action model, 475–476 Context, 527
Community conditions, 383 of awareness, 524–525
Comparative care, inclusion of, 428–429 environmental, 422, 659
Compassion, 359–360 of knowledge, 524–525
Competency, 124–126, 134, 359–360 physical, 659
Competency-based testing, 132 psychospiritual, 659
Complete person, 363 sociocultural, 659
Complex Caring Dynamics, 108–109 in Symphonological Bioethical Theory, 522
Complexity, 101–102 Contextual stimulus, 293, 306
Complexity theory, 104 Continuous concepts, 24, 25
Comportment, 359–360 Continuum of care, 634–635
Concept analysis, 26 Contradictory axioms, 30
Concept-building process, 26–27 Control
Concepts, 24–27 in Behavioral System Model, 335
abstract, 24 loss of, 675
analysis of, 26 regaining, 675
classifying, 24 Cooperative inquiry, 453–454
concrete, 24 Coping, 123, 563
continuous, 24, 25 acquired mechanisms for, 306
defined, 24 cognitive strategies, 614
development of, 25–26 emotional strategies, 614
discrete, 24, 25 innate mechanisms of, 306
nonvariable, 24, 25 internal strategies, 612–613, 614
Conceptual system development, 261–262 interpersonal strategies, 614
Concrete concepts, 24 processes of, 306
Conditions, 28, 383 Core, Care, and Cure model, 48–50
Confidence, 359–360 Core ideas, 472
Conforming-not conforming, 470 Corrective mental provision for Transpersonal Caring, 82

726 Index

Cotranscending with possibles Deduction, 180, 528, 663–664
in Humanbecoming Theory, 470 Deductive inquiry, 16
originating, 470 Deductive logic, 287, 450, 706
powering, 470 Deductive reasoning, 23
transforming, 470 Deductive reformulation, 575
Counselor, 43–44 Deductive science, 15
CPDMs. See Clinical practice development models (CPDMs) Deductive thinking, 340
Created environment, 284, 287 Degree of reaction, 285
Credible authority, 557 Degree on a continuum, 25
Criterion-Reference Measure of Goal Attainment Tool, 262–263 Deliberate action, 242–243
Critical events, 383 Demand
Critical hermeneutics, 154 dependent-care, 246
Critical incidents, 131 immediate competing, 400
Critical points, 383 therapeutic self-care, 245
Cross-cultural nursing, 420 Den Mångdimensionella Hälsan (Multidimensional Health), 182
Cues of infant, 542 Deontology, 521–522
Culturally based caring, 424 Dependency subsystems, 334–335, 346–347
Culturally competent nursing care, 422 Dependent-care, 244, 250–251
Culturally sensitive care, 529 deficit, 246, 251
Cultural structure dimensions, 422 demand, 246
Culture Dependent-care agency, 246, 250–251
caring, 176 Dependent-care system, 251
in Culture Care Theory of Diversity and Universality, 421 Dependent-care theory, 248–249
inclusion of, 428–429 Depression, 541
Culture care, 421 history of, 676
accommodation in, 422 postpartum, 675
diversity in, 421 prenatal, 676
maintenance in, 422 Derivable consequences, 70–71, 88
negotiation in, 422 De Shazer, Steve, 629
preservation in, 422 Deterministic model, 28
repatterning in, 422 Developmental Resources of Later Adulthood (DRLA), 576–577
restructuring in, 422 Developmental self-care requisites, 245
universality in, 422 Diet, 63–64
Culture Care Theory of Diversity and Universality, 417–441 Differences, in transition experiences, 382–383
case study based on, 432b Differential Caring, 103, 106
critiquing of, 431–432 Dignity, 175, 703
empirical evidence for, 423–424 Direct invitation, 361, 365
further developments by, 430–431 Disciplinary knowledge, 471
logical form of, 425–427 Disciplines
major assumptions of, 424–425 for graduate research education, 616
major concepts & definitions of, 421–422b meaning of, 6b
nursing communities acceptance of, 427–430 of nursing, 20–21, 363–364, 420
summary of, 432 nursing theory, significance of, 6–8
theoretical assertions of, 425 scientific, 14
theoretical sources for, 420–422 Discovery, 633
Curing, 85 Discrete concepts, 24, 25
Curriculum era, 3 Disequilibrium, 346
Disorders, 340–341. See also Postpartum mood disorders
D attention-deficit/hyperactivity, 317
behavior, 346
Dalhousie University, 641 postpartum obsessive-compulsive, 675
Dance of Caring Persons, 364, 368, 369 postpartum-onset panic, 675
Da Silva, Antonio Barbosa, 174 Disturbances, 346
Decision-making Diversity, culture care, 421
end-of-life, 582, 704 Dodd, Marylin J., 593–608. See also Illness Trajectory Theory
ethical, 527, 531 background of, 593–595
model of, 526–528 credentials of, 593–595
scientific problem-solving method for, 82 Doing, dimension of health, 179

Index 727

Doing for, 690, 695 Education (Continued)
Domains undergraduate, 615–616
of inquiry enabler, 427 in Unitary Human Beings Theory, 226–227
others, 633, 643 Educational structures, 112
self, 632–633, 643 Effective management, 613
of Theory of Nursing Practice Expertise, 126 Efficient drainage, 63–64
of Tidal Model of Mental Health Recovery, 632–633 Einstein, Albert, 15, 222–223
world, 633, 643 theory of relativity, 30, 222–223
Dreyfus, Hubert, 122 Eliminative subsystems, 335, 346–347, 348
Dreyfus Model of Skill Acquisition, 122, 123, 131, 134. See also Embodied knowing, 123
Theory of Nursing Practice Expertise Emic, 421, 422
Drive, 348 Emotional coping mechanisms, 614
DRLA. See Developmental Resources of Later Adulthood (DRLA) Emotional liability, 677
Dunne, Joseph, 122 Emotional support, 542
Dying of self, 675 Emotivism, 521–522
Empathy, 371
E Empirical evidence
in Adaptation Model, 308
Eakes, Georgene Gaskill, 609–625. See also Chronic Sorrow in Behavioral System Model, 336–337
Theory in Bureaucratic Caring Theory, 102–105
background of, 609–612 in Caring, Theory of, 690–692
credentials of, 609–612 in Caritative Caring Theory, 176–177
Earthquake model, 674 in Chronic Sorrow Theory, 613–614
Ease, 658 in Comfort Theory, 660–662
Eating disturbances, 677 in Conservation Model, 208
Economic factors, 103 in Culture Care Theory of Diversity and Universality, 423–424
Economic structures, 112 in Goal Attainment Theory, 260–263
Education, 615–616 in Health as Expanding Consciousness Theory, 445
in Adaptation Model, 314 in Health Promotion Model, 401
in Behavioral System Model, 343 in Humanbecoming Theory, 471–472
in Bureaucratic Caring Theory, 102, 108 in Illness Trajectory Theory, 597–599
in Caritative Caring Theory, 181 in Maternal Role Attainment Theory, 540–543
in Chronic Sorrow Theory, 615–616 in Modeling and Role-Modeling Theory, 502–505
in Comfort Theory, 664 in Modern Nursing, 64–65
in Conservation Model, 210 Nightingale’s use of, 64–65
continuing, 616 in Nursing as Caring Theory, 362
in Culture Care Theory of Diversity and Universality, 428–429 in Peaceful End-of-Life Theory, 702–703
in Goal Attainment Theory, 266 in Philosophy of Caring Theory, 154–156
graduate research, 616 in Postpartum Depression Theory, 678
in Health as Expanding Consciousness Theory, 452–453 in Self-Care Deficit Theory of Nursing, 247
in Health Promotion Model, 404 in Self-Transcendence Theory, 576–577
in Humanbecoming Theory, 476 in Symphonological Bioethical Theory, 523–524
in Illness Trajectory Theory, 600 in Systems Model, 282–285
in Maternal Role Attainment Theory, 549 in Theory of Nursing Practice Expertise, 126–128
in Modeling and Role-Modeling Theory, 506 in Tidal Model of Mental Health Recovery, 635–636
Nightingale’s principles of, 68–69 in Transitions Theory, 384–385
in Nursing as Caring Theory, 366–367 in Transpersonal Caring, 84
in Peaceful End-of-Life Theory, 704–705 in Uncertainty in Illness Theory, 558–559
in Philosophy of Caring Theory, 159 in Unitary Human Beings Theory, 222–223
in Postpartum Depression Theory, 680 Empirical patterns, 371
in Self-Transcendence Theory, 580 Empirical precision, 70, 88
in Symphonological Bioethical Theory, 529 Empiricism, 15–16
in Systems Model, 289 Empiricist science, 15
in Theory of Nursing Practice Expertise, 132–133 Empowering Interactions Model, 636
in Tidal Model of Mental Health Recovery, 641 Empowerment, 317–318, 629, 636
in Transitions Theory, 386 Enabler
in Transpersonal Caring, 87 acculturation health assessment, 427
in Uncertainty in Illness Theory, 561–562 inquiry, 427

728 Index

Enabler (Continued) Erickson, Helen C., 496–519. See also Modeling and Role-
observation participation reflection, 427 Modeling Theory
stranger to trusted friend, 427 background of, 496–498
Enabling, 690 credentials of, 496–498
Enabling-limiting, 469 Erickson Maternal Bonding-Attachment Tool, 504–505
Enabling process, 690, 695 Erikkson, Katie, 150, 171–202
Encountering terror, 675 credentials of, 171–173
End-of-Life Care, 704 Erikkson Psychosocial Stage Inventory, 504–505
End-of-life decision making, 582, 704 Essential values, 630–632b
End-of-own-life issues, 578 Eternity, 175
Endowment, inherent, 501 Ethical behavior, 525–526
Energy, conservation of, 207 Ethical comportment, 126
Energy field, 222 Ethical decisions, 527, 531
Enfolded order, 101 Ethical interaction, 529
Engagement, 382, 628–629, 634 Ethical patterns, 371
Engineered me, 642–643 Ethical standards, 525–526
Environment Ethics, 521
in Adaptation Model, 310 caritas-based caring, 174
assessment of, 348 caritative caring, 175
in Behavioral System Model, 338 human existence, as primary condition of, 152–153
in Bureaucratic Caring Theory, 105–106 in nursing practice (See Theory of Nursing Practice Expertise)
in Caring, Theory of, 693 Ethnohistory, 422
in Caritative Caring Theory, 179 Ethnomethodology, 19–20
in Chronic Sorrow Theory, 614–615 Ethnonursing, 423, 424, 429
in Comfort Theory, 662 Ethnonursing Research Method, 425, 430
conceptual models of, 4–5 Ethos, 179
in Conservation Model, 206, 209 Etic, 421, 422
context of, 422, 659 European Standards for Nursing, 52–53
created, 284, 287 Evaluation, 340–341
in Culture Care Theory of Diversity and Universality, 424–425 Events
external, 287 congruence, 557
facilitative, 663 critical, 383
in Goal Attainment Theory, 263 familiarity with, 557
in Health as Expanding Consciousness Theory, 447 trigger, 613
internal, 287 Everyday-life work, 596
in Maternal Role Attainment Theory, 544 Examining gaze, 154
metaparadigm of, 4–5 Excess disabilities, 663
in Modeling and Role-Modeling Theory, 505 Exemplar, 126
modern nursing, 63–64 Exercise Benefits-Barriers Scale (EBBS), 401
Nightingale’s concept of, 65–66 Existence statements, 30–31
in Nursing as Caring Theory, 363 Existential being as caring, 152
in Peaceful End-of-Life Theory, 703 Existential-phenomenological forces, allowance for, 82
in Philosophy of Caring Theory, 157–158 Experiences, 126, 471–472, 642
in Postpartum Depression Theory, 678 Experiential process of nurse-client, 450
in Self-Transcendence Theory, 578 Expert, 125, 134
spiritual, 82 Explicate conscious level, 101
in Symphonological Bioethical Theory, 522–523, 524–525 Explicit-tacit imaging, 468
in Systems Model, 283–284, 287 Exploitation of nurse-patient relationship, 43–44
theoretical assertions in, 86 External environment, 287
in Tidal Model of Mental Health Recovery, 638 External management, 614
in Transitions Theory, 385 Extraction-synthesis process, 472
in Unitary Human Beings Theory, 224 Eye of the heart concept, 156
Episteme Award, 51
Epistemology, 14–15, 16 F
analysis of, 16
rationalist, 15 Facilitative environment, 663
Equilibrium, 223, 335 Facilitators, 406
Equilibrium adaptation, 346 Faith-hope, instillation of, 82

Index 729

Family, 542 Generality (Continued)
Far-from-equilibrium system, 560 in Transitions Theory, 387
Father, Maternal Role Attainment Theory, 544 in Transpersonal Caring, 88
Fawcett, Jacqueline, 252, 689 in Uncertainty in Illness Theory, 564
Fear, 445 in Unitary Human Beings Theory, 230–231
Feedback, 283 Generalization, 135
Feelings, promotion and acceptance, 82 Gestalt theory, 282
Fidelity, 532 Getting in the swim, engagement process and, 634
Fight or flight syndrome, 206–207 Glasgow mental health services, 640
Flanagan’s Critical Incident Technique, 636 Global communities of nursing scholars, 715–716
Flexibility, 541 Goal, 348
Flexible line of defense, 284 Goal Attainment Theory, 258–280. See also Middle-Range Theory
Florida Nurses’ Association (FNA), 259 case study based on, 268–269b
Focal stimulus, 293, 306 credentials of, 258–260
Formal stage of Maternal Role Attainment Theory, 545 empirical evidence for, 260–263
Foss, Else, 159 further developments by, 267
Foucault, Michel, 151, 153–154 logical form of, 265
Fourth National Conference on Modeling and Role-Modeling major assumptions of, 263
Theory and Paradigm, 506, 507–508 major concepts & definitions of, 260b
Frankel, Victor, 50 Nightingale tribute to, 258–260
Frank-Stromborg, Marilyn, 397 nursing communities acceptance of, 265–267
Freedom, 466–467, 473, 532 propositions within, 264b
Free from pain, 703 summary of, 268–269
Functional requirements, 335, 348 theoretical assertions of, 263
theoretical sources for, 260
G Goal-oriented nursing record (GONR), 265
Gomez, Olga J., 108
Gable, Robert, 674 Good death analysis, 704
Gadamer, Hans-Georg, 173 Graduate education era, 4
General Comfort Questionnaire, 659, 661, 665–666 Graduate research education, 616
Generality Gratification-satisfaction, 541
in Adaptation Model, 319–320 Grief, morbid, 499–500
in Behavioral System Model, 346 Grounded theory approach, 102, 598–599, 600, 602
in Bureaucratic Caring Theory, 112 Group identity, 284
in Caring, Theory of, 696 Growing conscience-like feeling, 445
in Chronic Sorrow Theory, 618 Guided imagery, 660–661
in Comfort Theory, 666 Guilt, 677
in Conservation Model, 211
in Culture Care Theory of Diversity and Universality, 431 H
in Goal Attainment Theory, 268
in Health as Expanding Consciousness Theory, 454 Hainsworth, Margaret A., 609–625. See also Chronic Sorrow
in Health Promotion Model, 404–405 Theory
in Humanbecoming Theory, 478–479 background of, 609–612
in Illness Trajectory Theory, 602 credentials of, 609–612
in Maternal Role Attainment Theory, 551 Hall, Lydia, 48–50
in Modeling and Role-Modeling Theory, 508 Hall, Sir John, 61–62
of Nightingale’s works, 70 Hand massage, 661
in Nursing as Caring Theory, 370 Healing touch, 661
in nursing theory, analysis of, 10 Healing web, 452–453
in Peaceful End-of-Life Theory, 705–706 Health
in Philosophy of Caring Theory, 160 in Adaptation Model, 309–310
in Postpartum Depression Theory, 681 in Behavioral System Model, 338
in Self-Care Deficit Theory of Nursing, 251 in Bureaucratic Caring Theory, 105
in Self-Transcendence Theory, 583 in Caring, Theory of, 693
in Symphonological Bioethical Theory, 531 in Caritative Caring Theory, 179
in Systems Model, 291 in Chronic Sorrow Theory, 614
in Theory of Nursing Practice Expertise, 134–135 in Comfort Theory, 662
in Tidal Model of Mental Health Recovery, 643–645 conceptual models of, 4–5, 32

730 Index

Health (Continued) Health Promotion Model (HPM), 396–416, 400f
in Conservation Model, 209 background of, 396–398
in Culture Care Theory of Diversity and Universality, 422, 424 case study based on, 405–406b
definition of, 474 credentials of, 396–398
deviation, 245 critiquing of, 404–405
dimensions of, 179 empirical evidence for, 401
in Goal Attainment Theory, 263 further developments by, 404
in Health as Expanding Consciousness Theory, 444, 447–448 logical form of, 403
in Humanbecoming Theory, 474 major assumptions of, 401–403
humanuniverse, viewed as, 474 major concepts & definitions of, 399–400b
illness, 284 nursing communities acceptance of, 403–404
justice, 640 revised, 402f
as mastery, 380 summary of, 405–406
in Maternal Role Attainment Theory, 544 theoretical assertions of, 403
meaning of, 445 theoretical sources for, 398–400
mental, 577 Health-seeking behaviors, 660
metaparadigm of, 4–5 Healthy People 2020, 405
in Modeling and Role-Modeling Theory, 505 Healthy Start CORPS: Inter-Conceptual Care Case Management
Nightingale’s definition of, 65 Project, 680
in Nursing as Caring Theory, 363 Heidegger, Martin, 149–150, 152
passive, 223 Helicy, 224–225, 466
in Peaceful End-of-Life Theory, 703 Helping methods, 246
personhood is living life grounded in caring, 363 Helping-trust relationship, development of, 82
phases of, 32 Henderson, Virginia, 45–46, 52
in Philosophy of Caring Theory, 157 nurse-patient relationships, levels identified by, 45–46
in Postpartum Depression Theory, 678 nursing defined by, 45–46
rituals of, 445 scope of influence of, 45
in Self-Transcendence Theory, 578 Herbert, Sidney, 61
status, 541, 542 Hermeneutic dialectic, 453–454
in Symphonological Bioethical Theory, 523, 524 Hermeneutic phenomenology, 154
in Systems Model, 284, 287 Hermeneutics, 126, 154
theoretical assertions of, 86 HIV. See Human immunodeficiency virus (HIV)
in Theory of Nursing Practice Expertise, 130 Holism, 20, 206, 333, 501
in Tidal Model of Mental Health Recovery, 637–638 Holistic comfort, 661
in Transitions Theory, 385 Holistic intervention, 660–661
in Unitary Human Beings Theory, 223–224 Holistic science, 15
wellness and, 284 Hologram, 101
Health as Expanding Consciousness Theory, 442–463 Holographic theory, 108
case study based on, 455b Holographic Theory of Bureaucratic Caring Theory, 105f
critiquing of, 454 Holography, 102
empirical evidence for, 445 Homeodynamics, 224–225, 224t
further developments by, 454 Homeostasis, 223
logical form of, 450 Hopkins Clinical Assessment of APAM, 504–505
major assumptions of, 445–448 HPLP-II. See Health Promotion Lifestyle Profile II (HPLP-II)
major concepts & definitions of, 444–445b HPM. See Health Promotion Model (HPM)
nursing communities acceptance of, 450–454 Humanbecoming Theory, 464–495
summary of, 454–455 case study based on, 481b
theoretical assertions of, 448–450 conceptualization of, 466
theoretical sources for, 443–445 critiquing of, 478–481
Health care administration, 529 empirical evidence for, 471–472
Health care needs, 659–660 logical form of, 475
Health care teams, 529 major assumptions of, 472–474
Health is the expansion of consciousness thesis, 446 major concepts & definitions of, 468–470b
Health-promoting behavior, 400 mentoring model, 480
Health Promotion Lifestyle Profile, 401, 404, 405 nursing communities acceptance of, 475–478
Health Promotion Lifestyle Profile II (HPLP-II), 401 summary of, 481

Index 731

Humanbecoming Theory (Continued) Immediate preferences, 400
theoretical assertions of, 474 Implicate conscious level, 101
theoretical sources for, 465–470 Importance
Human being, 265. See also Personhood in Adaptation Model, 320
Human care, 421 in Behavioral System Model, 346
Human cognitive functioning, 17 in Bureaucratic Caring Theory, 112–113
Human existence, ethics as primary condition of, 152–153 in Caring, Theory of, 696
Human experience, all-at-onceness of, 467 in Caritative Caring Theory, 184
Human immunodeficiency virus (HIV), 453, 581, 616 in Chronic Sorrow Theory, 618–619
Humanistic values, 83 in Comfort Theory, 666–667
Humanity, 70, 160 in Conservation Model, 211
Human needs, 82, 499 in Culture Care Theory of Diversity and Universality, 432
Humanness, 363 in Goal Attainment Theory, 268
Human science, 479–480. See also Nursing in Health as Expanding Consciousness Theory, 454
Human social systems, 290 in Health Promotion Model, 405
Human subjectivity, 466 in Humanbecoming Theory, 479–481
Human-to-Human Relationship model, 50–51 in Illness Trajectory Theory, 602
Humanuniverse, 466, 467, 474 in Maternal Role Attainment Theory, 551
Husserl, Edmund, 16, 149–150, 151–152 in Modeling and Role-Modeling Theory, 508
Husted, Gladys L. and James H., 520–536. See also in Nursing as Caring Theory, 370
Symphonological Bioethical Theory in nursing theory, analysis of, 10–11
background of, 520–521 in Peaceful End-of-Life Theory, 706–707
credentials of, 520–521 in Philosophy of Caring Theory, 161
Husted Symphonological model, 528 in Postpartum Depression Theory, 682
in Self-Care Deficit Theory of Nursing, 251–252
I in Self-Transcendence Theory, 583
in Symphonological Bioethical Theory, 531
ICN. See International Council of Nurses (ICN) in Systems Model, 291–292
Identification, phase of nurse-patient relationship, 43–44 in Theory of Nursing Practice Expertise, 135–136
Identity in Tidal Model of Mental Health Recovery, 646
in Illness Trajectory Theory, 596 in Transitions Theory, 387
maternal, 541, 550 in Uncertainty in Illness Theory, 564
personal role, 546 in Unitary Human Beings Theory, 231
role, 550 Individual, 265
Illimitability, 467, 473 Individuation, affiliated, 499–500, 501
Illinois Nurses Association, 205 Induction, 180, 528, 663
Illness, 284 Inductive logic, 287, 450, 706
health, 284 Inductive method, 15–16
mental, 638, 639 Inductive reasoning, 23, 67, 600
related to work, 596 in Modern Nursing, 67
suffering related to, 175–176 Nightingale, use of, 67
Illness Trajectory Theory, 593–608 Inductive science, 15
case study based on, 602–603b Inductive thinking, 340
critiquing of, 601–602 Ineffective management, 613
empirical evidence for, 597–599 Ineffective responses, 306
further developments by, 601 Ineffective transitions, 379
logical form of, 600 Infant
major assumptions of, 599 characteristics of, 542
major concepts & definitions of, 596–597b cues of, 542
nursing communities acceptance of, 600–601 health status of, 542
summary of, 602–603 temperament of, 542, 676
theoretical assertions of, 599–600 Infectious diseases, 68
theoretical sources for, 595–597 Inference, 180, 557
Illusion, 557 Infinity, 175
Imaging, 468 Inflammatory response, 207
Immediate competing demands, 400 Informal stage of Maternal Role Attainment Theory, 545