432 UNIT IV Nursing Theories express that this theory and method makes sense to
use in nursing. They contend that the theory is natu-
Importance ral to nursing and leads to fresh insights about care,
Transcultural nursing theory has important outcomes health, and well-being. Unquestionably, it is the the-
for nursing. Rendering culture-specific care is an ory of today and tomorrow in our growing and
essential goal in nursing. It places the transcultural increasingly multicultural world. The research and
nursing theory central to the domain of nursing theory provide a pathway to advance the profession of
knowledge acquisition and use. The theory is highly nursing and the body of transcultural knowledge for
useful, applicable, and essential to nursing practice, application in nursing practice, education, research,
education, and research. The concept of care as the and clinical consultation worldwide.
primary focus of nursing and the base of nursing
knowledge and practice is long overdue and essential CASE STUDY
for advancing nursing knowledge and practices. This An elderly Arab-American Muslim man who
theory could be the means to establish a sound and spoke little English was admitted to the hospital
defensible discipline and profession, guiding practice for increasing pain in his left foot while at rest. His
to meet a multicultural world. foot was cool and pale, and he had a history of
vascular surgical procedures. He had many chronic
Summary health problems, including type 2 diabetes, hyper-
tension, and chronic obstructive pulmonary dis-
This chapter introduces Dr. Madeline Leininger, who ease. He also had had a myocardial infarction and
has championed the nature, importance, and major several cerebral vascular accidents. While in the
features of the Theory of Culture Care Diversity and hospital, he developed abdominal pain and under-
Universality. Leininger’s ethnonursing research method went a cholecystectomy. This elderly grandfather
and the enablers are presented to show the fit between had a large family, including a wife, nine children,
the theory and the method. Fully understanding the and many grandchildren. His wife insisted that all
theory and the method (with the enablers) leads to family members visit him every day while he was
credible and meaningful study findings. With under- in the hospital. The family wanted the man’s face
standing, the research becomes meaningful, exciting, turned toward Mecca (toward the East) while they
and rewarding to do, and the researcher develops con- prayed with him. They brought tape-recorded pas-
fidence and competence in use of the theory and the sages from the Koran, which they played at his
method. bedside. Other families who were visiting their
sick relatives complained to the nurses that the
As a premier theory in nursing, culture care is Arab family was taking up the entire waiting
greatly valued worldwide. Other disciplines have also room, and there was no place for anyone else to sit.
found the theory and the method helpful. Nurses who
use the theory and the method frequently communi- As a nurse, how might you use the three modes
cate how valuable it is to discover culturally based from the Theory of Culture Care Diversity and
ways to know and practice. Practicing nurses now Universality to provide culturally congruent care
have holistic, culturally based research findings for for this elderly man and his family, as well as for
use as they care for clients of diverse and similar the other clients and their families in the critical
cultures or subcultures in different countries. New- care unit?
comers to the theory and the method may benefit
from experienced expert mentors in addition to
studying transcultural research conducted using the
theory and the method. Most important, nurses often
CHAPTER 22 Madeleine M. Leininger 433
CRITICAL THINKING ACTIVITIES minerals, and other over-the-counter medica-
tions and preparations, which demands a trans-
1. Select four research studies reported in the Journal cultural knowledge base
of Transcultural Nursing that used Leininger’s g. Spiraling health care costs; forced use of health
Theory of Culture Care Diversity and Universality. maintenance organizations; lack of health in-
Select studies that represent different cultures, surance; increased reliance on self-diagnosis,
different research settings, and culture that is treatment, and care; and increased availability
different from your own. of diagnostic test kits for acquired immunode-
a. Review each of the studies and outline the rela- ficiency syndrome, glucose monitoring, choles-
tionship of the theory to the domains of inquiry, terol screening, ovulation and pregnancy, fecal
purpose, assumptions, definitions, methods, occult blood, and the like
research design, data analysis, nursing deci- h. Problems related to cultural conflicts, stress,
sions, and conclusions. pain, and cultural imposition practices
b. Identify evidence from these studies, and confirm 3. Arrange an interview experience at a health center
the Theory in relation to the domain of inquiry or public health department with persons of diverse
theory tenets and derivable consequences. cultures. Ascertain the following:
a. Identify the cultures represented by the clientele
2 . Imagine you are to give a 3-minute class presenta- with the use of Leininger’s theory and the Sunrise
tion on the usefulness of the Theory of Culture Enabler.
Care Diversity and Universality in the twenty-first b. What is the cultural mix of the staff (physicians,
century and prepare an outline of your presenta- nurses, social workers, and clerics) of the center
tion. Consider the current trends of consumers or health department? How does the cultural
of health care, cultural diversity factors, and background of the staff differ from that of the
changes in medical and nursing school curricula. clientele?
Following are some examples of trends and c. Arrange a conference with the director and
changes you may want to consider: nursing staff, and ascertain their culture-based
a. The importance of transcultural nursing knowl- attitudes, values, and beliefs, and those that are
edge in an increasingly diverse world reflected in the clients using the center or de-
b. Growth of lay support groups to provide infor- partment. Compare and contrast the values,
mation and sharing of experiences and support attitudes, and beliefs of the staff with those of
for clients, families, and groups experiencing the clients. What are the cultural similarities
chronic, terminal, or life-threatening illnesses and differences?
or treatment modalities from diverse or similar d. Survey the printed materials (e.g., visual aids,
(common) cultures artifacts, and paintings) in the waiting and
c. Use of cultural values, beliefs, health practices, examination rooms and in the classrooms to
and research knowledge in undergraduate and identify the cultures and languages that are
graduate nursing curricula across the life span depicted.
d. Inclusion of alternative or generic care in nurs- e. On the basis of data obtained from this experi-
ing curricula, such as medicine men (Native ence, how can the Theory of Culture Care
American healers, curers, and herbalists in the Diversity and Universality be used to provide
Southwest) and selected substantiated Chinese culturally sensitive and congruent care to cli-
methods shown to be effective for the treatment ents who use the center or department?
of chronic disease 4. Identify the type of prerequisite knowledge, expe-
e. Use of cultural caring research knowledge as riences, attitudes, and skills needed to effectively
the new and future direction of nursing in the use the Theory of Culture Care Diversity and
twenty-first century Universality.
f. The increased number of books, audiotapes,
and videotapes published on health mainte-
nance, alternative medicine, herbs, vitamins,
434 UNIT IV Nursing Theories n Leininger, M. M. (2011). Leininger’s reflection on
her ongoing father protective care research. Online
POINTS FOR FURTHER STUDY Journal of Cultural Competence in Nursing and
Healthcare, 1(2), 1–13.
n Leininger, M. M. (2006). Envisioning the future of
the culture care theory and the ethnonursing n McFarland, M. R., & Eipperle, M. K. (2008).
method. In M. M. Leininger and M. R. McFarland Culture care theory: A proposed theory guide
(Eds.), Culture care diversity and universality: A for nurse practitioners in primary care settings.
worldwide theory of nursing (2nd ed., pp. 389–394). Contemporary Nursing Journal, 28(2), 48–63.
Sudbury, (MA): Jones & Bartlett.
n McFarland, M. R., Mixer, S. J., Webhe-Alamah,
n Leininger, M., & McFarland, M. R. (2006). Trans- H., Burk, R. (2012). Ethnonursing: A qualitative
cultural nursing: The theory of culture care. DVD research method for all disciplines. Online Inter-
set of three. national Journal of Qualitative Methods, 11(3).
University of Alberta, Canada.
n Morgan, M. G. (2010). Leininger’s theory of culture
care diversity and universality in nursing practice. n McFarland, M., Wehbe-Alamah, H., Wilson, M., &
In M. R. Alligood (Ed.), Nursing theory: Utilization Vossos, H. (2011). Synopsis of findings discovered
and application (4th ed., pp. 411–428). Maryland within a descriptive meta-synthesis of doctoral
Heights, (MO): Mosby-Elsevier. dissertations guided by the Culture Care Theory
with use of the ethnonursing research method.
n Leininger, M. (1998). Transcultural Nursing Society Online Journal of Cultural Competence in Nursing
website at: www.tcns.org. and Healthcare, 1(3), 24–39.
n Leininger, M. (2005). Major contributions of n Miller, J. E., Leininger, M., Leuning, C., Paquiao, D.,
qualitative and quantitative criteria to evaluate Andrews, M., Ludwig-Beymer, P., Papadopoulos, I.
research. PowerPoint Presentation. Available at: (2008). Transcultural nursing society position state-
www.madeleine-leininger.com. ment on human rights. Unpublished manuscript.
Available at: www.madeleine-leininger.com.
n Leininger, M. M. (2007). The evolution of trans-
cultural nursing with breakthroughs to discipline
status. Unpublished manuscript. Available at:
www.madeleine-leininger.com.
n Leininger, M. M. (2008). TCN certification: A global
mandate. Unpublished manuscript. Available at:
www.madeleine-leininger.com.
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Leininger, M. (2011). Leininger’s reflection on the ongoing on infant feeding practices in western New York. Journal
father protective care research. Online Journal of Cul- of Transcultural Nursing, 11(1), 19–30.
tural Competence in Nursing and Healthcare, 1(2), 1–13.
Hubbert, A. (2008). A partnership of a Catholic-based
Leininger, M., & Cummings, S. H. (1996). Nursing’s new health system, nursing, and American Indian traditional
paradigm is transcultural nursing: An interview with medicine practitioners. Contemporary Nursing Journal,
Madeleine Leininger. Advanced Nursing Practice 28(2), 64–72.
Quarterly, 2(2), 62–70.
Leuning, C. L., Swiggum, P. D., Wiegert, H. M. B., &
Selected Secondary Sources McCullough-Zander, K. (2002). Proposed standards for
Books transcultural nursing. Journal of Transcultural Nursing,
Andrews, M. M., & Boyle, J. S. (2007). Transcultural con- 13(1), 40–46.
cepts in nursing care (5th ed.). Philadelphia: Lippincott. Mareno, N. (2012). Cultural competency in delivering
Fawcett, J. (2005). Leininger’s theory of culture care diversity family weight management programs: A summary of
lessons learned. Online Journal of Cultural Competence
and universality. In Analysis and evaluation of contempo- in Nursing and Healthcare, 2(1), 10–17.
rary nursing knowledge: Nursing models and theories
(pp. 511–547). Philadelphia: F.A. Davis. McFarland, M. R. (1997). Use of the culture care theory
Meleis. A. I. (1997). Theoretical nursing: Development and with Anglo- and African Americans in a long-term
Progress (3rd ed., pp. 245–274). Philadelphia: Lippincott. care setting. Nursing Science Quarterly, 10(4), 186–192.
Book Chapters
Ray, M. D., & McFarland, M. R. (invited 2012). Qualitative McFarland, M. R. (October 2010). Theoretical basis for
nursing methods: Ethnonursing, in D. E. Polit & C. T transcultural care: Theory of culture care diversity and
Beck (Eds.), Essentials of nursing research (8th ed.). universality (Madeleine Leininger). In D. F. Pacquiao
Oxon, UK: Taylor & Francis. and M. K. Douglas (Eds.), Core Curriculum for trans-
Selected Journal Articles cultural nursing and health care. Thousand Oaks, CA:
Aga, F., Kylmä, J., & Nikkonen, M. (2009). The conceptions Dual printing as supplement to Journal of Transcultural
of care among family caregivers of persons living with Nursing, 21(1), 92S- 101S.
HIV/AIDS in Addis Ababa, Ethiopia. Journal of Trans-
cultural Nursing, 20(1), 37–50. McFarland, M. R. (2010). Research methodologies for
Andrews, M. M. (2008). Global leadership in transcultural investigating cultural phenomena and evaluating inter-
practice, education, and research. Contemporary Nursing ventions: Ethnonursing: A research method designed to
Journal, 28(2), 13–16. facilitate discovery of data focused on Leininger’s theory
Berry, A. (1999). Mexican American women’s expressions of culture care diversity and universality (Leininger,
of the meaning of culturally congruent prenatal care. 2002a, p. 85). In D. F. Pacquiao and G. McNeal (Eds.),
Journal of Transcultural Nursing, 10(3), 203–212. Core Curriculum for Transcultural Nursing and Health
Bialoskurski, M., Cox, C. L., & Hayes, J. A. (1999). The Care. Thousand Oaks, (CA): Sage. Dual printing as
nature of attachment in a neonatal intensive care unit. supplement to Journal of Transcultural Nursing, 21(1),
Journal of Perinatal and Neonatal Nursing, 10(3), 66–77. 378S-380S.
McFarland, M. R., & Eipperle, M. K. (2008). Culture care CHAPTER 22 Madeleine M. Leininger 439
theory: A proposed theory guide for nurse practitio-
ners in primary care settings. Contemporary Nursing through the use of Leininger’s culture care modes. Con-
Journal, 28(2), 48–63. temporary Nursing Journal, 28(2), 83–97.
Wehbe-Alamah, H. (2011). The use of culture care theory
McFarland, M. R., Mixer, S. J., Webhe-Alamah, H., Burk, R. with Syrian Muslims in the Mid-western United States.
(2012). Ethnonursing: A qualitative research method Online Journal of Cultural Competence in Nursing and
for all disciplines. Online International Journal of Quali- Health-care, 1(3), 1–12.
tative Methods, 11(3). University of Alberta, Canada. Wehbe-Alamah, H., & McFarland, M. R. (2010). Cultural
health assessment: Leininger’s assessment guides. In
McFarland, M., Wehbe-Alamah, H., Wilson, M., & Vossos, H. D. F. Pacquiao and G. McNeal (Eds.), Core curriculum
(2011). Synopsis of findings discovered within a for transcultural nursing and health care. Thousand
descriptive meta-synthesis of doctoral dissertations Oaks, (CA): Sage. Dual printing as supplement to
guided by the Culture Care Theory with use of the eth- Journal of Transcultural Nursing, 21(1), 317S-322S.
nonursing research method. Online Journal of Cultural Wehbe-Alamah, H., McFarland, M. R., Macklin, J., &
Competence in Nursing and Healthcare, 1(3), 24–39. Riggs, N. (2011). The lived experiences of African
American women receiving care from nurse practitio-
Mixer, S. J. (2011). Use of the culture care theory to dis- ners in a nurse-managed clinic in an urban context.
cover nursing faculty care expressions, patterns, and Online Journal of Cultural Competence in Nursing and
practices related to teaching culture care. Online Jour- Healthcare, 1(1), 15–26.
nal of Cultural Competence in Nursing and Healthcare, Zoucha, R., Mayle, K., & Colizza, D. (2011). The bridging
1(1), 3–14. of transcultural response in health care and service
learning courses in a community based baccalaureate
Mixer, S., & McFarland, M. R. (2010). Cross cultural com- nursing curriculum: A natural connection. Online Jour-
munication: Use of Leininger’s action modes in conflict nal of Cultural Competence in Nursing and Healthcare,
resolution. In D. F. Pacquiao and G. McNeal (Eds.), 1(4), 1–10.
Core Curriculum for Transcultural Nursing and Health
Care. Thousand Oaks, (CA): Sage. Dual printing as Selected Projects Using Leininger’s Theory
supplement to Journal of Transcultural Nursing, 21(1), Wehbe-Alamah, H., McFarland, M. R., Farmer, M., Call, C.,
147S-150S.
& Jones, M. (2010). CultureCopia©: Developing a
Morris, E. (2012). Respect, protection, faith and love: Computer-based electronic transcultural simulation
Major care constructs identified within the subculture game based on Leininger’s culture care theory. Depart-
of selected urban African American adolescent gang ment of Nursing & Department Computer Science,
members. Journal of Transcultural Nursing, 23(3), Engineering, and Physics, University of Michigan, Flint.
262–269.
Selected Dissertations Using Leininger’s Theory
Omeri, A. (1997). Culture care of Iranian immigrants in (*mentored by Leininger)
New South Wales, Australia: Sharing transcultural *Berry, A. (1995). Culture care statements, meanings, and ex-
nursing knowledge. Journal of Transcultural Nursing,
8(2), 5–16. pressions of Mexican American women within Leininger’s
culture care theory. (Unpublished doctoral dissertation).
Pacquiano, D. A., Archeval, L., & Shelley, E. E. (1999). Wayne State University.
Transcultural nursing study of emic and etic care in the Bowles, M. E. (2009).Culture care beliefs, meanings, and
home. Journal of Transcultural Nursing, 10(2), 112–119. practices related to health and well-being of South Suda-
nese “lost boy and lost girl” refugees. (Doctoral disserta-
Ray, M. A. (1999). Transcultural caring in primary health tion.) Duquesne University. PA. UMI 3374252. Retrieved
care. National Academies of Practice Forum, 1(3), 177–182. from ProQuest.
*Cameron, C. (1990). An ethnonursing study of health status
Rosenbaum, J. N. (1997). Leininger’s theory of culture care of elderly Anglo Canadian wives providing extended care
diversity and universality: Transcultural critique. Jour- giving to their disabled husbands. (Unpublished doctoral
nal of Multicultural Nursing & Health, 3(3), 24–30. dissertation). Wayne State University.
*Curtis, M. (1997). Cultural care by private practice APRNs in
Schumacher, G. (2010). Culture care meanings, beliefs, community contexts. (Unpublished doctoral dissertation).
and practices in rural Dominican Republic. Journal of Wayne State University.
Transcultural Nursing, 21(2), 93–103. deRuyter, L. (2008). Cultural care education and experiences
of African American students in predominantly Euro
Swanson, C.R. (2012). The case for studying cultural com-
petence from the perspective of the Hispanic immigrant
patient: A state of the science. Online Journal of Cultural
Competence in Nursing and Healthcare, 2(1), 1–9.
Webbe-Alamah, H. (2008). Bridging the gap between generic
and professional care practices for Muslim patients
440 UNIT IV Nursing Theories culture care theory. (Unpublished doctoral dissertation).
Wayne State University.
American associate degree nursing programs. (Unpub- *MacNeil, J. (1994). Cultural care: Meanings, patterns, and
lished doctoral dissertation). Duquesne University. expressions for Baganda women as AIDS caregivers
*Ehrmin, J. (1998). Culture care meanings and statements, within Leininger’s theory. (Unpublished doctoral disser-
and experiences of care of African American women tation). Wayne State University.
residing in an inner city transitional home for substance *McFarland, M. R. (1995). Cultural care of Anglo and African
abuse. (Unpublished doctoral dissertation). Wayne State American elderly residents within the environmental con-
University. text of a long term care institution. (Unpublished doctoral
Farrell, L. S. (2001). Culture care: Meanings and expressions dissertation). Wayne State University.
of caring and non-caring of the Potawatami who have *Miller, J. E. (1996). Politics and care: A study of Czech
experienced family violence. (Unpublished doctoral Americans within Leininger’s theory of culture care
dissertation). Wayne State University. diversity and universality. (Unpublished doctoral
*Finn, J. (1993). Professional nurse and generic caregiving of dissertation). Wayne State University.
childbearing women conceptualized with Leininger’s the- Mixer, S. (2008). Faculty care expressions, patterns, and
ory of culture care theory. (Unpublished doctoral disser- practices related to teaching culture care. (Unpublished
tation). Wayne State University. doctoral dissertation). University of Northern Colorado
Fox-Hill, E. J. (1999). The experiences of persons with AIDS School of Nursing, Greeley, CO.
living-dying in a nursing home. (Doctoral dissertation). *Morgan, M. (1994). African American neonatal care in
University of Tennessee Health Science Center, Memphis. northern and southern contexts using Leininger’s culture
UMI 99345492. Retrieved from ProQuest. care theory. (Unpublished doctoral dissertation).
*Gates, M. (1988). Care and meanings, experiences and Wayne State University, Detroit, MI.
orientations of persons dying in hospitals and hospital *Morris, E. (2004). Culture care values, meanings, and
settings. (Unpublished doctoral dissertation). Wayne experiences of African American adolescent gang mem-
State University. bers. (Unpublished doctoral dissertation). Wayne State
*Gelazis, R. (1994). Lithuanian care: Meanings and experiences University.
with humor using Leininger’s culture care theory. (Unpub- Moss, J. A. (2010). Discovering the healthcare beliefs and
lished doctoral dissertation). Wayne State University. practices of rural Metizo Ecuadorians: An ethnonursing
*George, T. (1998). Meanings and statements and experi- study. (Doctoral dissertation). Rush University College
ences of care of chronically mentally ill in a day treatment of Nursing. UMI 3408062. Retrieved from ProQuest.
center using Leininger’s culture care theory. (Unpublished *Omeri, A. S. (1996). Transcultural nursing care values,
doctoral dissertation). Wayne State University. beliefs, and practices of Iranian immigrants in
Higgins, B. (1995). Puerto Rican cultural beliefs: Influence on New South Wales, Australia. (Unpublished doctoral
infant feeding practices in Western New York. (Doctoral dissertation). University of Sydney.
dissertation). University of Colorado Health Sciences Prince, L. (2005). Culture care and resilience in minority
Center. UMI 9604699. Retrieved from ProQuest. women residing in a transitional home recovering from
Hiscup, V. (2011). Cultural expressions, meanings, beliefs, prostitution. (Doctoral dissertation). Loyola University
and practices of Mexican American women during the of Chicago, IL. UMI 3174259. Retrieved from ProQuest.
post-partum period: An ethnonursing study. (Doctoral *Rosenbaum, J. (1990). Cultural care, culture health and
dissertation.) Duquesne University. UMI 3449963. grief phenomena related to older Greek Canadian
Retrieved from ProQuest. widows with Leininger’s theory of culture care.
*Horton, G. (1998). Culture care by private practice APRN (Unpublished doctoral dissertation). Wayne State
in a community context. (Unpublished doctoral disser- University.
tation). Wayne State University. Schumacher, G. C. (2006). Culture care meanings, beliefs,
Johnson, C. (2005). Understanding the culture care prac- and practices of rural Dominicans in a rural village of
tices of rural immigrant Mexican women. (Doctoral the Dominican Republic: An ethnonursing study
dissertation.) Duquesne University. UMI 3175853. conceptualized within the culture care theory. (Unpub-
Retrieved from ProQuest. lished doctoral dissertation). Duquesne University.
*Lamp, J. (1998). Generic and professional care meanings Spangler, Z. (1991). Nursing care values and practices of
and practices of Finnish women in birth within Leini- Philippine American and Anglo American nurses. (Unpub-
nger’s theory of culture care diversity and universality. lished doctoral dissertation). Wayne State University.
(Unpublished doctoral dissertation). Wayne State *Stitzlein, D. (1999). The phenomenon of moral care/caring
University. conceptualized within Leininger’s theory of culture care
*Luna, L. (1989). Care and cultural context of Lebanese
Muslims in an urban US community within Leininger’s
diversity and universality. (Unpublished doctoral CHAPTER 22 Madeleine M. Leininger 441
dissertation). Wayne State University.
*Thompson, T. (1990). A qualitative investigation of rehabili- residing in Hampton Roads, Virginia. (Unpublished
tation nursing care in an inpatient rehabilitation unit using doctoral dissertation). University of Utah.
Leininger’s theory. (Unpublished doctoral dissertation). *Wenger, A. F. (1988). The phenomenon of care of old order
Wayne State University. Amish: A high context culture. (Unpublished doctoral
*Villarruel, A. (1993). Mexican American cultural meanings, dissertation). Wayne State University.
expressions: Self care and dependent care actions associ- Wekselman, K. (1999). The culture of natural childbirth.
ated with experiences of pain. (Unpublished doctoral (Doctoral dissertation). University of Cincinnati. UMI
dissertation). Wayne State University. 9936027. Retrieved from ProQuest.
Vlassas, F. R. (1997). Too familiar for words: An analysis of Witt, D. E. (2006). Growing old on the farm: An ethnonursing
“invisible” nursing work. (Doctoral dissertation). Loyola examination of aging and health within the agrarian rural
University. UMI 9726404. Retrieved from ProQuest. subculture. (Doctoral dissertation). Duquesne University.
Webhe-Alamah, H. (2005). Culture care of Syrian American UMI 3238548. Retrieved from ProQuest.
immigrants living in Midwestern United States. (Unpub- Zajac, L. K. (2010). The culture care meaning of comfort for
lished doctoral dissertation). Duquesne University, ethnically diverse pre licensure baccalaureate nursing
Pittsburgh, PA. students in the educational setting. (Doctoral disserta-
Welch, A. (1987). Concepts of health, illness, caring, aging, tion). University of Northern Colorado. UMI 3439986.
and problems of adjustment among elderly Filipinas Retrieved from ProQuest.
23C H A P T E R
Margaret A. Newman
1933 to Present
Health as Expanding Consciousness
Janet Witucki Brown and Martha Raile Alligood
“We have to embrace a new vision of health. Our caring must be linked
with a concept of health that encompasses and goes beyond disease. The
theory of health as expanding consciousness provides that perspective”
(Newman, 2008, p. 2).
Credentials and Background University, Newman was a Professor at the University of
of the Theorist Minnesota in Minneapolis until her retirement in 1996,
where she is Professor Emeritus. During her nursing
Margaret A. Newman was born on October 10, 1933, education career, she was Director of Nursing for the
in Memphis, Tennessee. She earned a bachelor’s Clinical Research Center at the University of Tennessee,
degree in home economics and English from Baylor Acting Director of the PhD Program in the Division
University in Waco, Texas, and a second bachelor’s of Nursing at New York University, and Professor-
degree in nursing from the University of Tennessee in in-Charge of the Graduate Program and Research in
Memphis (M. Newman, curriculum vitae, 1996). Her Nursing at Pennsylvania State University (M. Newman,
master’s degree in medical-surgical nursing and teach- curriculum vitae, 2000).
ing is from the University of California, San Francisco.
She earned her PhD in nursing science and rehabilita- Newman achieved numerous honors, including
tion nursing in 1971 from New York University. admission to the American Academy of Nursing
in 1976; the Outstanding Alumnus Award from the
After holding academic positions at the University of University of Tennessee College of Nursing in Mem-
Tennessee, New York University, and Pennsylvania State phis in 1975 and 2002; the Distinguished Alumnus
Courtesy New York University, 2009
Previous authors: Snehlata Desai, M. Jan Keffer, DeAnn M. Hensley, Kimberly A. Kilgore-Keever, Jill Vass Langfitt, and LaPhyllis Peterson.
The authors wish to thank Margaret A. Newman for her contributions to the chapter.
442
Award, Division of Nursing, from New York University CHAPTER 23 Margaret A. Newman 443
in 1984; admission to the Hall of Fame at the University
of Mississippi School of Nursing in 1988; Latin- and discussed conclusions concerning changes neces-
American teaching fellow in 1976 and 1977; and sary for hospital nursing practice (Newman & Autio,
American Journal of Nursing scholar in 1979. She was 1986). From 1986 to 1997, Newman investigated
Distinguished Faculty at the Seventh International sequential patterns of persons with heart disease and
Conference on Human Functioning at Wichita, Kansas, cancer in relation to the theory of health as expanding
in 1983; received the E. Louise Grant Award for Nursing consciousness (Newman, 1995c; Newman & Moch,
Excellence from the University of Minnesota in 1996; is 1991). Other publications reflect her passion for inte-
listed in Who’s Who in American Women, Who’s Who in gration of nursing theory, practice, and research;
America,and Who’s Who in American Nursing;and was evolving viewpoints on trends in philosophy of nurs-
included in the Nursing Theorists, Portraits of Excellence, ing; and analysis of theoretical models of nursing
vol. 1, 1990 videotape series sponsored by the Helene practice and nursing research (Newman, 1992, 1997b,
Fuld Health Trust (M. Newman, curriculum vitae, 1999, 2003). During 1989 and 1990, Newman was
2000; personal communication, 2004). She was a Dis- principal investigator of a project that explored the
tinguished Resident at Westminster College in Salt Lake theory and structure of a professional model of nurs-
City, Utah, in 1991; received the Distinguished Scholar ing practice at Carondelet St. Mary’s Community
in Nursing Award at the New York University Division Hospitals and Health Centers in Tucson, Arizona
of Nursing in 1992; received the Sigma Theta Tau (Newman, 1990b; Newman, Lamb, & Michaels, 1991).
Founders Elizabeth McWilliams Miller Award for Ex-
cellence in Research in 1993; and received the Nurse Newman has consulted regarding the expansion
Scholar Award at Saint Xavier University School of of her theory of health in more than 40 states and
Nursing in 1994 (M. Newman, curriculum vitae, 2000). numerous foreign countries and has served on edito-
rial review panels, including Nursing Research, West-
Newman first presented her ideas on a theory of ern Journal of Nursing Research, Nursing and Health
health in 1978 at a conference on nursing theory in Care, Advances in Nursing Science, Nursing Science
New York. During this time, she was also pursuing Quarterly, and the advisory board of Advances in
research on the relationship of movement, time, and Nursing Science(M. Newman, personal communica-
consciousness and expanding development of her tion, 2004).
theory of health as expanding consciousness. In 1985,
as a traveling research fellow, Newman conducted Theoretical Sources
workshops in New Zealand and at the University of
Tampere in Finland, where she was featured at a The theory, Health as Expanding Consciousness,
weeklong conference on the theory of consciousness stems from Rogers’ (1970) science of unitary human
as it related to nursing (M. Newman, personal com- beings. Rogers’ assumptions regarding wholeness,
munication, 1988). pattern, and unidirectionality are foundational to
Newman’s theory (M. Newman, personal communi-
Newman has presented and published papers, cation, 2004). Hegel’s fusion of opposites (Acton,
articles, and book chapters on topics pertaining to her 1967) helped Newman conceptualize fusion of health
theory of health as expanding consciousness. She and illness into a new concept of health. Bentov’s
published Theory Development in Nursing(1979), (1977) explication of life as the process of expanding
Health as Expanding Consciousness(1986, 1994), A consciousness prompted Newman to assert her new
Developing Discipline: Selected Works of Margaret concept of health as the process of expanding con-
Newman(1995a), and Transforming Presence: The Dif- sciousness (M. Newman, personal communication,
ference That Nursing Makes (2008). In 2011, Nursing 2004).
Science Quarterly,volume 24, number 3, recognized
Dr. Newman with a special issue honoring her and Bohm’s (1980) theory of implicate order supports
her work. Newman’s postulate that disease is a manifestation
of the pattern of health. Newman (1994) stated that
In 1986, Newman did a case study analysis of prac- she began to comprehend “the underlying, unseen
tice at three sites within the Minneapolis-St. Paul area pattern that manifests itself in varying forms, in-
cluding disease, and the interconnectedness and
444 UNIT IV Nursing Theories regarding the nature of health (Newman, 1994).
omnipresence of all that there is” (p. xxvi). Young’s Newman incorporated Prigogine’s (1976) theory
(1976) theory of human evolution pinpointed the of dissipative structures as an explanation for the
role of pattern recognition for Newman. She ex- timing of nursing presence as the patient fluctuates
plained that Young’s ideas provided impetus for her from one level of organization to a higher level
to integrate the basic concepts of her new theory, (M. Newman, personal communication, 2004). Al-
movement, space, time, and consciousness, into a though Newman (1997a) acknowledges the contri-
dynamic portrayal of life and health (Newman, butions of these theories to her theory, she states that
1994). Moss’s (1981) experience of love as the high- her theory “was enriched by them, but was not based
est level of consciousness was important to Newman, on them” (p. 23).
providing affirmation and elaboration of her intuition
MAJOR CONCEPTS & DEFINITIONS manifestations of the pattern of a person are the
Health genetic pattern that contains information that
Health is the “pattern of the whole” of a person and directs becoming, the voice pattern, and the move-
includes disease as a manifestation of the pattern of ment pattern (Newman, 1986). Characteristics of
the whole, based on the premise that life is an ongo- pattern include movement, diversity, and rhythm.
ing process of expanding consciousness (Newman, Pattern is conceptualized as being somehow inti-
1986). It is regarded as the evolving pattern of the mately involved in energy exchange and transfor-
person and environment and is viewed as an increas- mation (Newman, 1994). According to Newman
ing ability to perceive alternatives and respond in a (1987b), “Whatever manifests itself in a person’s life
variety of ways (Newman, 1986). Health is “a trans- is the explication of the underlying implicate pat-
formative process to more inclusive consciousness” tern . . . the phenomenon we call health is the man-
(Newman, 2008, p. 16). ifestation of that evolving pattern” (p. 37).
Using Hegel’s dialectical fusion of opposites, In Health as Expanding Consciousness, Newman
Newman explained conceptually how disease fuses (1986, 1994) developed pattern as a major concept
with its opposite, nondisease or absence of disease, that is used to understand the individual as a
to create a new concept of health that is relational whole being. Newman described a paradigm shift
and is “patterned, emergent, unpredictable, unitary, in the field of health care: the shift from treatment
intuitive, and innovative,” rather than a traditional of disease symptoms to a search for patterns and
linear view that is “causal, predictive, dichotomous, the meaning of those patterns. Newman (1994)
rational, and controlling” (Newman, 1994, p. 13). stated that the patterns of interaction of person-
Health and the evolving pattern of consciousness environment constitute health. Individual life pat-
are the same. The essence of the emerging paradigm terns according to Newman (2008) move “through
of health is recognition of pattern. Newman (1994) peaks and troughs, variations in order-disorder
sees the life process as progression toward higher that are meaningful for the person” (p. 6). An
levels of consciousness. event such as a disease occurrence is part of
a larger process. By interacting with the event,
Pattern no matter how destructive the force might be, its
Pattern is information that depicts the whole and energy augments the person’s energy and enhances
understanding of the meaning of all of the relation- his or her power. One must grasp the pattern of
ships at once (M. Newman, personal communica- the whole to see this (Newman, 1986).
tion, 2004). It is conceptualized as a fundamental
attribute of all there is, and it gives unity in diversity Consciousness
(Newman, 1986). Pattern is what identifies an indi- Consciousness is both the informational capacity of
vidual as a particular person. Examples of explicit the system and the ability of the system to interact
CHAPTER 23 Margaret A. Newman 445
MAJOR CONCEPTS & DEFINITIONS—cont’d
with its environment (Newman, 1994). Newman contrasting concepts become reconciled and fused.
asserts that understanding of her definition of Movement and rest fuse into one” (p. 67). Absolute
consciousness is essential to understanding the the- consciousness is equated with love, where all oppo-
ory. Consciousness includes not only cognitive and sites are reconciled and all experiences are accepted
affective awareness, but also the “interconnected- equally and unconditionally, such as love and hate,
ness of the entire living system which includes pain and pleasure, and disease and non-disease.
physicochemical maintenance and growth processes Reed (1996) concurred with Newman’s theory that
as well as the immune system” (Newman, 1990a, the phase of evolutionary development is when the
p. 38). person moves beyond a focus on self that is limited
by time, space, and physical concerns suggesting
In 1978, Newman identified three correlates of transcendence as a process through which the per-
consciousness (time, movement, and space) as man- son moves to a high level of consciousness.
ifestations of the pattern of the whole. The life pro-
cess is seen as a progression toward higher levels of Movement-Space-Time
consciousness. Newman (1979) views the expansion Newman emphasizes the importance of examin-
of consciousness as what life and health is all about, ing movement-space-time together as dimensions
and the sense of time is an indicator in the changing of emerging patterns of consciousness rather than
level of consciousness. as separate concepts of the theory (M. Newman,
personal communication, 2004).
Newman (1986) integrates Bentov’s (1977) defi-
nition of absolute consciousness as “a state in which
Use of Empirical Evidence in terms of theory development, it must have three
components, as follows: (1) having as its purpose
Evidence for the theory of health as expanding con- the testing of theory, (2) making explicit the theo-
sciousness emanated from Newman’s early personal retical framework upon which the testing relies, and
family experiences. Her mother’s struggle with amy- (3) reexamining the theoretical underpinnings in
otrophic lateral sclerosis and her dependence on light of the findings (Newman, 1979). She believed
Newman, then a young college graduate, sparked her that if health is considered an individual personal
interest in nursing. From that experience, the idea process, then research should focus on studies that
that “illness reflected the life patterns of the person explore changes and similarities in personal mean-
and that what was needed was the recognition of that ing and patterns.
pattern and acceptance of it for what it meant to that
person” (Newman, 1986, p. 3). Major Assumptions
Throughout Newman’s writings, terms such as call to The foundation for Newman’s assumptions (M. New-
nursing, growing conscience-like feeling, fear, power, man, personal communication, 2000) is her definition
meaning of life and health, belief of life after death, rituals of health, which is grounded in Rogers’ 1970 model for
of health, and love are used, providing a clue concerning nursing, specifically, the focus on wholeness, pattern,
Newman’s endeavors to make a disturbing life experi- and unidirectionality. From this, Newman developed
ence logical. Her life experience triggered beginning the following assumptions that support her theory to
maturation toward theory development in nursing. this day (Newman, 2008).
Within her philosophical framework, Newman began 1. Health encompasses conditions heretofore described
to develop a synthesis of disease-nondisease-health as
recognition of the total patterning of a person. as illness or, in medical terms pathology . . .
2. These “pathological” conditions can be considered a
Research has been conducted on the theoretical
sources (Newman, 1987b). In 1979, Newman wrote manifestation of the total pattern of the individual . . .
that in order for nursing research to have meaning
446 UNIT IV Nursing Theories Nurses facilitate pattern recognition in clients by
forming relationships with them at critical points in
3. The pattern of the individual that eventually mani- their lives and connecting with them in an authentic
fests itself as pathology is primary and exists prior way. The nurse-client relationship is characterized by
to structural or functional changes . . . “a rhythmic coming together and moving apart
as clients encounter disruption of their organized,
4 . Removal of the pathology in itself will not change predictable state” (Newman, 1999, p. 228). She states
the pattern of the individual . . . that the nurse will continue to connect with clients as
they move through periods of disorganization and
5. If becoming “ill” is the only way an individual’s unpredictability to arrive at a higher, organized state
pattern can manifest itself then that is health for (Newman, 1999). The nurse comes together with
that person . . . clients at these critical choice points in their lives and
From these assumptions, Newman set forth the participates with them in the process of expanding
consciousness. The relationship is one of rhythmicity
thesis: Health is the expansion of consciousness (Newman, and timing, with the nurse letting go of the need
personal communication, 2008). to direct the relationship or fix things. As the nurse
relinquishes the need to manipulate or control, there
Newman’s implicit assumptions about human nature is greater ability to enter into this fluctuating, rhyth-
include being unitary, an open system, in continuous mic partnership with the client (Newman, 1999).
interconnectedness with the open system of the uni- Newman has diagrammed this nurse-client interac-
verse, and continuously engaged in an evolving pattern tion of coming together and moving apart through
of the whole (M. Newman, personal communication, the processes of recognition, insight, and transforma-
2000). She views unfolding consciousness as a process tion (Figure 23–1) Nurses are seen as partners in the
that will occur regardless of what actions nurses per- process of expanding consciousness, and are trans-
form. However, nurses assist clients in getting in touch formed and have their lives enhanced in the dialogical
with what is going on and in that way facilitate the pro- process (Newman, 2008). As facilitator, the nurse
cess (Newman, 1994). helps an individual, family, or community to focus on
patterns of relating (M. Newman, personal communi-
Newman designated “caring in the human health cation, 2004). Thus the nursing process is one of pat-
experience” (M. Newman, personal communication tern recognition.
2004; Newman, Sime, & Corcoran-Perry, 1991, p. 3) as
the focus of nursing and specified this focus as the Newman’s early suggestion (Newman, 1995b) was
metaparadigm of the discipline. She asserts the interre- that the NANDA health assessment framework, which
lated concepts of nursing, person, health, and environ- was based on unitary person-environment patterns of
ment as inherent in this focus (M. Newman, personal interaction, be used to facilitate clients’ pattern recog-
communication, 2004). Coming from a unitary, trans- nition (Roy, Rogers, Fitzpatrick, et al., 1982). At the
formative paradigm of the discipline, Newman does not time, the patterns were intended to guide nurses to
see these concepts in isolation, and therefore she does make holistic observations of “person-environment
not discuss them separately, but has elaborated on nurs- behaviors that together depict a very specific pattern
ing and health. In the following paragraphs, implicit of the whole for each person” (Newman, 1995b,
definitions from Newman’s work are used to discuss the p. 261). Newman (2008) since has emphasized con-
four components. centrating on what is most meaningful to clients in
Nursing their own stories and patterns of relating.
Newman emphasizes the primacy of relationships as
a focus of nursing, both nurse-client relationships and Within the theory, the role of the nurse in nurse-
relationships within clients’ lives (Newman, 2008). client interactions is seen as a “caring, pattern-
During dialectic nurse-client relationships, clients get recognizing presence” (Newman, 2008, p. 16). The
in touch with the meaning of their lives through iden- nurse perceives patterns in client’s stories or se-
tification of meanings in the process of their evolving quences of events that change with new informa-
patterns of relating (Newman, 2008). “The emphasis tion. According to Newman (2008), it is important
of this process is on knowing/caring through pattern for nurses to view clients’ stories comprehensively.
recognition” (Newman, 2008, p. 10). Insight into
these patterns provides clients with illumination of
action possibilities, which then opens the way for
transformation (Newman, 1990a).
PATIENT SeLaarcckhoinfgcofonrnpelcatcioenisn world CHAPTER 23 Margaret A. Newman 447
RMePleelaaanscieengoinffuwal noregrlleadrt/ihounrsthips
Pulsating as
ONE
Connection
FuUllnyRcepofrnleedsciettiinnotgnaplaatctecrenptance with nurse
NURSE poEwxepreroief npcreinsgentrcaensforming
FIGURE 23-1 N urse and patient coming together and moving apart in process recognition, insight, and
transformation. (From Newman, M. A. [2008]. Transforming presence: The difference that nursing makes.
Philadelphia: F. A. Davis.)
Through active listening, nurses enter the whole family consciousness and within the pattern of com-
through the parts and intuit the whole from the pat- munity interactions (Newman, 1986). A major as-
tern. Differences are viewed as part of a unified sumption is that “consciousness is coextensive in the
whole. The nurse facilitates client insight through universe and resides in all matter” (Newman, 1986,
sharing the process of pattern recognition, opening p. 33). Client and environment are viewed as a unitary
action possibilities (Newman, 1987b). evolving pattern (Newman, 2008).
Person Newman identifies interaction between person and
Throughout Newman’s work, the terms client, patient, environment as a key process that creates unique con-
person, individual,and human being are used inter- figurations for each individual. Patterns of person-
changeably. Clients are viewed as participants in the environment evolve to higher levels of consciousness.
transformative process. The assumption is that all matter in the universe-
environment possesses consciousness, but at different
Persons as individuals are identified by their indi- levels. Interpretation of Newman’s view clarifies that
vidual patterns of consciousness (Newman, 1986) and health is the interaction pattern of a person with the
defined as “centers of consciousness within an overall environment. Disease in a human energy field is a mani-
pattern of expanding consciousness” (Newman, 1986, festation of a unique pattern of person-environment
p. 31). The definition of persons includes family and interaction.
community (Newman, 1994).
Health
Environment Health is the major concept of Newman’s theory of
Although environment is not explicitly defined, it is expanding consciousness. A fusion of disease and
described as being the larger whole, which contains nondisease creates a synthesis regarded as health
the consciousness of the individual. The pattern of (Newman, 1979, 1991, 1992). Disease and non-disease
person consciousness interacts within the pattern of each reflect the larger whole; therefore, a new concept
448 UNIT IV Nursing Theories which an individual expresses thoughts and feelings
about the reality of experiences. An individual con-
of health, “pattern of the whole,” is formed (Newman, veys awareness of self through the movement
1986, p. 12). Newman (1999) further elaborated her involved in language, posture, and body movement
view of health by stating that “health is the pattern of (Newman, 1979). An indication of the internal orga-
the whole, and wholeness is” (p. 228). This wholeness nization of a person and of that person’s perception
cannot be gained or lost. Becoming ill does not dimin- of the world can be found in the rhythm and pattern
ish wholeness within this perspective, but wholeness of the person’s movement. Movement patterns pro-
takes on a different form. Newman (2008) states that vide additional communication beyond that which
pattern recognition is the essence of emerging health. language can convey (Newman, 1979).
“Manifest health, encompassing disease and non-
disease, can be regarded as the explication of the un- The concept of time is seen as a function of move-
derlying pattern of person-environment” (Newman, ment (Newman, 1979). This assertion was supported
1994, p. 11). Therefore, health and evolving pattern of by Newman’s (1972) studies of the experience of time
consciousness are the same; specifically, health is as related to movement and gait tempo. Newman’s
viewed “as a transformative process to more inclusive research demonstrated that the slower an individual
consciousness” (Newman, 2008, p. 16). walks, the less subjective time is experienced. How-
ever, when compared with clock time, time seems to
Theoretical Assertions “fly.” Although individuals who are moving quickly
Early Designation of Concepts subjectively feel that they are “beating the clock,” they
and Propositions report that time seems to be dragging when checking
a clock (Newman, 1972, 1979).
Early writings focused heavily on the concepts of
movement, space, time, and consciousness. In Theory Time is also conceptualized as a measure of con-
Development in Nursing, Newman (1979) delineated sciousness (Newman, 1979). Bentov (1977) measured
the relationships between movement, space, time, and consciousness with a ratio of subjective to objective
consciousness. One proposition was that there was a time and proposed this assertion. Newman applied
complimentary relationship between time and space this measure of consciousness to subjective and objec-
(Newman, 1979, 1983). Examples of this relationship tive data from her research. She found that the con-
were given at the macrocosmic, microcosmic, and sciousness index increased with age. Some of her
humanistic (everyday) levels. At the humanistic level, research has also supported the finding of “increasing
highly mobile individuals live in a world of expanded consciousness with age” (Newman, 1982, p. 293).
space and compartmentalized time. There is an in- Newman cited this evidence as support for her posi-
verse relationship between space and time in that tion that the life process evolves toward consciousness
when a person’s life space is decreased, such as by expansion. However, she asserted that certain moods,
physical or social immobility, then that person’s time such as depression, might be accompanied by a dimin-
is increased (Newman, 1979). ished sense of time (Newman & Gaudiano, 1984).
Movement is a “means whereby space and time Synthesis of Patterns of Movement,
become a reality” (Newman, 1983, p. 165). Human- Space-Time, and Consciousness
kind is in a constant state of motion and is constantly As the theory evolved, Newman developed a synthesis
changing internally (at the cellular level) and exter- of the pattern of movement, space, time, and con-
nally (through body movement and interaction with sciousness (M. Newman, personal communication,
the environment). This movement through time and 2004, 2008). Time was not merely conceptualized as
space is what gives humankind a unique perception subjective or objective, but was also viewed in a holo-
of reality. Movement brings change and enables the graphic sense (M. Newman, personal communication,
individual to experience the world (Newman, 1979). 2000). According to Newman (1994), “Each moment
has an explicate order and also enfolds all others,
Movement was also referred to as a “reflection of meaning that each moment of our lives contains all
consciousness” (Newman, 1983, p. 165). It is the
means of experiencing reality and also the means by
others of all time” (p. 62). Newman (1986) illustrated CHAPTER 23 Margaret A. Newman 449
the centrality of space-time in the following example: In Health as Expanding Consciousness (Newman,
1986, 1994), Newman’s theory encompassed the work
Mrs. V. made repeated attempts to move away of Young’s spectrum of consciousness (Young, 1976).
from her husband and to move into an educa- She saw Young’s central theme as one in which self
tional program to become more independent. She and universe were of the same nature. This essential
felt she had no space for herself, and she tried to nature could not be defined but was characterized by
distance herself (space) from her husband. She complete freedom and unrestricted choice at both the
felt she had no time for leisure (self), was over- beginning and the end of life’s trajectory (Newman,
worked, and was constantly meeting other peo- 1986).
ple’s needs. She was submissive to the demands Newman established a corollary between her
and criticism of her husband (p. 56). model of health as expanding consciousness and
Young’s conception of the evolution of human beings
Space, time, and movement later became linked (Figure 23–2). She explained that individuals came
with Newman’s (1986) assertion that the intersection into being from a state of consciousness, and that they
of movement-space-time represented the person as a were bound in time, found their identity in space,
center of consciousness. Further, this varied from and, through movement, learned the “law” of the way
person to person, place to place, and time to time. that things worked; they then made choices that ulti-
Newman (1986) also emphasized that the crucial task mately took them beyond space and time to a state of
of nursing is to be able to see the concepts of move- absolute consciousness (Newman, 1994).
ment-space-time in relation to each other, and con- Newman (1994) also stated that restrictions in
sider them all at once, recognizing patterns of evolving movement-space-time have the effect of forcing an
consciousness. awareness that extends beyond the physical self.
Ground of
CONSCIOUSNESS
(Potential freedom) (Real freedom)
TIME TIMELESSNESS
(Binding) (Unbinding)
SPACE BOUNDARYLESSNESS
(Centering) (Decentering)
MOVEMENT
(Choice)
FIGURE 23-2 P arallel between Newman’s theory of expanding consciousness and Young’s stages
of human evolution. (From Newman, M. A. [1990]. Newman’s theory of health as praxis. Nursing Science
Quarterly, 3[1], 37–41.)
450 UNIT IV Nursing Theories Logical Form
When natural movement is altered, space and time are Newman used both inductive and deductive logic in
also altered. When movement is restricted (physical or early theory development. Inductive logic is based on
social), it is necessary for an individual to move beyond observing particular instances and then relating those
self, thereby making movement an important choice instances to form a whole. Newman’s theory develop-
point in the process of evolving human consciousness ment derived from her earlier research on time per-
(Newman, 1994). She assumed that the awareness cor- ception and gait tempo. Time and movement, with
responded to the “inward, self-generated reformation space and consciousness, were subsequently used as
that Young [spoke] of as the turning point of the central components in her early conceptual frame-
process” (Newman, 1994, p. 46). When a person pro- work. These concepts helped explain “the phenomena
gresses to the state of timelessness, there is increasing of the life process and therefore of health” (Newman,
freedom from time. Finally, the last stage is absolute 1979, p. 59). Newman (1997a) describes the evolution
consciousness, which Newman asserted is equated of the theory as it moved from linear explication and
with love (Newman, 1994). testing of concepts of time, space, and movement to
Emphasis on the Experiential Process an elaboration of interacting patterns as manifesta-
of Nurse-Client tions of expanding consciousness. Evolution of the
With the realization that the early research testing of theory of health as expanding consciousness as a process
propositional statements stemmed from a mechanis- of evolving in conjunction with research progressed
tic view of movement-space-time consciousness and through several stages (Newman, 1997a, 1997b).
failed to honor the basic assumptions of her theory, These stages included testing the relationships of the
Newman shifted focus to authentic involvement of concepts of movement, space, and time; identifying
the nurse researcher as a participant with the client in sequential person-environmental patterns; and rec-
the unfolding pattern of expanding consciousness ognizing the centrality of nurse-client relationships
(Newman, 2008). The unitary, transformative para- or dialogue in the clients’ evolving insight and
digm demanded that the research honor and reveal accompanying potential for action. The process
the mutuality of interaction between nurse and client, actually became cyclical as the original concepts of
the uniqueness and wholeness of pattern in each movement-space-time emerged as dimensions in the
client situation, and movement of the life process unitary evolving process of consciousness (Newman,
toward higher consciousness. Newman (2008) states, 1997a).
“The nature of nursing practice is the caring, pattern-
recognizing relationship between nurse and client—a Acceptance by the Nursing Community
relationship that is a transforming presence” (p. 52). Practice
The protocol for this research was first started Newman believes that research within the theory of
in 1994, and variations of this guide continue to be health as expanding conscious is praxis, which she
implemented in current praxis research. Litchfield defines as a “mutual process between nurse and client
(1999) explicated this process as “practice wisdom” in with the intent to help” (Newman, 2008, p. 21). Fur-
her work with families of hospitalized children, and ther, this process focuses “on transformation from
Endo (1998) analyzed the phases of the process in her one point to another and incorporates the guidance of
work with women with ovarian cancer. The data an a priori theory” (Newman, 2008, p. 21). Research
of this praxis research reveal evidence of expanding and practice with the theory are interwoven.
consciousness in the quality and connectedness of the
client’s relationships and support the importance of In Newman’s view, the responsibility of profes-
the nurse’s creative presence in participants’ insight sional nurses is to establish a primary relationship
(M. Newman, personal communication, 2004, 2008). with the client for the purpose of identifying mean-
Variations of the praxis research have been utilized in ingful patterns and facilitating the client’s action po-
numerous populations and settings (Newman, 2008; tential and decision-making ability (Newman, 2008).
Picard & Jones, 2007).
Communication and collaboration with other nurses, CHAPTER 23 Margaret A. Newman 451
associates, and health care professionals are essential (Jonsdottir, 1998; Noveletsky-Rosenthal, 1996); life
(Newman, 1989). Nurses as primary care providers patterns of people with hepatitis C (Thomas, 2002); and
who are focused completely on relationships with patterns of expanding consciousness in persons with
clients can relate well to her view of the role of profes- HIV and AIDS (Lamendola & Newman, 1994).
sional nursing, which Newman (Newman, Lamb, &
Michaels, 1991) refers to as nursing clinician-case Litchfield (1999) described the patterning of nurse-
manager, which is the sine qua non of the integrative client relationships in families with frequent illness
model. and hospitalization of toddlers, and its use in family
health. Magan, Gibbon, and Mrozek (1990) reported
Relating her theory of health as expanding con- on implementation of the theory, as one of several
sciousness and acknowledging the contemporary and theories, in the care of the mentally ill. Weingourt
radical shift in philosophy of nursing that views health (1998) reported on the use of Newman’s theory
as a unitary human field dynamic embedded in a of health with elderly nursing home residents, and
larger unitary field, Newman (1979) believes that “the Capasso (2005) reported increased emotional and
goal of nursing is not to make people well, or to pre- physical client healing as a result of use of the theory
vent their getting sick, but to assist people to utilize the in nurse-client interactions.
power that is within them as they evolve toward
higher levels of consciousness” (p. 67). The task of Additional research includes studies that involved
nursing is not to try to change the pattern of a person, recognizing health patterns in persons with multiple
but to recognize it as information that depicts the sclerosis (Gulick & Bugg, 1992; Neill, 2005) and
whole and relate to it as it unfolds (Newman, 1994). spousal caregivers of partners with dementia (Brown
& Alligood, 2004; Brown, Chen, Mitchell, et al.,
From the Newman perspective, nursing is the study 2007; Schmitt, 1991), as well as patterns in adoles-
of “caring in the human health experience” (Newman, cent males incarcerated for murder (Pharris, 2002)
Lamb, & Michaels, 1991, p. 3). The role of the nurse in and life experiences of Black Caribbean women
this experience is to help clients recognize their pat- (Peters-Lewis, 2006). Additional studies have in-
terns, which results in the illumination of action pos- cluded life patterns of women who successfully lose
sibilities that open the way for transformation. weight and maintain weight loss (Berry, 2002); vic-
timizing sexuality and healing patterns (Smith,
The theory has been used in practice with various 1997); meaning of the death of an adult child to an
client populations. Kalb (1990) applied Newman’s the- elder (Weed, 2004); experience of family members
ory of health in the clinical management of pregnant living through the sudden death of a child (Picard,
women hospitalized for complications of maternal-fetal 2002); nurse facilitation of health as expanding con-
health. Smith (1995) worked with the health of rural sciousness in families of children with special health
African-American women. Yamashita (1995, 1999) care needs (Falkenstern, 2003); and health as ex-
studied Japanese and Canadian family caregivers, and panding consciousness to conceptualize adaptation
Rosa (2006) worked with persons living with chronic in burn patients (Casper, 1999).
skin wounds. Several studies have focused on patterns
of persons with rheumatoid arthritis (Brauer, 2001; Newman’s research as praxis has also been used to
Neill, 2002; Schmidt, Brauer, & Peden-McAlpine, 2003). describe the lived experience of life passing in middle-
Research studies have focused on patterns of patients adolescent females (Shanahan, 1993); patterns of
with cancer as a meaningful part of health (Barron, expanding consciousness in women in midlife (Picard,
2005; Bruce-Barrett, 1998; Endo, 1998; Endo, Nitta, 2000) and women transitioning through menopause
Inayoshi, et al., 2000; Gross, 1995; Karian, Jankowski, & (Musker, 2005); pattern recognition of high-risk preg-
Beal, 1998; Kiser-Larson, 2002; Moch, 1990; Newman, nant women (Schroeder, 1993) and low-risk pregnant
1995c; Roux, Bush, & Dingley, 2001; Utley, 1999). Other women (Batty, 1999); and patterns in families of med-
studies include life patterns of persons with coronary ically fragile children (Tommet, 2003). It was the
heart disease (Newman & Moch, 1991); patterns of framework for analysis of patterns for evidence of
persons with chronic obstructive pulmonary disease empowerment in community health care workers by
Walls (1999).
452 UNIT IV Nursing Theories that nursing is at the intersection of the focus of the
health care industry; therefore, “nursing is in position
Quinn (1992) reconceptualized therapeutic touch to bring about the fluctuation within the system that
as shared consciousness. Lamb and Stempel (1994) will shift the system to a new higher order of func-
described the role of the nurse as an insider-expert. tioning” (p. 90). Newman (2008) proposes that,
Newman, Lamb, and Michaels (1991) described the “attention to the nature of transformative learning
role of the nurse case manager at St. Mary’s as ema- will help to establish the priorities of the discipline”
nating from a philosophical and theoretical base (p. 73). As students and teachers directly engage in
agreeing with the unitary-transformative paradigm intuitive awareness, they resonate with each other in
and exemplifying an integrated stage of professional a transforming way (Endo, Takaki, Abe, et al., 2007).
nursing. Further, the theory of health as expanding However, as the paradigm shift has taken place
consciousness has been proposed as beneficial for the in nurses’ views of their relationships with clients,
school nurse working with adolescents with insulin- examples of application of the theory in traditional
dependent diabetes (Schlotzhauer & Farnham, 1997). roles are evident (Newman, personal communication,
2008).
Gustafson (1990) found that practice as a parish
nurse supported Newman’s theory of health as dem- Examining the pragmatic adequacy of Newman’s
onstration of pattern recognition. More recently, theory in relation to nursing education reveals that
Endo and colleagues (2005) conducted action re- teaching the research method associated with the the-
search involving practicing nurses and found that ory also teaches students a practice method that is
nurses experienced deeper meaning in their lives as a congruent with the theory, and it is a means for students
result of the transformative power of pattern recog- to experience transformation through pattern recogni-
nition in their work with clients. Flanagan (2005) tion (Newman, 2008). Newman sees theory, practice,
found that preoperative nurses working within the and research as a process rather than as separate
theory saw the effect of their presence in changing domains of the nursing discipline. Teaching the theory
patient experiences. Ruka (2005) developed a model of health as expanding consciousness necessitates a shift
of nursing home practice for use in pattern recogni- in thinking from a dichotomous view of health to a
tion with persons with dementia. Pierre-Louis and synthesized view that accepts disease as a manifestation
colleagues (2011) studied patterns in the lives of of health. Not only that, learning to let go of the profes-
African-American women with diabetes within sional’s control and respecting the client’s choices
health as expanding consciousness, and MacLeod are integral parts of practice within this framework.
(2011) studied experiences of spousal caregivers. Students and practicing nurses who plan to use
Ness (2009) studies pain expression in perioperative Newman’s theory face personal transformation in learn-
Somali women. Dyess (2011) focused on the concept ing to recognize patterns through nurse-client interac-
of faith in the context of health as expanding con- tions. An individual’s personal experience will be the
sciousness. Haney and Tufts (2012) used health as core not just of teaching and practice, but of research
expanding consciousness to frame a home health care as well. Newman (1994) explained that the nurse needs
study of electronic communication for parental well- to sense his or her own pattern of relating as an indica-
being and satisfaction in medically fragile children. tion of the nurse-client interacting pattern. She empha-
Education sized that there needs to be a sense of the process of the
Newman (1986) stated that ideally, a new role is relationship with clients from within, giving attention to
needed for the nurse in the paradigm of the evolving the “we” in the nurse-client relationship (Newman,
consciousness of the whole. “Nurses need to be free to 1997b).
relate to patients in an ongoing partnership that is not
limited to a particular place or time” (Newman, 1986, Newman’s theory has been used in nursing educa-
p. 89). She suggested that nursing education revolve tion to provide some content into a model called the
around pattern as a concept, substance, process, and healing web. This model was designed to integrate
method. Education by this method would enable nursing education and nursing service together with
nursing to be an important resource for the continued private and public education programs for baccalau-
development of health care. Newman (1986) stated reate and associate nursing degree programs in South
Dakota (Bunkers, Bendtro, Holmes, et al., 1992). CHAPTER 23 Margaret A. Newman 453
Jacono and Jacono (1996) suggested that student cre- With evolution of the theory, the praxis research
ativity could be enhanced if nursing faculty applied incorporated practice and assisted clients in pattern
the theory recognizing that all experience has the recognition (Newman, 1990a). Schorr, Farnham,
potential for expanding the creativity (consciousness) and Ervin (1991) investigated the health patterns in
of individuals. Picard and Mariolis (2002, 2005) 60 aging women, using the theory as a framework. A
described the application of the health as expanding study of music and pattern change in chronic pain
consciousness theory to teaching psychiatric nursing. by Schorr (1993) also supported Newman’s theory of
Endo and colleagues (2007) describe faculty becom- health as expanding consciousness. Fryback’s (1991)
ing involved with students in a project of pattern dissertation revealed that persons with acquired
recognition that resulted in transformation of student immunodeficiency syndrome (AIDS) and human
relationships. Clarke and Jones (2011) discuss immunodeficiency virus (HIV) infection did, in fact,
expanding consciousness theory in nursing education describe health within physical, health promotion,
and practice. and spiritual domains consistent with Newman’s
theory.
Research Newman observed that her research not only
At first, Newman’s theory of health was useful in the assisted clients who participated, but she and fellow
practice of nursing because it contained the concepts researchers also gained a better understanding of self
of movement and time that are used by the nursing as a nurse researcher and insight of the limitations of
profession and intrinsic to nursing interventions such methods in earlier studies. Newman (1994) stated
as range of motion and ambulation (Newman, 1987a). that research should center on investigations that are
Early research with the theory manipulated concepts participatory in which client-subjects are partners
of space, time, and movement. Besides Newman, sev- and co-researchers in the search for health patterns.
eral researchers conducted research about time, space, This method of inquiry is called cooperative inquiry or
or movement. Newman and Gaudiano (1984) fo- interactive, integrative participation. Newman (1989,
cused on the occurrence of depression in older adults 1990a) developed a method to describe patterns as
and decreased subjective time. Mentzer and Schorr unfolding and evolving over time. She used the
(1986) used Newman’s model of duration of time as method of interviewing a subject regarding different
an index to consciousness in a study of institutional- time frames to establish a pattern for that subject
ized older adults. Engle (1986) addressed the relation- (Newman, 1987b). Newman (1990a) stated that dur-
ship between movement, time, and assessment of ing the development of a methodology to test the
health. Schorr and Schroeder (1989) studied differ- theory of health, “sharing our (researcher’s) percep-
ences in consciousness with regard to time and move- tion of the person’s pattern with the person was
ment, and in another study found that relationships meaningful to the participants and stimulated new
among type A behavior, temporal orientation, and insights regarding their lives” (p. 37). In 1994, she
death anxiety as manifestations of consciousness had described a protocol for the research and labeled
mixed results (Schorr & Schroeder, 1991). During the it hermeneutic dialectic. This method allows the pat-
1980s, Marchione, using health as expanding con- tern of person-environment to reveal itself without
sciousness, investigated and reported the meaning disturbing the unity of the pattern (M. Newman, per-
of disabling events in families, presenting a case study sonal communication, 2000). From the inception
in which an additional person became part of the of Newman’s theory in the 1970s until the present,
nuclear family. The addition was a disruptive event numerous nurse practitioners and scientists have
for the family and created disturbances in time, used the theory to incorporate the concepts into their
space, movement, and consciousness, suggesting that nursing practice or to elaborate the theory through
Newman’s work with patterns could be used to under- research. Newman advocates convergence of nursing
stand family interactions (Marchione, 1986). Marchione theories as the basis of the discipline (Newman,
(1986) and Pharris (2005) both advocate application of 2003). She sees health as expanding consciousness as
the theory to practice with communities. emerging from a Rogerian perspective, incorporating
theories of caring, and projecting a transformative
454 UNIT IV Nursing Theories mode. However, quantitative methods are inadequate
process (Newman, 2005). Future researchers will to capture the dynamic, changing nature of this the-
be greatly assisted by Smith’s (2011) comprehensive ory. A hermeneutic dialectic approach was developed
review of the theory of health as expanding con- and has been used extensively for full explication of
sciousness research literature. its meaning and application.
Further Development Importance
The focus of Newman’s theory of health as expanding
Previously discussed research studies have supported consciousness provides an evolving guide for all
the theory of health as expanding consciousness, health-related disciplines. In the quest for under-
illuminating the importance of pattern recognition in standing the phenomenon of health, this unique view
the process of expanding consciousness. The theory of health challenges nurses to make a difference in
has been used extensively in exploring and under- nursing practice by the application of this theory. The
standing the experience of health within illness, sup- volume and breadth of literature cited in this chapter
porting a basic premise of the theory, that disruptive is evidence that Newman’s theory has stood the test of
situations provide a catalytic effect and facilitate time with global importance.
movement to higher levels of consciousness.
Critique Summary
Clarity
Although Newman started with a rational, empirical
Semantic clarity is evident in the definitions, de- approach that was both inductive and deductive, she
scriptions, and dimensions of the concepts of the found it restrictive and “not consistent with the para-
theory. digm from which the theory was drawn” (1997a,
p. 23). Little by little, she relinquished some of the
Simplicity experimental control, and her work evolved to a more
The deeper meaning of the theory of health as expand- interactive, integrative approach that continued to be
ing consciousness is complex. The theory as a whole objective and controlled. When that still did not
must be understood rather than isolating the concepts. work, she shifted from the scientific paradigm with its
As Newman advocated in the 1994 edition of her book, objectivity and control and allowed the principles of
Health As Expanding Consciousness, the holistic ap- her theoretical paradigm to guide her research. Then
proach of the hermeneutic dialectic method is consistent she began to see the core of pattern and process
with the theory and requires a high level of understand- as nursing practice. She saw the evolving pattern
ing of the theory on the part of the researcher to extend as meaning in process that required an approach
the theory in praxis research (M. Newman, personal of mutual process, not just objective observation.
communication, 1996). Patterns showed that expanding consciousness was
related to quality and connectedness of relationships.
Generality The nurse researcher’s creative presence was impor-
The concepts in Newman’s theory are broad in scope tant to the participant’s insight. Newman (1986) con-
because they all relate to health. The theory has been cluded that individuals experience a theory in living
applied in many cultures and is applicable across the it. She labeled her research as hermeneutic dialectic.
spectrum of nursing care situations (M. Newman, The theory of health as expanding consciousness,
personal communication, 2004). Application of the along with the research as praxis method, has been
theory is universal in nature. The broad scope pro- used extensively in nursing practice with a variety
vides a focus for middle-range theory development. of individuals, family and community situations,
nursing education, and practice models and nursing
Accessibility research in the United States and many other coun-
In the early stages of development, aspects of the tries. Newman continues to write, consult, and lec-
theory were tested with the traditional scientific ture, advancing her work.
CASE STUDY CHAPTER 23 Margaret A. Newman 455
Alice is an 81-year-old widow who has lived alone two sisters and their sole daughter. They were
in a low-income apartment complex in a small very self-sufficient, grew large gardens, had their
rural, Appalachian town since her husband’s death own livestock, and rarely went into town. All
8 years ago. She has one surviving family member, these family members are now deceased except
a granddaughter, who lives 30 miles away. Alice the granddaughter, who insisted that Alice leave
has never learned to drive and depends on her the cabin and move into town after the death
granddaughter for all transportation to physician of her husband. It is apparent that Alice’s past
appointments and for shopping and getting medi- patterns have been those of independence and
cations. Her income is $824 monthly, and she limiting social contact to mainly family members.
requires several expensive prescriptions for arthri-
tis, hypertension, and cardiac problems. She has The nurse shares her perceptions with Alice,
osteoarthritis in her knees and requires a quad who confirms and verifies the pattern identifica-
cane for support and safety when getting around tion. Alice states, “I just don’t know how long I am
her apartment. A visiting nurse stops by weekly going to manage by myself anymore.” The nurse
to check her blood pressure and to give her an helps her explore sources of help, besides the
injection for her arthritis. The visiting nurse notes granddaughter, that will help Alice remain in her
that Alice’s blood pressure is elevated, and Alice apartment as independently as possible. Alice
states that she has been unable to get her medica- relates that there is one man, a few doors away
tion because her granddaughter’s car is broken. who has stopped several times to ask if she needed
Alice mentions that she is low on food in the anything from the grocery store, but she hasn’t
apartment because she can’t get out to shop. asked him because she hates to bother him and
doesn’t want “to be beholden.” After further dis-
Alice admits that she hardly knows or speaks cussion, she decides that she will ask him to pick
to her neighbors despite having lived there for up staples and medications for her and will pay
8 years, and she still feels like a stranger and him back by baking him some bread, saying,
doesn’t want to “push myself in.” She says that she “I just love to bake anyway and haven’t had anyone
hates to bother people and “won’t hardly unless much to bake for.”
I just have to.” She says she sometimes gets lonely
for “her people,” who are all deceased. In subsequent weekly visits, Alice and the
nurse explore the possibility of getting medica-
The visiting nurse, in working with Alice, rec- tions at a reduced price through the local nurse-
ognizes the current situation as a choice point, managed clinic. Alice states that she might try
with potential for increased interaction with oth- getting to know some of her neighbors. The nurse
ers and increased consciousness. The old ways no helps Alice make arrangements to be picked up
longer work for Alice, and new ways of relating by the Senior Van for physician appointments. As
are necessary. The nurse incorporates the ele- Alice begins to build her own support system,
ments of Newman’s method to assist Alice in pat- she finds that she relies on the nurse less for help
tern recognition for the purpose of discovering with maintaining her independence, and they
new potentials for action. As the nurse has Alice resume their previous pattern of the nurse check-
relate her story, through dialogue and interacting ing her blood pressure and giving her injections
with Alice, she helps Alice recognize past patterns weekly. However, Alice and the nurse have now
of relating and how present circumstances have developed a relationship that has transformed
changed those patterns. Alice talks about how she them both, and the nurse is often met at the door
and her husband lived for 56 years in a rural with the smell of fresh-baked bread and an invi-
mountain cabin with few neighbors except for tation to “have a bite.” They both enjoy this new
relationship.
456 UNIT IV Nursing Theories
CRITICAL THINKING ACTIVITIES 5. Consider a patient you have cared for in the past,
and describe how health as expanding conscious-
1 . What is the nurse scientist view of nursing with ness (pattern of the whole) might have changed
health as expanding consciousness? what you did with that patient.
2. How does this view direct knowledge development
for nursing?
3. What changed Newman’s view of health, health
care practice, and nursing practice?
4. Describe your own view of health, health care
practice, and nursing practice, and compare your
views with those of Newman.
POINTS FOR FURTHER STUDY Available through: Fitne, Inc, 5 Depot Street,
Athens, OH 45701, (800) 691–8480.
n http://www.healthasexpandingconsciousness.org n Newman, M. A. (2008). Transforming presence:
n Brown, J. W. (2010). Newman’s theory of health The difference that nursing makes. Philadelphia:
F.A. Davis.
and nursing practice. In M. R. Alligood (Ed.), n Smith, M.C. (2011). Integrative Review of Research
Nursing theory: Utilization & application Related to Margaret Newman’s Theory of Health
(4th ed., pp. 457–478). Maryland Heights, as Expanding Consciousness. Nursing Science
MO: Mosby-Elsevier. Quarterly, 24(3), pp. 256–263.
n Margaret Newman, nurse theorists: Portraits of
excellence (Videotape). (1990). Helene Fuld
Health Trust. Oakland, (CA): Studio Three
Production. Athens, OH: Fitne, Inc.
n Newman, M. A. (1997). Margaret Newman:
Health as expanding consciousness (CD-ROM).
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Alligood, M. R. (2011). Nursing theory–guided research. ing (pp. 3–10). New York: National League for Nursing.
Newman, M. A. (2003). The immediate applicability of
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Brown, J. W. (2010). Newman’s theory of health in nursing Nursing Education and Nursing Research, 9(5), 4–6.
Yamashita, M. (1997). Family caregiving: Application of
practice. In M. R. Alligood (Ed.), Nursing theory: Utili- Newman’s and Peplau’s theories. Journal of Psychiatric
zation & application (4th ed., pp.457–478). Maryland and Mental Health Nursing, 4, 401–405.
Heights, (MO): Mosby-Elsevier. Yamashita, M. (1998). Family coping with mental illness:
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Newman. International Journal for Human Caring, 6, 70. Yamashita, M. (1998). Newman’s theory of health as ex-
Ford-Gilboe, M. V. (1994). A comparison of two nursing panding consciousness: Research on family caregiving
models: Allen’s developmental health model and in mental illness in Japan. Nursing Science Quarterly,
Newman’s theory of health as expanding conscious- 11(3), 110–115.
ness. Nursing Science Quarterly, 7(3), 113–118.
Jonsdottir, H., Litchfield, M., & Pharris, M. D. (2003).
Partnership in practice. Research and Theory for
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Marchione, J. (1993). Margaret Newman: Health as expand-
ing consciousness. Newbury Park, (CA): Sage.
24C H A P T E R
Rosemarie Rizzo Parse
Humanbecoming
Debra A. Bournes and Gail J. Mitchell
“The assumptions and principles of humanbecoming incarnate
a deep concern for the delicate sentiments of being human and
show a profound recognition of human freedom and dignity”
(Parse, 2007b, p. 310).
Credentials and Background New York University College of Nursing, and she is
of the Theorist currently adjunct professor. Dr. Parse is founder and cur-
rent editor of Nursing Science Quarterly, and President of
Rosemarie Rizzo Parse is a graduate of Duquesne Discovery International. She founded the Institute of
University in Pittsburgh and received her master’s and Humanbecoming, where she teaches the ontological,
doctorate degrees from the University of Pittsburgh. epistemological, and methodological underpinnings of
She was a faculty member of the University of Pittsburgh, the humanbecoming school of thought (Parse, 1981,
Dean of the Nursing School at Duquesne University, 1998, 2005, 2007b, 2010, 2011b, 2012b).
(1977 to 1982), Professor and Coordinator of the Center
for Nursing Research at Hunter College of the City Dr. Parse is a Fellow in the American Academy
University of New York (1983 to 1993), Professor and of Nursing, where she initiated and chaired the nurs-
Niehoff Chair at Loyola University Chicago (1993 to ing theory–guided practice expert panel. As editor
2006), and Distinguished Professor Emeritus at Loyola of Nursing Science Quarterly, she spearheaded a
University Chicago (2006 to present). In January 2007, well-known, highly cited venue for nurse scholars
she became a Consultant and Visiting Scholar at to share and debate matters important to nursing
research and theory development. For this and other
Photo copyright 1998 by Jonas, Pittsburgh, PA.
The authors wish to thank Dr. Rosemarie Rizzo Parse for reviewing this chapter.
464
works, Dr. Parse has received several honors. She has CHAPTER 24 Rosemarie Rizzo Parse 465
received two Lifetime Achievement Awards (one laughing, joy-sorrow, feeling respected, contentment,
from the Midwest Nursing Research Society and one feeling very tired, and quality of life for persons with
from the Asian American Pacific Islander Nurses™ Alzheimer’s disease); and taught theory and research
Association), the Rosemarie Rizzo Parse Scholarship courses in institutions of higher learning, for example,
was endowed in her name at the Henderson State Loyola University Chicago, University of Cincinnati,
University School of Nursing, her books were twice University of Dayton, University of South Carolina, and
named “best picks” by Sigma Theta Tau International, others.
and the Society of Rogerian Scholars honored her with
the Martha E. Rogers Golden Slinky Award. In 2008, Parse is an articulate, courageous, and vibrant leader
she received the New York Times Nurse Educator of with a strong vision and deliberate determination to
the Year Award, and in 2012 she received the Medal of advance the discipline of nursing. She is well-known
Honor at the University of Lisbon in Portugal. internationally for her humanbecoming school of
thought—a nursing perspective focused on quality of
Throughout her career, Dr. Parse has made out- life and human dignity from the perspective of patients,
standing contributions to the discipline and profession families, and communities. She is an inspirational men-
of nursing through progressive leadership in nursing tor whose diligent loving presence, consistent and will-
knowledge development, research, education, and prac- ing availability, and respectful and gentle urgings have
tice. She has explored the ethics of human dignity, helped many seasoned and budding nurse scholars to
set forth humanbecoming tenets of human dignity pursue their dreams. Those who have had the honor of
(Parse, 2010), and developed teaching-learning (Parse, working with her as students and colleagues are hon-
2004), mentoring (Parse, 2008b), leading-following ored to have been mentored by this truly outstanding
(Parse, 2008a, 2011a), community (Parse, 2003, 2012b), nurse leader (Bournes, 2007; Cody, 2012).
and family (Parse, 2009a) models that are used world-
wide. She has published 9 books (Morrow, 2012b; Parse, Theoretical Sources
1974, 1981, 1985, 1987, 1995, 1998, 1999a, 2001b, 2003)
and more than 150 articles and editorials about matters The humanbecoming school of thought is grounded
pertinent to nursing and other health-related disci- in human science proposed by Dilthey and others
plines. Dr. Parse has shared her knowledge in over 300 (Cody & Mitchell, 2002; Mitchell & Cody, 1992;
local, national, and international presentations and Parse, 1981, 1987, 1996, 1998, 2007b, 2010, 2012b).
workshops in more than 35 countries on 5 continents. The humanbecoming school of thought is “consistent
Her works have been translated into many languages, with Martha E. Rogers’ principles and postulates
and she consults throughout the world with nursing about unitary human beings, and it is consistent
education programs and health care settings that with major tenets and concepts from existential-
are utilizing her work to guide research, practice, lead- phenomenological thought, but it is a new product, a
ership, education, and regulation of quality standards. different conceptual system” (Parse, 1998, p. 4). She
She has planned and implemented many international developed her theory while working at Duquesne
conferences on nursing theory, the humanbecoming University in Pittsburgh (during the 1960s and
school of thought, qualitative research, and quality 1970s) when Duquesne was regarded as the center of
of life. the existential-phenomenological movement in the
United States. Dialogue with scholars such as van
Parse has chaired over 40 doctoral dissertations, Kaam and Giorgi stimulated her thinking on the
guided over 300 students with creative research con- lived experiences of human beings and their situated
ceptualizations, and mentored faculty and students freedom and participation in life.
on qualitative and quantitative research proposals,
grant applications, and manuscripts for publications. Parse synthesized the science of unitary human
She developed basic and applied science research beings, developed by Martha E. Rogers (1970, 1992)
methods (Parse, 2001b, 2005, 2011b); conducted mul- with the fundamental tenets from existential-
tiple qualitative research studies about living experi- phenomenological thought, articulated by Heidegger,
ences of health and quality of life (such as hope, Sartre, and Merleau-Ponty and secured nursing as a
human science. She contends that humans cannot be
466 UNIT IV Nursing Theories The basic tenet, human subjectivity, means viewing
reduced to component parts and be understood. human beings not as things or objects, but as indivis-
Rather, persons are living beings who are different ible, unpredictable, everchanging beings (Parse, 1998,
from schemata that divide them. Parse challenges the 2007b) and as a mystery of being with nonbeing.
traditional medical view of nursing and distinguishes Human beings live all-at-onceness as the becoming
the discipline of nursing as a unique, basic science visible–invisible becoming of the emerging now
focused on human experiences. She supports the no- (Parse, 2012b). Parse posits that humans’ presence
tion that nurses require a unique knowledge base with the world is personal and that humans live mean-
that informs their practice and research, knowledge ing as their becoming who they are. As people choose
of humanuniverse and health that is essential to ful- meanings and projects according to their value priori-
fill their commitment to humankind (Parse, 1981, ties, they coparticipate with the world in indivisible,
1987, 1993, 2007b, 2010, 2012b). unbounded ways (Parse, 1981, 1998, 2007b, 2012b).
Persons are inseparable from the world and craft
She drew on Rogers’ principles of helicy, inte- unique relationships. A person’s becoming is complex
grality, and resonancy and her postulates (energy and full of explicit-implicit meaning (Parse, 1981,
field, openness, pattern, and pandimensionality) 1998, 2007b, 2012b).
(Parse, 1981; Rogers, 1970, 1992). These ideas un-
derpin Parse’s notions about persons as open beings Coconstitution means any moment is cocreated
who relate with the universe illimitably, that is, with the constituents of the situation (Parse, 1981,
“with indivisible, unbounded knowing extended to 1998, 2007b, 2012b). Human beings choose mean-
infinity” (Parse, 2007b, p. 308), and who are indivis- ing with the particular constituents of day-to-day
ible, unpredictable, everchanging, and recognized life. Life happens, events unfold in expected and
by patterns (Parse, 1981, 1998, 2007b, 2012b). unexpected ways, and the human being coconsti-
tutes personal meaning and significance. Coconsti-
From existential-phenomenological thought, Parse tution surfaces with opportunities and limitations
drew on the tenets of intentionality and human sub- for human beings as they live their presence with
jectivity and the corresponding concepts of coconsti- the world, and as they make choices about what
tution, coexistence, and situated freedom (Parse, things mean and how to proceed. The term coconsti-
1981, 1998, 2007b, 2012b). She uses the prefix co on tution refers to creating different meanings from the
many of her words to denote the participative nature same situations. People change and are changed
of persons. Co means together with, and, for Parse, through their personal interpretations of life situa-
humans can never be separated from their relation- tions. Various ways of thinking and acting unite
ships with the universe—thus her 2007b conceptual- familiar patterns with newly emerging ones as peo-
izations of humanbecoming and humanuniverse as one ple craft their unique realities.
word. Relationships with the universe include all the
linkages humans have with other people and with Coexistence means “the human is not alone in any
ideas, projects, predecessors, history, and culture dimension of becoming” (Parse, 1998, p. 17). Human
(Parse, 1981, 1998, 2007b, 2012b). beings are always with the world of things, ideas, lan-
guage, unfolding events, and cherished traditions,
From Parse’s perspective, humans are intentional and they also are always with others—not only con-
beings. That is, human beings have an open and temporaries, but also predecessors and successors.
meaningful stance with the universe and people, proj- Humans are community (Parse, 2003). Indeed, Parse
ects, and ideas that constitute lived experience. Hu- posits that “without others, one would not know that
man beings are intentional whose involvements are one is a being” (Parse, 1998, p. 17). Persons think
not random but are chosen for reasons known and about themselves in relation to others and how they
not known. Parse says that being human is being in- might be with their plans and dreams. Connected
tentional and present, open, and knowing with the with freedom, Parse describes an abiding respect for
world. Intentionality is also about purpose and how human change and possibility.
persons choose direction, ways of thinking, and act-
ing with projects and people. People choose attitudes Finally, situated freedom means that human be-
and actions with illimitable options (Parse, 1981, ings emerge in the context of a time and history,
1998, 2007b, 2012b).
a culture and language, physicality, and potentiality. CHAPTER 24 Rosemarie Rizzo Parse 467
Parse suggests that human freedom means “reflec- For example, all humans live paradoxical rhythms
tively and prereflectively one participates in choosing of certainty-uncertainty, joy-sorrow, and others,
the situations in which one finds oneself as well as and they move with the rhythm of their paradoxical
one’s attitude toward the situations” (Parse, 1998, experiences—at times focusing on certainty or joy,
p. 17). Humans are always choosing what is important for instance, yet always having an awareness of living
in their lives. They decide the attention to give to situ- the uncertainty or sorrow inherent in situations.
ations, projects, and people. In day-to-day living, Likewise, freedom, although a cornerstone of Parse’s
people choose and act on their value priorities, and early thinking, is seen in a new light in her most recent
value priorities shift as life unfolds. Sometimes acting thinking. Parse (2007b) stated that freedom is “contex-
on beliefs is as important as achieving a desired out- tually construed liberation” (p. 309). People have
come. Personal integrity is intimately connected to freedom with their situations to choose ways of being.
situated freedom. Finally, mystery, the fourth postulate, is presented
in a more specific way as something special that
In 2007 and in 2012, Parse published important transcends the conceivable and as the unfathomable
conceptual refinements for the humanbecoming school and unknowable that always accompanies the “indi-
of thought. First, in 2007, she changed human becom- visible, unpredictable, everchanging humanuniverse”
ing and human-universe to humanbecoming and huma- (p. 309).
nuniverse. These changes, according to Parse (2007b),
further specify her commitment to the indivisibility of In 2012, Parse introduced new conceptualiza-
cocreation. Parse’s new concepts of humanbecoming tions that further specify the meaning of the all-
and humanuniverse demonstrate through language at-onceness of human experience from a humanbe-
that there is no space for thinking that humans can coming perspective. Her belief system (ontology)
be separated from becoming or the universe—these underpinning humanbecoming “specifies that with
notions are irreducible. humanuniverse the human is an august presence, a
seamless symphony of becoming, living the emerg-
In addition, Parse (2007b) specified four postulates ing now. Becoming visible–invisible becoming of the
that permeate all principles of humanbecoming. The emerging now is the living moment that brings to
four postulates are illimitability, paradox, freedom, and the fore the idea that meaning changes with each
mystery. The four postulates further specify ideas em- unfolding living experience incarnating the remem-
bedded within Parse’s school of thought. Illimitability bered with the prospected all-at-once” (Parse,
represents Parse’s thinking about the indivisible, un- 2012b, p. 44). The becoming visible–invisible be-
predictable, everchanging nature of humanbecoming. coming of the emerging now is the universe of his-
Parse (2007b) stated, “Illimitability is the ‘unbounded tories and experiences and hopes and dreams that
knowing extended to infinity, the all-at-once remem- cocreate each moment, as humans live and shape
bering and prospecting with the moment’” (p. 308). their lives with their illimitable, unbounded know-
Indivisible, unbounded knowing “is a privileged ing. Human living experiences surface moment to
knowing accessible only to the individual living the moment like waves surfacing from an ocean. What
life” (Parse, 2008e, p. 46). Paradox has always been is becoming visible in human experience is what is
affiliated with humanbecoming, and Parse’s bringing happening in the moment that is explicitly known
it forth as a postulate that permeates all theoretical and described by the person living it. It is like waves
principles emphasizes the importance of paradox with that are swelling to the top of the ocean—visible for
humanuniverse cocreation. She stated, “paradoxes are a moment, yet always shifting and changing and be-
not opposites to be reconciled or dilemmas to be over- ing cocreated with what is happening in the entirety
come but, rather, are lived rhythms . . . expressed as a of the ocean, invisible beneath the surface yet cocre-
pattern preference” (Parse 2007b, p. 309), “incarnating ating the waves that are becoming visible with their
an individual’s choices in day-to-day living” (Parse, invisible becoming.
2008e, p. 46). Humans make choices about how they
will be with paradoxical experiences and continuously Based on her latest thinking, Parse (2007b, 2012b)
make choices about where to focus their attention. refined the wording of the three principles of her
theory as indicated in the following.
468 UNIT IV Nursing Theories
MAJOR CONCEPTS & DEFINITIONS meaning, possibility, and consequence. Nurses cannot
Three principles constitute the humanbecoming completely know another’s imaging, but they explore,
theory flowing from these themes—meaning, rhyth- respect, and bear witness as people struggle with shap-
micity, and transcendence (Parse, 1981, 1998, 2007b, ing, exploring, integrating, rejecting, and interpreting.
2012b). Each principle contains three concepts that
require thoughtful exploration to understand the Valuing
depth of the humanbecoming theory. The principles Paradox: Confirming–Not Confirming
(Parse, 2012b) are as follows: Valuing is the second concept of the first principle.
1. Structuring meaning is the imaging and valuing The paradox of valuing is confirming–not confirming
(Parse, 1998, 2007b, 2012b). This concept is about
of languaging. how persons confirm and do not confirm beliefs in
2. Configuring rhythmical patterns is the revealing- light of a personal perspective or worldview (Parse,
1981, 1998, 2007b, 2012b). Persons are continuously
concealing and enabling-limiting of connecting- confirming–not confirming beliefs as they are making
separating. choices about how to think, act, and feel. These
3. Cotranscending with possibles is the powering choices may be consistent with prior choices, or they
and originating of transforming (p. 45). may be radically different and require a shifting of
value priorities. Sometimes people may think about
Principle I: Structuring Meaning anticipated choices, and once the choice arrives they
“Structuring meaning is the imaging and valuing of change their thinking and direction in life. Values
languaging” (Parse, 2012b, p. 45), proposing that per- reflect what is important in life to a person or a family.
sons structure, or choose, the meaning of their reali- For Parse, living one’s value priorities is how an indi-
ties, and this choosing happens with explicit-tacit vidual expresses health and humanbecoming. Nurses
knowing. Sometimes questions are not answerable, learn about persons’ values by asking them what is
since people may not know why they think or feel one most important.
way or another. This first principle posits that people
create their reality illimitably with others, and they Languaging
show or language their reality in the ways they speak Paradoxes: Speaking–Being Silent and Moving–
and remain silent and in the ways they move and stay Being Still
still. As people language their realities, they language Languaging is the third concept of the first principle.
their value priorities and meanings according to this The paradoxes of languaging are speaking–being
principle. This principle has three concepts: (1) imag- silent and moving–being still (Parse, 1998, 2007b,
ing, (2) valuing, and (3) languaging. 2012b). Languaging is a concept that is visible and
relates to how humans symbolize and express their
Imaging imaged realities and their value priorities. When lan-
Paradoxes: Explicit-Tacit and Reflective- guaging is visible to others, it is expressed in patterns
Prereflective that are shared with those who are close. Family
Imaging is the first concept of the first principle. The members or close friends often share similar patterns,
paradoxes of imaging are explicit-tacit and reflective- such as speaking, moving, and being quiet (Parse,
prereflective (Parse, 1998, 2007b, 2012b). Imaging is 1981, 1998, 2007b, 2012b). People disclose things
an individual’s view of reality. It is the shaping of per- about themselves when they language and when they
sonal knowledge in explicit and tacit ways (Parse, are silent and remain still. Nurses witness the lan-
1981, 1998, 2007b, 2012b). Some knowing is a reflec- guaging that people show, but cannot know the
tive, deliberate process, while other knowing is prere- meaning of the languaging. To understand the lan-
flective. For Parse, people are inherently curious and guaging, nurses ask people what their words, actions,
seek answers. The answers to questions emerge as
persons explore meaning in light of reality and their
view of things. Imaging is a personal interpretation of
CHAPTER 24 Rosemarie Rizzo Parse 469
MAJOR CONCEPTS & DEFINITIONS—cont’d
and gestures mean. It is possible that persons still may how to be with others, nurses cocreate what happens
not know the meaning of their languaging, and in when they are with persons.
that case the nurse respects the process of coming to
understand the meaning of a situation. Explicating Enabling-Limiting
meaning takes time, and people know when it is right Paradox: Potentiating-Restricting
to illuminate the meaning and significance of an Enabling-limiting is the second concept of the
event or happening. second principle. It is connected with the paradox
potentiating-restricting (Parse, 2007b, 2012b).
Principle 2: Configuring Rhythmical Enabling-limiting is related to the potentials and
Patterns opportunities that surface with the restrictions and
The second principle of humanbecoming is “configur- obstacles of everyday living. Every choice, even those
ing rhythmical patterns is the revealing-concealing made prereflectively, has potentials and restrictions.
and enabling-limiting of connecting-separating” It is not possible to know all the consequences of any
(Parse, 2012b, p. 45). This principle means that human given choice; therefore, people make choices amid
beings create patterns in day-to-day life, and these the reality of ambiguity. Every choice is pregnant
patterns tell about personal meanings and values. In with possibility in both opportunity and restriction.
the patterns of relating that people create, many free- This is verified in practice daily when patients and
doms and restrictions surface with choices; all pat- families say things like, “This is the worst thing that
terns involve complex engagements and disengage- could have happened to our family, but it has helped
ments with people, ideas, and preferences. The second us in many ways.” Enabling-limiting is about choos-
principle has three concepts: (1) revealing-concealing, ing from the possibilities and living with the conse-
(2) enabling-limiting, and (3) connecting-separating. quences of those choices. Nurses help others as they
contemplate the options and anticipated conse-
Revealing-Concealing quences of difficult choices.
Paradox: Disclosing-Not Disclosing
Revealing-concealing is the first concept of the sec- Connecting-Separating
ond principle. The paradox of revealing-concealing Paradox: Attending-Distancing
is disclosing–not disclosing (Parse, 2007b, 2012b). Connecting-separating is the third concept of
Revealing-concealing is the way persons disclose and the second principle. The paradox connected with
keep hidden the persons they are becoming with the connecting-separating is attending-distancing (Parse,
becoming visible–invisible becoming of the emerg- 2007b, 2012b). This concept relates to the ways
ing now (Parse, 1981, 1998, 2007b, 2012b). There is persons create patterns of connecting and separating
always more to tell and more to know about self as with people and projects. Patterns created reveal
well as others. Sometimes people know what they value priorities. Connecting-separating is about com-
want to say, and they deliver messages about what is munion-aloneness and the ways people separate from
becoming visible to them with great clarity; at other some to join with others. Connecting-separating
times, people may surprise themselves with the mes- is also about the paradox attending-distancing and
sages they give as what is becoming visible shifts and explains the way two people can be very close and
changes with the invisible becoming of their emerg- yet separate. Sometimes there is connecting when
ing now. Some aspects of reality and experience people are separating because persons can dwell with
remain concealed. People also disclose–not disclose an absent presence with great intimacy, especially
differently in different situations and with different when grieving for another (Bournes, 2000a; Cody,
people. Patterns of revealing-concealing are cocre- 1995b; Pilkington, 1993). Nurses learn about persons’
ated and intimately connected with the intentions of patterns of connecting-separating by asking about
those persons cocreating the moment. In choosing their important relationships and projects.
Continued
470 UNIT IV Nursing Theories
MAJOR CONCEPTS & DEFINITIONS—cont’d
Principle 3: Cotranscending with Possibles following two paradoxes: (1) conforming–not
The third principle of humanbecoming is “cotrans- conforming and (2) certainty-uncertainty (Parse,
cending with possibles is the powering and originating 1998, 2007b, 2012b). People strive to be like oth-
of transforming” (Parse, 2012b, p. 45). The meaning ers, and yet they also strive to be unique. Choices
of this principle is that persons continuously change about originating occur with the reality of cer-
and unfold in life as they engage with and choose from tainty-uncertainty. It is not possible to know all
infinite possibilities about how to be, what attitude that may come from choosing to be different or
or approach to have, whom to relate with, and what from choosing to be like others. For some, there is
interests or concerns to explore. Choices reflect the danger in being too much like others; for others,
person’s ways of moving and changing with the be- the danger is in being different. Each person de-
coming visible–invisible becoming of the emerging fines and lives originating in light of their world-
now. The three concepts of this principle are as follows: view and values. Originating and creating anew is
(1) powering, (2) originating, and (3) transforming. a pattern that coexists with constancy and confor-
mity (Parse, 1981, 1998, 2007b, 2012b). Humans
Powering craft their unique patterning of originating as they
Paradoxes: Pushing-Resisting, Affirming–Not engage the possibilities of everyday life. Nurses
Affirming, Being-Nonbeing witness originating with persons choosing how
Powering, the first concept of the third principle, is they are going to be with their changing health
connected with the paradoxes pushing-resisting, patterns.
affirming–not affirming, and being-nonbeing (Parse,
1998, 2007b, 2012b). Powering is a concept that conveys Transforming
meaning about struggle and life and the will to go on Paradox: Familiar-Unfamiliar
despite hardship and threat. Parse (1981, 1998, 2012b) Transforming, the third concept of the third principle,
describes powering as pushing-resisting that is always is explicated with the paradox familiar-unfamiliar
happening and that affirms being in light of the possi- (Parse, 1998, 2007b, 2012b). Transforming is about
bility of nonbeing. People constantly engage being and the continuously changing and shifting views that
nonbeing. Nonbeing is about loss and the risk of death people have about their lives as they live what is
and rejection. Powering is the force exerted, the push- becoming visible to them with the invisible becoming
ing to act and live with purpose amid possibilities for of their emerging now. People are always struggling
affirming and holding what is cherished while simulta- to integrate the unfamiliar with the familiar in living
neously living with loss and the threat of nonbeing. everydayness. When new discoveries are made, peo-
There is resistance with the pushing force of powering, ple change their understanding and life patterns, and
because persons live with others who are powering with worldviews shift with insights that illuminate a famil-
different possibilities in the visible-invisible becoming iar situation in a new light. Transforming is the ongo-
of the emerging now. Conflict, according to Parse ing change cocreated as new information and insights
(1981, 1998, 2007b, 2012b), presents opportunities to become visible in the emerging now, as people find
clarify meanings and values, and nurses enhance this ways to change in the direction of their cherished
process by being present with persons who are explor- hopes and dreams (Parse, 1981, 1998, 2007b, 2012b).
ing issues, conflicts, and options. Nurses, in the way they are present with others, help
or hinder a person’s efforts to clarify their hopes,
Originating dreams, and desired directions.
Paradoxes: Certainty-Uncertainty, Conforming–
Not Conforming
Originating, the second concept of the third prin-
ciple, is about human uniqueness and holds the
Use of Empirical Evidence CHAPTER 24 Rosemarie Rizzo Parse 471
builds new knowledge about humanbecoming
Research guided by the humanbecoming theory is (Doucet & Bournes, 2007; Parse, 2012b). Knowledge
meant to enhance understanding of the theoretical of humanbecoming contributes to the substantive
foundation, or the knowledge contained in the knowledge of the nursing discipline. Disciplinary
assumptions, postulates, principles, and concepts of knowledge is different from the practical or technical
humanbecoming (Doucet & Bournes, 2007; Parse, knowledge that nurses use in health care settings.
1998, 2007b, 2012b). Research is not used to test Disciplinary knowledge is theoretical that identifies
Parse’s theory. Nurses assume people have unique the phenomenon of concern for nurses—for Parse
meanings of life situations; persons have freedom; (1998, 2007b, 2012b) is humanbecoming. According
humans are indivisible, unpredictable, ever changing to Parse (1998), “scholarly research is formal inquiry
beings; and persons relate with others and the uni- leading to the discovery of new knowledge with the
verse in paradoxical patterns. To test these beliefs enhancement of theory” (p. 59). The idea of new
would be comparable to testing the assumption that knowledge with enhancement of theory requires
humans are spiritual beings or that people are com- attention to clarify distinctions among different ways
posed of complex systems. These statements are ab- of thinking.
stract beliefs based on experience, observation, and
beliefs about the nature of reality. The foundational or Research guided by humanbecoming explores uni-
ontological statements are value laden, and, as noted versal living experiences with people as they live them
earlier, a nurse either has an attraction and commit- with the becoming visible–invisible becoming of their
ment to these foundational beliefs or not. The idea day-to-day lives. Parse contends there are universal
of a human being who is indivisible, unpredictable, human experiences, such as hope, joy, sorrow, grief,
everchanging and free to choose meaning is an as- fear, and confidence. Research participants’ accounts
sumption that is either believable or not. Assumptions of their living experiences in humanbecoming-guided
about human beings are theoretical, not factual. A research are descriptions of their “remembering-
student or a nurse relates to one notion of human prospecting of the phenomenon [being studied] as it
being or another. According to Parse (1991, 1999b, is appearing with the emerging now. It is living the
2008c, 2008d, 2009b) this is why there is a need for experience being described” (Parse, 2012b, p. 49) in
multiple views; the discipline of nursing can and does light of what is becoming visible to them about the
accommodate different views and different theories experience in the moment. This means that research
about the phenomenon of concern to nursing— guided by humanbecoming explores universal experi-
human-universe-health. In agreement with Hall, Parse ences as people live them. People live in the moment,
(1993) stated the following when discussing the issue and what is remembered and what is hoped for are
of testing the humanbecoming theory: always viewed within the context of what is becoming
visible in the emerging now. Universal experiences
The human becoming theory does not lend itself are not reduced to linear time frames because living
to testing, since it is not a predictive theory and is experiences are cocreated with “indivisible, un-
not based on a cause-effect view of the human- bounded knowing” (Parse, 2007b, p. 308). A nurse
universe process. The purpose of the research is not researcher conducting a Parse method study invites
to verify the theory or test it but, rather, the focus is persons to speak about a particular universal experi-
on uncovering the essences of lived phenomena to ence. For instance, a participant might talk about his
gain further understanding of universal human or her experience of grieving (Cody, 1995a, 2000;
experiences. This understanding evolves from con- Pilkington, 1993). The researcher guided by human-
necting the descriptions given by people to the the- becoming knows that the person’s reality encom-
ory, thus making more explicit the essences of being passes what is remembered and what is imagined or
human. (p. 12) hoped for as it is appearing in the moment (Parse,
2007b). The researcher assumes that the person
Therefore, research with Parse’s theory expands knows his or her experience and can offer an account
understanding about human living experiences and of the experience as he or she lives and knows it. What
is shared about the experience under study is what
472 UNIT IV Nursing Theories happen over and over as context and earth are separated
from the core ideas or nuggets that eventually stand out
Parse (2008e) calls “truth for the moment” (p. 46). from the surrounding context or earth. Panning for
Truth for the moment is the person’s description of gold is backbreaking work, and Parse’s research method
his or her reality, an expression of “personal wisdom” is also arduous. Both processes include excitement and
(Parse, 2008e, p. 46) about the phenomenon under anticipation of what is to be discovered. The extraction-
study in light of what is happening and known in that synthesis processes of the Parse method separates out
instant. Truth, from this perspective, is “unfolding core ideas that are present in all participants’ descrip-
evidence, testimony to everchanging knowing, as new tions of the living experience under study. Core ideas,
insights shift meaning and truth for the moment” like gold nuggets, are isolated but not yet refined to a
(Parse, 2008e, p. 46). Thus, research evidence is “truth form that makes them meaningful in the world at large.
for the moment” (p. 46). Gold nuggets are refined into coins or jewelry. Core
ideas are refined to the language of humanbecoming
In 1987, Parse first developed a specific research and nursing science, so other nurses see not only the
method consistent with the humanbecoming theory; gold nuggets but also the meaningfulness of the newly
since then, her humanbecoming hermeneutic method refined ideas in light of a language of nursing science.
has been articulated (Cody, 1995c; Parse, 1998, 2001b, Because all research is theory driven, research findings
2005, 2007a, 2011b). A third applied science method are interpreted in light of the guiding frame of reference
(qualitative descriptive preproject-process-postproject) to advance disciplinary knowledge.
has also been articulated (Parse, 1998, 2001b, 2005,
2011b). For information about these methods, see The Major Assumptions
Human Becoming School of Thought: A Perspective for
Nurses and Other Health Professionals (Parse, 1998) Parse (1998) synthesized “principles, tenets, and con-
and Qualitative Inquiry: The Path of Sciencing (Parse, cepts from Rogers, Heidegger, Merleau-Ponty, and
2001b). Additional detail and updates about the Sartre . . . in the creation of the assumptions about the
humanbecoming modes of inquiry are found in Parse’s human and becoming, underpinning a view of nurs-
and others articles (Doucet & Bournes, 2007; Parse, ing grounded in the human sciences. Each assumption
2005, 2011b). The Parse research method records is unique and represents a synthesis of three of the
accounts of personal experiences and systematically postulates and concepts drawn from Rogers’ work and
examines these accounts to identify the aspects of from existential phenomenology” (p. 19). Parse draws
living experiences shared across participants. Core upon the work of other theorists to build a solid foun-
concepts, or ideas shared across all participants, form a dation for a new nursing science. Accordingly, the
structure of the phenomenon under study. The struc- assumptions underpinning humanbecoming focus
ture defined by Parse (2011b) is “a description of the on beliefs about humans and about their becoming
emerging now…The emerging now incarnates remem- visible–invisible becoming, which is health (Parse,
bering-prospecting about the [living] experience” 2012a). Parse does not specify separate assumptions
(p. 13). New knowledge is embedded in the core con- about the universe because the universe is illimitable
cepts and, once discovered, enhances theory and and cocreated with humans—rather than separate
understanding in ways beyond the particular study. The from humans as evident in Parse’s (2012b) newly
weaving of new knowledge with the theoretical concepts updated assumptions about humans and becoming:
expands understanding of the content of the humanbe-
coming theory, and new knowledge develops disciplin- Parse (1998; 2012b) synthesized the original nine
ary and interdisciplinary thinking and dialogue. assumptions about humans and becoming into four
assumptions about humanbecoming as follows:
A metaphor of panning for gold describes the Parse
method. The researcher gathers descriptions from par- 1. Humanbecoming is structuring meaning, freely
ticipants like a person panning for gold gathers up the choosing with situation.
earth. The extraction-synthesis processes of the Parse
method is likened to the gathering, sifting, swirling, 2. Humanbecoming is configuring rhythmical hu-
seeking, and separating, as when panning. Researchers manuniverse patterns.
following the Parse method work to separate particular
context from core ideas. The gathering and discovering
3. Humanbecoming is cotranscending illimitably CHAPTER 24 Rosemarie Rizzo Parse 473
with emerging possibles.
struggle or acquiesce, to be certain or uncertain,
4. Humanbecoming is humanuniverse cocreating to hope or despair—all these options surface in day-
a seamless symphony. to-day living. Considering and choosing from these
(Parse, 2012b, p. 45) options is cotranscending with the possibles.
Three themes arise from the assumptions of the Nursing
humanbecoming school of thought. These include Consistent with her beliefs, Parse writes about nurs-
(1) meaning, (2) rhythmicity, and (3) transcendence ing as a basic science. Parse (2000) wrote, “It is the
(Parse, 1998). The postulates illimitability, paradox, hope of many nurses that nursing as a discipline will
freedom,and mystery (Parse, 2007b) permeate the enjoy the recognition of having a unique knowledge
three themes. Meaning is borne in the messages that base and the profession will be sufficiently distinct
persons give and take with others in speaking, mov- from medicine that people will actually seek nurses
ing, silence, and stillness (Parse, 1998, 2012b). for nursing care, not medical diagnoses” (p. 3). For
Meaning indicates the significance of something and over 30 years, Parse has been advanced the belief that
is chosen by people. Outsiders cannot decide the nursing is a basic science, and that nurses require
meaning or significance of something for another theories that are different from other disciplines.
person. Nurses cannot know what it will mean for a Parse believes that nursing is a unique service to
family to hear news of an unexpected illness or humankind. This does not mean that nurses do
change in health until they learn the meaning it not benefit from and employ knowledge from other
holds from the family’s perspective. Sometimes the disciplines and fields of study. It means that nurses
significance of something is not known until mean- primarily rely on and value the knowledge of nursing
ing is explored and possibilities examined. Personal theory in their practice and research activities. Parse
meanings are shared with others when people (1992) has articulated clearly that she believes “nurs-
express their views, concerns, hopes, and dreams. ing is a science, the practice of which is a performing
According to Parse (1998) meaning is connected art” (p. 35). From this view, nursing is a learned disci-
with moments of day-to-day living, as well as with pline, and nursing theories guide research and prac-
the meaning or purpose of life. tice. These beliefs reflect those of Rogers (1970).
Rhythmicity is about patterns and possibility. Nursing practice for those choosing Parse’s theory is
Parse (1981, 1998) suggests that people live unrepeat- guided by a methodology that emerges directly from
able patterns of relating with others, ideas, objects, humanbecoming ontology. The practice dimensions
and situations. Their patterns of relating incarnate and processes are illuminating meaning (explicating),
their priorities, and these patterns are changing con- synchronizing rhythms (dwelling with), and mobilizing
stantly as they integrate new experiences and ideas transcendence (moving beyond). For practice method-
with what is becoming visible-invisible in the emerg- ology, refer to The Human Becoming School of Thought:
ing now. For Parse, people are recognized by their A Perspective for Nurses and Other Health Profes-
unique patterns. People change their patterns when sionals (Parse, 1998). For humanbecoming-guided
they integrate new priorities, ideas, and dreams, and practice, refer to Bournes & Naef, 2006; Bunkers, 2011,
show consistent patterns that continue like threads of 2012b; Hayden, 2010; Hegge, 2012; Jasovsky, Morrow,
familiarity and sameness throughout life. Clementi, & Hindle, 2010; Jonas-Simpson, 2010; Oaks
& Drummond, 2009; Peterson-Lund, 2011; Smith,
Transcendence is the third major theme of the 2010; and Tanaka, Katsuno, & Takahashi, 2012. Parse
humanbecoming school of thought. Transcendence is (1993) describes nursing practice as living the art of
about change and possibility, the infinite possibility humanbecoming in the following way:
that is humanbecoming. “The possibilities arise with
. . . [humanuniverse] . . . as options from which to The nurse is in true presence with the individual
choose personal ways of becoming” (Parse, 1998, (or family) as the individual (or family) uncovers
p. 30). To believe one thing or another, to go in one the personal meaning of the situation and makes
direction or another, to be persistent or let go, to choices to move forward in the now moment with
474 UNIT IV Nursing Theories Human beings come into the world through others
and live their life cocreating patterns of communion-
cherished hopes and dreams. The focus is on the aloneness. This means that persons change and are
meaning of the liv[ing] experience for the person changed in relating with others, ideas, objects, and
(or family) unfolding “there with” the presence of events. People become known and understood as they
the nurse . . . The living of the theory in practice cocreate patterns of relating with people, ideas, cul-
is indeed what makes a difference to the people ture, history, meanings, and hopes. To understand
touched by it. (p. 12) human life and human beings, an individual must
start from the premise that all people are intercon-
Nursing, for Parse, is a science, and the performing nected with predecessors, contemporaries, and even
art of nursing is practiced in relationships with persons people who are not yet present in the world. Parents
(individuals, groups, and communities) in their pro- may imagine and have a relationship with a child long
cesses of becoming. Parse (1989) sets forth the follow- before the child is conceived and long after a child is
ing set of fundamentals for practicing the art of nursing: lost through death (Jonas-Simpson, 2010; Pilkington,
• Know and use nursing frameworks and theories. 1993). That people have relationships with their par-
• Be available to others. ents and other loved ones who are no longer in this
• Value the other as a human presence. world are examples of the indivisibility, mystery, and
• Respect differences in view. complexity of humanuniverse and humanbecoming.
• Own what you believe and be accountable for your
Theoretical Assertions
actions.
• Move on to the new and untested. Parse’s (1981, 1998, 2012b) principles are the asser-
• Connect with others. tions of the humanbecoming theory. Each principle
• Take pride in self. interrelates the nine concepts of humanbecoming:
• Like what you do. (1) imaging, (2) valuing, (3) languaging, (4) reveal-
• Recognize the moments of joy in the struggles of ing-concealing, (5) enabling-limiting, (6) connect-
ing-separating, (7) powering, (8) originating, and
living. (9) transforming (Figure 24–1). Research projects
• Appreciate mystery and be open to new discoveries. generate structures that further specify relation-
• Be competent in your chosen area. ships among theoretical concepts. For example,
• Rest and begin anew. (p. 111) Naef and Bournes (2009) studied the experience
of waiting for persons on a list to receive a lung
Person, Environment, Health Viewed transplant, and presented the following theoreti-
as Humanuniverse, Humanbecoming, cal structure: “The lived experience of waiting is
and Health enabling-limiting the imaging-valuing of powering
Parse (1998, 2007b, 2012b) views the concepts human, connecting-separating” (Naef & Bournes, 2009,
universe,and health as inseparable and irreducible. To p. 145). Theoretical structures are used to enhance
emphasize this inseparability, she specified humanuni- understanding of phenomena as readers consider
verse and humanbecoming as one word (Parse, 2007b). participant descriptions that connect to the con-
For Parse, health is humanbecoming. It is the becoming cepts of humanbecoming. For more humanbecom-
visible-invisible of the emerging now as humans live ing research, the reader is referred to an overview of
their lives structuring meaning, configuring rhythmical studies (Doucet and Bournes, 2007 and other recent
patterns, and cotranscending with possibles (Parse, publications; Baumann, 2008, 2012b; Bournes &
2012a). Parse (1990) speaks of health as a personal com- Milton, 2009; Bunkers, 2010b, 2012a; Condon,
mitment, which means, “an individual’s way of becom- 2010a, 2010c; Doucet, 2012a, 2012b; Florczak, 2010,
ing is cocreated by that individual, incarnating his or 2012; Maillard-Struby, 2012; Morrow, 2010; Parse,
her own value priorities” (p. 136). For Parse (1990), 2005, 2008e, 2009c, 2011b, 2012b; Peterson-Lund,
health is a flowing process, a personal creation, and a 2012; Smith, 2012).
personal responsibility. Personal health may be changed
as commitment is changed, which “include[s] creative
imagining, affirming self, and spontaneous glimpsing of
the paradoxical” (Parse, 1990, p. 138).
CHAPTER 24 Rosemarie Rizzo Parse 475
Principle 1: Structuring Principle 2: Configuring Principle 3:
meaning is the imaging rhythmical patterns is the Cotranscending with
and valuing of revealing-concealing and possibles is the powering
languaging. enabling-limiting of and originating of
connecting-separating. transforming.
Imaging Valuing Revealing- Enabling- Powering Originating
Concealing Limiting
Languaging Connecting- Transforming
Separating
Concepts in the squares: Powering emerges with the revealing-concealing of imaging.
Concepts in the ovals: Originating emerges with the enabling-limiting of valuing.
Concepts in the triangles: Transforming emerges with the languaging of connecting-separating.
FIGURE 24-1 Relationship of principles, concepts, and theoretical structures of the human becoming theory. (From Parse, R. R.
[1998]. The human becoming school of thought: A perspective for nurses and other health professionals [p. 56]. Thousand Oaks, (CA):
Sage. Principles updated from Parse, R. R. [2012b]. New humanbecoming conceptualizations and the humanbecoming community
model: Expansions with sciencing and living the art. Nursing Science Quarterly, 25, 44–52.)
Logical Form community (Bournes & Ferguson-Paré, 2007; Bournes
& Flint, 2003; Bournes & Naef, 2006; Bunkers, 2010a,
The inductive-deductive process was central to the 2010c, 2011, 2012b; Hayden, 2010; Hegge, 2012;
creation of the humanbecoming theory. The theory Jasovsky Morrow, Clementi, et al., 2010; Mitchell,
originated from Parse’s personal experiences with her Bournes, & Hollett, 2006; Oaks & Drummond, 2009;
readings and in nursing practice. She deductively- Peterson-Lund, 2011; Smith, 2010; Tanaka, Katsuno, &
inductively crafted major components of humanbe- Takahashi, 2012; and others). A community of nurse
coming from the science of unitary human beings and scholars is advancing humanbecoming in practice,
existential-phenomenological thought. She intuitively research, and education. The theory has made a differ-
and methodically derived the assumptions, postulates, ence to nurses and to persons (patients) experiencing
principles, concepts, and practice and research meth- humanbecoming practice. This includes nurses who
odologies of the humanbecoming school of thought. work with older adults and with children. The theory
Figure 24–1 illustrates how the principles, concepts, guides practice for nurses who work with families
and theoretical structures connect in simplicity and (Parse, 2009a) and with persons in hospital settings,
complexity. Abstraction and complexity create possi- clinics, and community settings (Parse, 2003, 2012b).
bility for growth, scholarship, and sustainability. A community-based health action model, for instance,
has been developed and has received support from the
Acceptance by the Nursing Community local community and other funding agencies (Crane,
Practice Josephson, & Letcher, 1999). The theory was used as an
overarching theoretical guide to develop a decisioning
The range of publications about humanbecoming dem- model for nurse regulators at a State Board of Nursing
onstrates the broad scope of acceptance by the nursing
476 UNIT IV Nursing Theories sequencing. The curriculum plan was updated in
1998 in The Human Becoming School of Thought:
(Benedict, Bunkers, Damgaard, et al., 2000; Damgaard A Perspective for Nurses and Other Health Profession-
& Bunkers, 1998, 2012). The theory has generated con- als. Parse outlined philosophy, goals, conceptual
troversy and scholarly dialogue about nursing as an framework, themes, program indicators, culture con-
evolving discipline and a distinct human science. It is tent, and evaluation in a sample curriculum plan
not a question of whether or not the theory works in a consistent with humanbecoming.
particular area of practice; it has been lived by nurses in
the operating theater, in parishes, in shelters, in boards A master’s curriculum consistent with humanbe-
of nursing, in acute care hospitals, in long-term and coming was developed at Olivet Nazarene University
community settings, and in any setting where nurses in Kankakee, Illinois (Milton, 2003a). To date, most
have relationships with persons and families. students who study the humanbecoming school of
Education thought and are guided by the theory in their practice
The humanbecoming school of thought and the phil- and research activities were introduced to it at the
osophical assumptions and theoretical beliefs speci- master’s level. Parse’s ideas and theory are increas-
fied by Parse (1981, 1998, 2012b) have fueled many ingly integrated into undergraduate programs to
scholarly dialogues about outcomes in practice, expand options for students being taught that nursing
research, and education when different theories guide is an art and a science. For example, an undergraduate
practice. In Nursing Science Quarterly and other jour- curriculum was designed, implemented, and accred-
nals, nurses have advanced dialogue and debate about ited at California Baptist University in Riverside,
the role of theory in nursing practice, the limitations California (C. Milton, personal communication, July
and contributions of the medical model, the ethics of 6, 2012). In addition, undergraduate and graduate
nursing diagnoses and the nurse-person relationship, students at York University and at Humber College in
paternalism and health care, the knowledge of ad- Toronto, Ontario, Canada, have opportunity to study
vanced nursing practice, paradigmatic issues in nurs- humanbecoming.
ing, the limitations of evidence-based nursing, the
possibilities and politics of human science, freedom Research
and choice, the focus of community-based nursing, Humanbecoming theory has guided research studies
the nature of truth, leadership and nursing theory, in many different countries about numerous living
and the scope of mistakes in nursing. experiences, including feeling loved, feeling very
tired, having courage, waiting, feeling cared for, griev-
Parse (2004) created a humanbecoming teaching- ing, caring for a loved one, persisting while wanting
learning model that has been used in a variety of ways to change, feeling understood, and being listened to,
with students in academic settings (Baumann, 2012a; as well as time passing, quality of life, health, lingering
Bunkers, 2009; Condon, 2009, 2012a, 2012b; Condon & presence, hope, and contentment (Doucet & Bournes,
Hegge, 2011; Delis, 2012; Letcher & Yancey, 2004; 2007). The Parse and humanbecoming hermeneutic
Milton, 2012b; Ursel & Aquino-Russell, 2010) and method generate new knowledge about universal liv-
practice settings (Bournes & Naef, 2006). Teachers in ing experiences (Cody, 1995b, 1995c; Parse, 2001a,
academic and practice settings have contributed new 2001b, 2005, 2007a, 2011b, 2012b). Research findings
understanding and new processes of teaching-learning, have enhanced understanding of how people experi-
and Parse’s theory was used as a model for explicating ence hope while imaging new possibilities and how
pros and cons of teleapprenticeship (Norris, 2002). The people create moments of respite amid the anguish of
humanbecoming school of thought is included in nurs- grieving a loss. Research findings are woven with the
ing courses at the undergraduate and graduate levels in theory, so findings also inform thinking beyond any
many schools of nursing. particular study.
In Man-Living-Health: A Theory of Nursing, Parse In the grieving and loss studies, researchers de-
(1981) presented a sample master’s in nursing cur- scribed a rhythm of engaging and disengaging with
riculum. She outlined this process-based curriculum the one lost and with others who remind the one
in detail, including course descriptions and course
CHAPTER 24 Rosemarie Rizzo Parse 477
grieving about the one lost (Cody, 1995a; Florczak, her own learning about the phenomenon of feeling
2008; Pilkington, 1993, 2008). Women who had a respected that surfaced through the research process—
miscarriage already had a relationship with their was the following poem:
babies, and the anguish of losing the child was so
intense that women invented ways to distance them- The oak tree stands
selves from the reality of the lost child. When they noble on the hill
were alone, the pain was unbearable, and when they even in
were with others, the anguish was both eased and cherry blossom time.
intensified as consoling expressions mingled with
words acknowledging the reality of the lost child Basho (1644–1694/1962)
(Pilkington, 1993; MacDonald & Jonas-Simpson,
2009). Women described rhythms of engaging- Parse (2006) interpreted the artistic expression
disengaging with the lost child and close others, pain, saying, “The oak tree stands noble, acknowledged as
and respite. Connecting the rhythm to the theoretical such with the potential of being disregarded amid the
concept connecting-separating and to the idea of lin- beauty of cherry blossoms, yet there is delight in the
gering presence means nurses can think about and be fortification of being known as oak tree. Oak tree and
present with those experiencing grieving and loss. cherry blossoms live a mutuality of being prized as
How do families in palliative care express their engag- individually unique and uniquely together” (p. 55).
ing and distancing from the one who is moving Subsequently, Parse (2011b) introduced metaphorical
toward death? How do parents losing adult children emergings to the Parse research method. She did this
engage and disengage with the absent children? after examining reports of many Parse research
Research studies about loss and grieving may further method studies and noting:
enhance understanding about connecting-separating
with knowledge for nursing practice. Linguistic descriptions of universal [living] experi-
ences by participants were rife with metaphors
In 2004, Mitchell developed a framework for cri- that creatively expressed the meaning of universal
tiquing humanbecoming research that expanded op- [living] experiences. Metaphors are phrases, attri-
tions for critics engaging humanbecoming-guided butions to objects or ideas that offer surprise twists
nursing science. Parse (2011b) continues to refine the on meanings . . . . To extract metaphors expressed
research method. Parse changed the name of the par- by participants from dialogues about universal
ticipant proposition to language-art, and she added a [living] experiences and to creatively conceptualize
process requiring the researcher to select or create an them in light of the ontology of humanbecoming
artistic expression showing how the researcher was expands knowledge of the experiences. (p. 13)
transfigured through the research process (Parse,
2005). The artistic expression enhances understand- Parse (2011b) used the 2006 study on feeling re-
ing of what the researcher learned about the phenom- spected to illustrate the use of metaphorical emergings
enon under study. For instance, in a study on the with the Parse research method. The metaphorical
experience of feeling respected, Parse (2006) reported emergings that arose from the participants’ descrip-
that 10 adult participants in her study described feel- tions of feeling respected in that study (Parse, 2006)
ing respected as “an acknowledgement of personal included: “Feeling respected feels like everything is fir-
worth” (p. 54). They described, for example, feeling ing on all cylinders; I’m just euphoric for half an hour
confident, being trusted, feeling appreciated, and after class” (p. 53). Describing what can be learned
experiencing joy when feeling respected (Parse, 2006). from this metaphor in light of the study, Parse (2011b)
Parse showed that in each case, the participant spoke wrote the following:
about feeling respected as a “fortifying assuredness
amid potential disregard emerging with the fulfilling This metaphor further illuminates the meaning
delight of prized alliances” (p. 54). Parse’s (2006) artis- of feeling respected when connected to the core
tic expression for this study—that is, her depiction of concepts (fortifying assuredness amid potential
disregard, fulfilling delight, and prized alli-
ances) and when elaborated with the ontology
478 UNIT IV Nursing Theories than with the actual concepts. The nondirectional
statements that do not specify causal or predictive
of humanbecoming. Firing on all cylinders is the relationships about humanuniverse are discomforting
driving force of pushing-resisting in powering for some.
onward with the buoyant momentum of fortify-
ing assuredness. The fortifying assuredness with The concepts of humanbecoming often resonate
feeling respected arises with illimitable imagin- with people when considered at the level of human
ings that cocreate anew the familiar-unfamiliar experience. For instance, the concept of valuing at the
preferred preferences lived with opportunities level of human experiences focuses on the ways per-
amid limitations. The euphoric feeling in the sons choose and act on what is important in their
metaphor is the fulfilling delight of being ele- lives. This idea should be inherently familiar, as
vated with regard, yet with the remembered and should the idea that people sometimes disclose inti-
ever-present potential for disregard. The living mate details about their lives and sometimes keep
paradox of regard-disregard reveals and at once secrets from others (revealing-concealing). Pickrell,
conceals the diversity in connecting-separating Lee, Schumacher, and Twigg (1998) noted that a first-
with prized alliances that surface with feeling time reader might be tempted to dismiss the concepts
respected. The metaphor “firing on all cylinders as too simple to convey the complexity inherent in
. . . [with euphoria]” brings feeling respected to the theory, but they caution that to do so would be a
light as a powerful force of unwavering buoy- mistake. Parse’s principles describe a complex and real-
ancy in confirming human engagements. It istic picture of humanbecoming that provides a mean-
shows the lived experience of feeling respected as ingful framework for understanding the illimitability,
a cocreation languaged in the emerging now mystery, freedom, and paradox of humanuniverse.
that all-at-once incarnates the mystery of being
human. (p. 14) Generality
The humanbecoming school of thought was selected
Critique as a theoretical guide by nurses and other health profes-
sionals in different settings, including acute care, long-
Clarity term care, and community. The theory helped nurses
Humanbecoming is an abstract and complex school be with individuals, families, and groups and was evalu-
of thought that includes the humanbecoming theory ated in practice settings where patients commented on
(the principles). It is a theory, rather than a model, the positive difference it made (Jonas, 1995; Mitchell,
since its concepts and interrelationships are in prin- Bernardo, & Bournes, 1997; Bournes & Ferguson-Paré,
ciples written at an abstract level of discourse—the 2007; Northrup & Cody, 1998; Williamson, 2000).
language of science. The theory penetrates the foun- Humanbecoming has helped leaders to create beneficial
dations of traditional nursing and health care in gen- change in organizational culture, and it has informed
eral. This penetration may be limited to cracklike development of standards of care (Mitchell & Bournes,
fissures or streams of activity to expand opportunities 1998), best-practice guidelines (Nelligan, Grinspun,
and advance thinking. This requires nurses to explore Jonas-Simpson, et al., 2002; Registered Nurses Associa-
ways that are helpful to enhance the quality of life for tion of Ontario, 2002), decision-making tools for nurse
patients. regulators (Benedict, Bunkers, Damgaard, et al., 2000;
Damgaard & Bunkers, 1998, 2012), mentoring pro-
Simplicity grams for novice nurses (Bournes & Plummer, 2011;
In keeping with the theoretical discourse, the major Bournes, Plummer, Hollett, et al., 2011), and leadership
concepts of humanbecoming are defined in abstract and research programs for nurses who work at the point
philosophical terms. The language has been a source of care (Bournes, 2013). The theory of humanbecoming
of comfort and discomfort for nurses (Mitchell & changes what professionals see when they engage with
Bournes, 2000; Mitchell, Bournes, & Hollett, 2006). persons in practice and research. The theory changes
Discomfort with the language is sometimes related the thinking, acting, attitudes, and approaches that pro-
more with unfamiliar beliefs and assumptions about fessionals rely on to fulfill their intentions with others
human beings and how they relate with the universe
(see Humanbecoming/80–20: An Innovative Profes- CHAPTER 24 Rosemarie Rizzo Parse 479
sional Development Program for Nurses at: http://
www.nursingchannel.org/programs.html).Indeed, the and on the other hand that. Finally nurses ask, how
humanbecoming theory changes the intentions and do I believe people change? Do people make choices
purposes of professionals, and there is no limit to how that help them move in the direction of their own
this learning may contribute to meaningful practices hopes and dreams? Humanbecoming theory explores
and approaches for all professional activities linked these questions.
with research, education, and leadership. Importance
Parse calls nursing a human science, and, as such, it
Accessibility represents particular beliefs that have been around for
Accessibility of the theory is evaluated with evidence longer than 100 years. The humanbecoming theory
addressed in the following questions: has taken human science beliefs into service and
• Does evidence (taken here to mean “does reality”) knowledge development in new and important ways.
The humanbecoming research and practice method-
support the theory? ologies are generating transformations in care and a
• Do the principles and concepts of the humanbe- renewed sense of professional purpose. Consider
these examples:
coming theory make sense to nurses when they are 1. Nurses in two Canadian provinces spent 24 months
with people in practice?
• Does the humanbecoming theory help nurses be evaluating humanbecoming-guided care, and these
with people in ways that are helpful and that make acute care nurses reported enhanced satisfaction
a difference from the patient’s perspective? and purpose in their work as professional nurses
• Is the theory useful for administrators and re- (Bournes & Ferguson-Paré, 2007; Mitchell, Bournes,
searchers? & Hollett 2006).
• Do research findings expand knowledge and en- 2. Teams of humanbecoming researchers, practitioners,
hance the theoretical base? artistic writers, actors, and consumers produced a
The answer to these questions is, clearly, an enthu- research-based drama called I’m Still Here about liv-
siastic “yes.” The theory is useful because it provides a ing with Alzheimer’s disease. The Murray Alzheimer
meaningful foundation that is helpful for nurses who Research and Education Program at the University
want to live certain values in practice and research of Waterloo funded the production of a DVD version
(Bournes & Ferguson-Paré, 2007; Mitchell, Jonas- of the drama, as well as an educational guide
Simpson, & Ivonoffski, 2006). informed by humanbecoming theory, research, and
A nurse who is learning the theory might ask the self-reflective practice (Mitchell, Jonas-Simpson, &
following questions: Ivonoffski, 2006). Hundreds of health professionals
• What does humanbecoming theory say about people, and families in countries around the globe have pur-
and do I believe in these ideas as they are presented? chased the DVD and educational guide (available at
• Am I comfortable with the basic beliefs espoused http://www.marep.uwaterloo.ca/products/still.html).
in the humanbecoming theory? Researchers Mitchell, Dupuis, and Jonas-Simpson
The answers to the initial questions about evidence toured a live performance of I’m Still Here to com-
or congruence with reality often lead to a decision to plete a longitudinal study funded by the Social Sci-
pursue the more difficult task of studying the theory. ences and Humanities Research Council of Canada
A commitment to learn more requires some attrac- (SSHRC); this study evaluated knowledge translation
tion to the basic underlying values and assumptions through artistic performance.
about humanuniverse and health. These values recog- 3. Jonas-Simpson’s work on loss for mothers who
nize that people have their own unique views about experience the loss of their baby has been in-
life and their health situations. They speak about what formed by humanbecoming and findings pre-
things mean on a personal level; value their priorities sented in New York in an interactive exhibit of
and pursue what is important to them; want to make stories, poetry, photographs, and research-inspired
their own choices; and speak about paradoxical paintings by artist Ann Bayly for professionals and
thoughts and feelings, saying on the one hand this mothers invited to share their own stories in a
480 UNIT IV Nursing Theories importance of listening and being nonjudgmental.
They also described being more satisfied in their
journal. Most recently, it has informed the cocre- roles, understanding how humanbecoming can
ation of two videos: Enduring Love: Transforming guide their relationships with their colleagues and
Loss is about how mothers and their families live with patients and families, feeling renewed in their
with the loss of a child, and Why Did Baby Die? commitment to nursing, and learning from
Mothering Children Living with the Loss, Love and younger nurses. Protégé participants also shifted
Continuing Presence of a Baby Sibling focuses on in the way they described the importance of the
the surviving children. Both videos are available mentoring experience. They appreciated the guid-
from http://bookstore.yorku.ca. ance and advice about work and skills that they
4. The humanbecoming mentoring model (Parse, had anticipated would come with the mentoring
2008b) was used in a study (Bournes & Plummer, experience, but they also shared that the mentor-
2011) that examined the impact of a mentoring ship was inspiring to them and helped them to
program with experienced critical care nurses and imagine many career possibilities for their future
new graduate nurses interested in a career in criti- in nursing. They also described respecting others’
cal care. It was designed to address critical issues views, being less judgmental and more under-
relating to recruitment and retention of critical standing, listening more attentively to others’ sto-
care nurses, to enhance nurse mentoring capacity ries, and gaining new friends. They described
at a university-affiliated teaching hospital, to eval- acquiring new insights about people and about
uate a mentoring program for staff nurses, and to nursing, feeling more rounded, and understanding
extend knowledge about the effectiveness and gen- themselves and their career goals more clearly.
eralizability the humanbecoming 80/20 model They also appreciated seeing the bigger picture in
(Bournes & Ferguson-Paré, 2007). A total of 11 relation to having a better understanding of the
experienced critical care nurse participants and 13 variety of nursing roles and of the various practice
new graduate nurse participants engaged in the settings represented by participants in the study.
program together. They spent 80% of their time in 5. The humanbecoming leading-following and teaching-
direct patient care and 20% on professional devel- learning models are used in Geneva, Switzerland,
opment, with a focus on learning about humanbe- in health care settings and community centers for
coming-guided nursing practice and mentoring families of persons living with cancer.
and working together in mentoring dyads. The There are convincing indications that the human-
experienced critical care nurses also participated becoming theory is a fitting guide for practitioners
in separate humanbecoming mentor development who want to create respectful partnerships with peo-
workshops throughout the study. Findings dem- ple seeking assistance with health and quality of life.
onstrated an overall increase in satisfaction of More than 2 decades ago, Phillips (1987) suggested
critical care nurses shown in the results of serial that Parse’s work would transform the knowledge base
employee opinion surveys. Sick time, overtime, and the practice of nursing to a unitary perspective.
and turnover trended downward among the par- Indeed, the humanbecoming theory is transforming
ticipant group as compared to nonparticipants. practice in numerous settings, and evaluations are
Mentor group participants shifted in the ways in positive (Bournes, 2002b; Bournes & Ferguson-Paré,
which they described the importance of the men- 2007; Bournes, Plummer, Hollett, et al., 2011; Jonas,
torship experience. Mentor participants, though 1995; Legault & Ferguson-Paré, 1999). The humanbe-
frustrated at times with having to learn theory, ap- coming theory directs attention to persons’ meanings
preciated the refreshing and satisfying opportunity of health and quality of life and to their wishes, needs,
to engage with their protégés. They described feel- concerns, and preferences for information and care.
ing respected, feeling supported, and being chal- The future of health care is based on the development
lenged in their learning to view the importance of theories and practices that honor and respect peo-
of nursing in a new way. They also described ple as experts about life experience and health. At least
deeper, more connected relationships than they five of the largest teaching hospitals in Canada have
had anticipated prior to the study. They spoke
about respect and concern for one another and the
supported nurses piloting and implementing stan- CHAPTER 24 Rosemarie Rizzo Parse 481
dards of practice that are explicitly informed by hu- and teach the humanbecoming school of thought, more
manbecoming. University Health Network, the largest nurses explore the theory in practice. Learning the
teaching hospital affiliated with the University of theory requires formal study, quiet contemplation, and
Toronto, supported nurses to use 20% of their time to creative synthesis. As more nurses use the theory in
participate in teaching-learning sessions informed by practice and research and leadership, their scholarly
humanbecoming. A 2-year-long pilot study evaluated dialogue advances the nursing discipline.
changes when a surgical unit used humanbecoming
patient-centered care (Bournes & Ferguson-Paré, The theory of humanbecoming continues as a
2007). This pilot was replicated on a cardiosciences theory for the future. As nurses question how they are
unit at Regina General Hospital in Saskatchewan, relating with others and question the knowledge base
Canada (Bournes, Ferguson-Paré, Plummer, & Kyle, of the discipline, the humanbecoming theory pro-
2009) and on two additional units at University Health vides a perspective and field of possibilities for change
Network in Toronto, Canada, with similar results and growth. Administrators who engage nurses are
(Bournes & Ferguson-Paré, 2007). continuing to clarify not only what they want from
professionals but also how they want professionals to
Summary perform. The mechanistic approach continues to lose
appeal for health care professionals whose mandate is
Work with the humanbecoming school of thought con- to relate to people as human beings living with health
tinues to evolve, as does the theory itself. An important and illness, hope and no hope, joy and sorrow, and life
development happened in 1998, when Parse extended and death. This theory is a humanbecoming approach
the humanbecoming school of thought and introduced for nurses and even more as humankind evolves.
the text, Community: A Humanbecoming Perspective
(2003), which offers new concepts about change in CASE STUDY
community. Further explication of the community Mrs. Brown, a 48-year-old woman, is living with a
model is found in Parse’s (2012b) article, “New Human- diagnosis of breast cancer. She has just come into
becoming Conceptualizations and the Humanbecom- the oncology clinic for her third round of chemo-
ing Community Model: Expansions with Sciencing and therapy. When asked how she is doing, Mrs. Brown
Living the Art.” Parse has created humanbecoming starts speaking about how tired she is and how she
teaching-learning (Parse, 2004), mentoring (Parse, is feeling burdened with keeping secrets from her
2008b), leading-following (Parse, 2008a, 2011a), and daughter. Mrs. Brown has not told her daughter
family models (Parse, 2009a) that are being utilized in about her cancer diagnosis because she is afraid of
research, leadership, practice, and education settings how her daughter might react. Mrs. Brown says
(Bournes, 2013; Condon, 2010b, 2011; Maillard-Struby, she is just barely holding on to things at this time,
2012; Florczak, Falkenstern, & Baumann, 2010; Kim, and she cannot take much more. She is also con-
Lee, & Baumann, 2011; Milton, 2010a, 2010b, 2011, cerned about the chemotherapy and what she can
2012a; Morrow, 2012a). Ongoing research expands un- expect, because the side effects are getting more
derstanding and illuminates new relationships among intense. Consider Mrs. Brown in the critical think-
theoretical concepts. As schools of nursing introduce ing activities that follow.
CRITICAL THINKING ACTIVITIES In order to invite Mrs. Brown to speak, the nurse
may initially ask her to say more about her situa-
1. Think about Parse’s (1998) practice methodology— tion. In the cadence of speech, Mrs. Brown may
illuminating meaning (explicating), synchronizing pause, giving the nurse an opening to pose ques-
rhythms (dwelling with), and mobilizing transcen- tions that assist Mrs. Brown’s exploration of how
dence (moving beyond). Nurses live true presence she is feeling. The nurse may ask: What is the
with persons, and this means centering and pre-
paring to bear witness to Mrs. Brown’s reality.
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