Nursing Theory alligood 8th edition

482 UNIT IV  Nursing Theories

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

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

n Parse, R. R. (2008b). The humanbecoming mentor- CHAPTER 24  Rosemarie Rizzo Parse 483
ing model. Nursing Science Quarterly, 21, 195–198.
n Parse, R. R. (2011c). What people want from
n Parse, R. R. (2008e). Truth for the moment: Per- professional nurses. Nursing Science Quarterly,
sonal testimony as evidence. Nursing Science 24, 93.
Quarterly, 21, 45–48.
n Parse, R. R. (2012b). New humanbecoming
n Parse, R. R. (2009a). The humanbecoming family conceptualizations and the humanbecoming
model. Nursing Science Quarterly, 22, 305–309. community model: Expansions with sciencing
and living the art. Nursing Science Quarterly,
n Parse, R. R. (2010). Human dignity: A humanbe- 25, 44–52.
coming ethical phenomenon. Nursing Science
Quarterly, 23, 257–262. n Parse interview. Nurse Theorists: Portraits of Excel-
lence, distributed by Fitne, Inc. (5 Depot Street,
n Parse, R. R. (2011a). Humanbecoming leading- Athens, OH 45701).
following: The meaning of holding up the mirror.
Nursing Science Quarterly, 24, 169–171. n www.discoveryinternationalonline.com
n www.humanbecoming.org
n Parse, R. R. (2011b). The humanbecoming modes n www.nursingchannel.org/programs.html\
of inquiry: Refinements. Nursing Science Quarterly,
24, 11–15.

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Quarterly, 2(4), 155.
Parse, R. R. (1989). Martha E. Rogers: A birthday celebra- Parse, R. R. (1993). Scholarly dialogue: Theory guides research
tion. Nursing Science Quarterly, 2(2), 55. and practice. Nursing Science Quarterly, 6(1), 12.
Parse, R. R. (1989). Qualitative research: Publishing and
funding. Nursing Science Quarterly, 2(1), 1–2. Parse, R. R. (1993). The experience of laughter: A phenom-
Parse, R. R. (1990). A time for reflection and projection. enological study. Nursing Science Quarterly, 6(1), 39–43.
Nursing Science Quarterly, 3(4), 143.
Parse, R. R. (1990). Health: A personal commitment. Nursing Parse, R. R. (1994). Charley Potatoes or mashed potatoes?
Science Quarterly, 3(3), 136–140. Nursing Science Quarterly, 7(3), 97.
Parse, R. R. (1990). Nursing theory–based practice: A chal-
lenge for the 90s. Nursing Science Quarterly, 3(2), 53. Parse, R. R. (1994). Laughing and health: A study using
Parse, R. R. (1990). Parse’s research methodology with an Parse’s research method. Nursing Science Quarterly,
illustration of the lived experience of hope. Nursing Sci- 7(2), 55–64.
ence Quarterly, 3(1), 9–17.
Parse, R. R. (1994). Martha E. Rogers: Her voice will not
be silenced. Nursing Science Quarterly, 7(2), 47.

Parse, R. R. (1994). Quality of life: Sciencing and living the
art of human becoming. Nursing Science Quarterly,
7(1), 16–21.

Parse, R. R. (1994). Scholarship: Three essential processes.
Nursing Science Quarterly, 7(4), 143.

Parse, R. R. (1995). Again: What is nursing? Nursing Science
Quarterly, 8(4), 143.

Parse, R. R. (1995). Building the realm of nursing knowledge.
Nursing Science Quarterly, 8(2), 51.

488 UNIT IV  Nursing Theories Parse, R. R. (1999). Expanding the vision: Tilling the field
Parse, R. R. (1995). Commentary: Parse’s theory of human of nursing knowledge. Nursing Science Quarterly, 12, 3.

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

Parse, R. R. (2003). A call for dignity in nursing. Nursing
Science Quarterly, 16, 193.

Parse, R. R. (2003). Research approaches: Likenesses and
differences. Nursing Science Quarterly, 16, 5.

Parse, R. R. (2003). Silos and schools of thought. Nursing
Science Quarterly, 16, 101.

Parse, R. R. (2003). The lived experience of feeling very
tired: A study using the Parse research method. Nursing
Science Quarterly, 16, 319–325.

Parse, R. R. (2003). What constitutes nursing research?
Nursing Science Quarterly, 16, 287.

Parse, R. R. (2004). A human becoming teaching-learning
model. Nursing Science Quarterly, 17, 33–35.

Parse, R. R. (2004). New directions. Nursing Science
Quarterly, 17, 5.

Parse, R. R. (2004). Power in position. Nursing Science CHAPTER 24  Rosemarie Rizzo Parse 489
Quarterly, 17, 101. Parse, R. R. (2007). A human becoming perspective on

Parse, R. R. (2004). A human becoming teaching-learning quality of life. Nursing Science Quarterly, 20, 217.
model. Nursing Science Quarterly, 17, 33–35. Parse, R. R. (2007). Building a research culture. Nursing

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

Parse, R. R. (2006). Concept Inventing: Continuing Clarifi-
cation. Nursing Science Quarterly, 19, 289.

Parse, R. R. (2006). Feeling respected: A Parse method
study. Nursing Science Quarterly, 19, 51–57.

Parse, R. R. (2006). Nursing and medicine: Continuing
challenges. Nursing Science Quarterly, 19, 5.

Parse, R. R. (2006). Outcomes: Saying what you mean.
Nursing Science Quarterly, 19, 189.

Parse, R. R. (2006). Research findings evince benefits of
nursing theory-guided practice. Nursing Science Quar-
terly, 19, 87.

490 UNIT IV  Nursing Theories Baumann, S. L. (1997). Qualitative research with children
as participants. Nursing Science Quarterly, 10(2), 68–69.
Parse, R. R. (2011). Humanbecoming leading-following:
The meaning of holding up the mirror. Nursing Science Baumann, S. L. (1999). Art as a path of inquiry. Nursing
Quarterly, 24, 169–171. Science Quarterly, 12(2), 106–110.

Parse, R. R. (2012). The 25-year evolution of Nursing Science Baumann, S. L. (2003). The lived experience of feeling very
Quarterly: Keeping the dream alive. Nursing Science tired: A study of adolescent girls. Nursing Science Quar-
Quarterly, 25, 5–6. terly, 16, 326–333.

Parse, R. R. (2012). New humanbecoming conceptualiza- Baumann, S., & Braddick, M. (1999). Out of their element:
tions and the humanbecoming community model: Fathers of children who are “not the same.” Journal of
Expansions with sciencing and living the art. Nursing Pediatric Nursing, 14(6), 269–278.
Science Quarterly, 25, 44–52.
Baumann, S. L., Dyches, T. T., & Braddick, M. (2005). Being
Parse, R. R. (2012). The things we make, make us. Nursing a sibling. Nursing Science Quarterly, 18, 51–58.
Science Quarterly, 25, 125.
Baumann, S. L., & Englert, R. (2003). A comparison of
Parse, R. R. (2012). Impact factor—one-size-fits-all: What’s three views of spirituality in oncology nursing. Nursing
wrong with this picture? Nursing Science Quarterly, 25, Science Quarterly, 16, 52–59.
209–210.
Baumann, S. L. & Söderhamn, O. (2005). Considering and
Parse, R. R., Bournes, D. A., Barrett, E. A. M., Malinski, V. M., enjoying tomorrow: Global aging through a human be-
& Phillips, J. R. (1999). A better way: 10 things health coming lens. Nursing Science Quarterly, 18, 353–358.
professionals can do to move toward a more personal
and meaningful system. On Call: A Magazine for Nurses Benedict, L. L., Bunkers, S. S., Damgaard, G. A., Duffy, C.
and Healthcare Professionals, 2(8), 14–17. E., Hohman, M. L., & Vander Woude, D. L. (2000). The
South Dakota board of nursing theory–based regula-
Secondary Sources tory decisioning model. Nursing Science Quarterly,
Allchin-Petardi, L. (1998). Weathering the storm: Persever- 13(2), 167–171.

ing through a difficult time. Nursing Science Quarterly, Bournes, D. A. (2000). A commitment to honoring people’s
11(4), 172–177. choices. Nursing Science Quarterly, 13(1), 18–23.
Andrus, K. (1995). Parse’s nursing theory and the practice
of perioperative nursing. Canadian Operating Room Bournes, D. A. (2000). Concept inventing: A process for
Nursing Journal, 13(3), 19–22. creating a unitary definition of having courage. Nursing
Aquino-Russell, C. E. (2006). A phenomenological study: Science Quarterly, 13(2), 143–149.
The lived experience of persons having a different sense
of hearing. Nursing Science Quarterly, 19, 339–348. Bournes, D. A. (2002). Having courage: A lived experience
Aquino-Russell, K., Struby, F. V. M., & Reviczky, K. (2007). of human becoming. Nursing Science Quarterly, 15,
Living attentive presence and changing perspectives with 220–229.
a web-based nursing theory course. Nursing Science
Quarterly, 20, 128–134. Bournes, D. A. (2002). Research evaluating human becom-
Arndt, M. J. (1995). Parse’s theory of human becoming in ing in practice. Nursing Science Quarterly, 15, 190–195.
practice with hospitalized adolescents. Nursing Science
Quarterly, 8(2), 86–90. Bournes, D. A. (2006). Human becoming-guided practice.
Baumann, S. (1994). No place of their own: An explor- Nursing Science Quarterly, 19, 329–330.
atory study. Nursing Science Quarterly, 7(4), 162–169.
Baumann, S. (1995). Two views of children’s art: Psycho- Bournes, D. A. (2007). Rosemarie Rizzo Parse over the
analysis and Parse’s human becoming theory. Nursing years. Nursing Science Quarterly, 20, 305.
Science Quarterly, 8(2), 65–70.
Baumann, S. (1996). Feeling uncomfortable: Children in Bournes, D. A., Bunkers, S. S., & Welch, A. J. (2004).
families with no place of their own. Nursing Science Human becoming: Scope and challenges. Nursing
Quarterly, 9(4), 152–159. Science Quarterly, 17, 227–232.
Baumann, S. (1996). Parse’s research methodology and the
nurse-researcher-child process. Nursing Science Quar- Bournes, D. A., & Das Gupta, T. L. (1997). Professional
terly, 9(1), 27–32. practice leader: A transformational role that addresses
Baumann, S. (1997). Contrasting two approaches in a human diversity. Nursing Administration Quarterly,
community-based nursing practice with older adults: 21(4), 61–68.
The medical model and Parse’s nursing theory. Nursing
Science Quarterly, 10(3), 124–130. Bournes, D. A., & Ferguson-Paré, M. (2005). Persevering
through a difficult time during the SARS outbreak in
Toronto. Nursing Science Quarterly, 18, 324–333.

Bournes, D. A., & Ferguson-Paré, M. (2007). Human becom-
ing and 80/20: An innovative professional development
model for nurses. Nursing Science Quarterly, 20, 237–253.

Bournes, D. A., & Flint, F. (2003). Mis-takes: Mistakes in
the nurse-person process. Nursing Science Quarterly,
16, 127–130.

Bournes, D. A., & Linscott, J. (1998). Patient-focused care: CHAPTER 24  Rosemarie Rizzo Parse 491
A process of discovery. Theoria,.(4), 3–5. Cody, W. K. (1994). Nursing theory–guided practice: What

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

Chan, E. A. (2005). The influence of the human becoming
theory on teaching-learning stories in Hangzhou,
China. Nursing Science Quarterly, 18, 306–312.

Cody, W. K. (1991). Grieving a personal loss. Nursing Science
Quarterly, 4, 61–68.

Cody, W. K. (1991). Multidimensionality: Its meaning and
significance. Nursing Science Quarterly, 4, 140–141.

Cody, W. K. (1993). Norms and nursing science: A ques-
tion of values. Nursing Science Quarterly, 6(3), 110–112.

Cody, W. K. (1994). Meaning and mystery in nursing science
and art. Nursing Science Quarterly, 7(2), 48–51.

492 UNIT IV  Nursing Theories Karnick, P. M. (2007). Nursing practice: Imaging the possi-
Fisher, M. A., & Mitchell, G. J. (1998). Patients’ views of bles. Nursing Science Quarterly, 20, 44–47.

quality of life: Transforming the knowledge base of Kelley, L. S. (1991). Struggling with going along when you
nursing. Clinical Nurse Specialist, 12(3), 99–105. do not believe. Nursing Science Quarterly, 4(3), 123–129.
Florczak, K. L. (2006). The lived experience of sacrificing
something important. Nursing Science Quarterly, 19, Kelley, L. S. (1995). Parse’s theory in practice with a group
133–141. in the community. Nursing Science Quarterly, 8(3),
Hamalis, P. (1999). Reaching out. Nursing Science Quarterly, 127–132.
12(4), 346.
Hansen-Ketchum, P. (2004). Parse’s theory in practice. Kelley, L. S. (1999). Evaluating change in quality of life
Journal of Holistic Nursing, 22, 57–72. from the perspective of the person: Advanced practice
Huch, M. H., & Bournes, D. A. (2003). Community dwellers’ nursing and Parse’s goal of nursing. Holistic Nursing
perspectives on the experience of feeling very tired. Nurs- Practice, 13(4), 61–70.
ing Science Quarterly, 16, 334–339.
Huchings, D. (2002). Parallels in practice: Palliative nurs- Kruse, B. G. (1999). The lived experience of serenity: Using
ing practice and Parse’s theory of human becoming. Parse’s research method. Nursing Science Quarterly,
American Journal of Hospice and Palliative Care, 19, 12(2), 143–150.
408–414.
International Consortium of Parse Scholars. (1999). A nurs- Lee, O. J., & Pilkington, F. B. (1999). Practice with persons
ing position on global healthcare: Our commitment to living their dying: A human becoming perspective.
humankind. Nursing Science Quarterly, 12(4), 347. Nursing Science Quarterly, 12(4), 324–328.
Jacono, B. J., & Jacono, J. J. (1996). The benefits of Newman
and Parse in helping nurse teachers determine methods Legault, F., & Ferguson-Paré, M. (1999). Advancing nursing
to enhance student creativity. Nursing Education Today, practice: An evaluation study of Parse’s theory of human
16, 356–362. becoming. Canadian Journal of Nursing Leadership, 12(1),
Janes, N. M., & Wells, D. L. (1997). Elderly patients’ expe- 30–35.
riences with nurses guided by Parse’s theory of human
becoming. Clinical Nursing Research, 6, 205–224. Letcher, D. C., & Yancey, N. R. (2004). Witnessing change
Jonas, C. M. (1992). The meaning of being an elder in with aspiring nurses: A human becoming teaching-
Nepal. Nursing Science Quarterly, 5(4), 171–175. learning process in nursing education. Nursing Science
Jonas-Simpson, C. M. (1996). The patient-focused care Quarterly, 17, 36–41.
journey: Where patients and families guide the way.
Nursing Science Quarterly, 9(4), 145–146. Liehr, P. R. (1989). The core of true presence: A loving
Jonas-Simpson, C. (1997). Living the art of the human be- center. Nursing Science Quarterly, 2(1), 7–8.
coming theory. Nursing Science Quarterly, 10(4), 175–179.
Jonas-Simpson, C. M. (1997). The Parse research method Markovic, M. (1997). From theory to perioperative practice
through music. Nursing Science Quarterly, 10(3), 112–114. with Parse. Canadian Operating Room Nursing Journal,
Jonas-Simpson, C. M. (2001). Feeling understood: A mel- 15(1), 13–16.
ody of human becoming. Nursing Science Quarterly, 14,
222–230. Mattice, M. (1991). Parse’s theory of nursing in practice:
Jonas-Simpson, C. M. (2003). The experience of being lis- A manager’s perspective. Canadian Journal of Nursing
tened to: A human becoming study with music. Nursing Administration, 4(1), 11–13.
Science Quarterly, 16, 232–238.
Jonas-Simpson, C. J. (2006). The possibility of changing Mattice, M., & Mitchell, G. J. (1990). Caring for confused
meaning in light of space and place. Nursing Science elders. The Canadian Nurse, 86(11), 16–18.
Quarterly, 19, 89–94.
Jonas-Simpson, C., & McMahon, E. (2005). The language of Melnechenko, K. L. (2003). To make a difference: Nursing
loss when a baby dies prior to birth: Co-creating human presence. Nursing Forum, 38, 18–24.
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25C H A P T E R

Helen C. Erickson Evelyn M. Tomlin Mary Ann P. Swain

1937 to present 1929 to present 1941 to present

Modeling and Role-Modeling

Margaret E. Erickson

“Unconditional acceptance of the person as a human in the process of Being and Becoming
is basic to the Modeling and Role-Modeling paradigm. It is a prerequisite to facilitating

holistic growth . . . Unconditional acceptance of the person as a human being who has an
inherent need for dignity and respect from others, and for connectedness—that kind of
Unconditional Acceptance is based on Unconditional Love”

(Erickson, 2006, p. 343).

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

Previous authors: Margaret E. Erickson, Jane A. Caldwell-Gwin, Lisa A. Carr, Brenda Kay Harmon, Karen Hartman, Connie Rae
Jarlsberg, Judy McCormick, and Kathryn W. Noone.
The authors express appreciation to Helen C. Erickson, Evelyn M. Tomlin, and Mary Ann P. Swain for critiquing earlier editions of
this chapter.
496

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

consultant to the Pediatric Nurse Practitioner Pro- Nursing was established in her honor in 1997 at the
gram at University of Michigan and University of University of Texas at Austin. The biennial lectureship
Michigan Hospitals—Adult Care. highlights international holistic nursing leaders.

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

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

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

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

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

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

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

MAJOR CONCEPTS & DEFINITIONS—cont’d

endowment, adaptation, and self-care knowledge concrete operations, and formal operations (Erickson,
(Erickson, Tomlin, & Swain, 1983). Tomlin, & Swain, 2002, pp. 63–64).

How People are Alike Affiliated Individuation
Holism Individuals have an instinctual need for affiliated
Human beings are holistic persons who have multiple individuation. They need to be able to depend on
interacting subsystems. Permeating all subsystems support systems while simultaneously maintaining
are the inherent bases. These include genetic makeup independence from these support systems. They
and spiritual drive. Body, mind, emotion, and spirit need to feel a deep sense of both the “I” and the “we”
are a total unit, and they act together. They affect and states of being, and to perceive freedom and accep-
control one another interactively. The interaction of tance in both states (Erickson, Tomlin, & Swain,
the multiple subsystems and the inherent bases cre- 2002, p. 47).
ates holism: Holism implies that the whole is greater
than the sum of the parts (Erickson, Tomlin, & Swain, How People are Different
2002, pp. 44–45). Inherent Endowment
Each individual is born with a set of genes that will
Basic Needs to some extent predetermine appearance, growth,
All human beings have basic needs that can be sat- development, and responses to life events . . . Clearly,
isfied, but only from within the framework of the both genetic makeup and inherited characteristics
individual (Erickson, Tomlin, & Swain, 2002, p. 58). influence growth and development. They might in-
fluence how one perceives oneself and one’s world.
Basic needs are met only when the individual They make individuals different from one another,
perceives that they are met (Erickson, Tomlin, & each unique in his or her own way (Erickson, Tomlin,
Swain, 2002, p. 57). & Swain, 2002, pp. 74–75).

Lifetime Development Adaptation
Lifetime development evolves through psychological Adaptation occurs as the individual responds to
and cognitive stages, as follows: external and internal stressors in a health-directed
n Psychological Stages and growth-directed manner. Adaptation involves
mobilizing internal and external coping resources.
Each stage represents a developmental task or a No subsystem is left in jeopardy when adaptation
decisive encounter resulting in a turning point, a occurs (Erickson, Tomlin, & Swain, 2002).
moment of decision between alternative basic atti-
tudes (e.g., trust versus mistrust or autonomy versus The individual’s ability to mobilize resources is
shame and doubt). As a maturing individual negoti- depicted by the APAM. The APAM identifies three
ates or resolves each age-specific crisis or task, the different coping potential states: (1) arousal, (2)
individual gains enduring strengths and attitudes equilibrium (adaptive and maladaptive), and (3)
that contribute to the character and health of the in- impoverishment. Each of these states represents a
dividual’s personality in his or her culture (Erickson, different potential to mobilize self-care resources.
Tomlin, & Swain, 2002, p. 61). “Movement among the states is influenced by one’s
n Cognitive Stages ability to cope [with ongoing stressors] and the
presence of new stressors” (Erickson, Tomlin, &
Consider how thinking develops rather than Swain, 2002, pp. 80–81).
what happens in psychosocial or affective develop-
ment . . . Piaget believed that cognitive learning Nurses can use this model to predict an individual’s
develops in a sequential manner, and he has identi- potential to mobilize self-care resources in response to
fied several periods in this process. Essentially, stress.
there are four periods: sensorimotor, preoperational,

Continued

502 UNIT IV  Nursing Theories

MAJOR CONCEPTS & DEFINITIONS—cont’d

Mind-Body Relationships or her effectiveness or fulfillment (given circum-
We are all biophysical, psychosocial beings who stances), or promote his or her growth (Erickson,
want to develop our potential, that is, to be the best Tomlin, & Swain, 2002, p. 48).
we can be (Erickson, Tomlin, & Swain, 2002, p. 70). n Self-Care Resources

Self-Care Self-care resources are “the internal resources, as
Self-care involves the use of knowledge, resources, well as additional resources, mobilized through self-
and actions, as follows: care action that help gain, maintain, and promote an
n Self-Care Knowledge optimum level of holistic health” (Erickson, Tomlin,
& Swain, 2002, pp. 254–255).
At some level, a person knows what has made n Self-Care Action
him or her sick, lessened his or her effectiveness, or
interfered with his or her growth. The person also Self-care action is “the development and utiliza-
knows what will make him or her well, optimize his tion of self-care knowledge and self-care resources”
(Erickson, Tomlin, & Swain, 2002, p. 254).

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

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

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

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

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

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

506 UNIT IV  Nursing Theories July 6, 1992). Nurses at Brigham and Women’s Hospi-
tal use an adaptation of the assessment tool developed
Acceptance by the Nursing Community at the University of Michigan Medical Center. At the
Practice Fourth National Conference on Modeling and Role-
Modeling (Boston, October 1992) implementation of
The book Modeling and Role-Modeling: A Theory and the professional practice model at Brigham and
Paradigm for Nursing (Erickson, Tomlin, & Swain, Women’s Hospital and case studies were first pre-
2002), chapters in nursing theory texts, and published sented by the staff nurses (J. James, personal commu-
research studies have exposed nurses in practice to nication, July 6, 1992). Nurses at the University of
this theory. Based on the applicability and interest in Pittsburgh Medical Center, Children’s Hospital of the
using this theory to guide holistic nursing practice, University of Wisconsin at Madison, University of
the Modeling and Role-Modeling Theory has been Tennessee Medical Center in Knoxville, Oregon Health
implemented in many hospitals throughout the country. Sciences University Hospital, University Health Sys-
For example, nurses on surgical units at the Univer- tem in San Antonio, Texas, Salina Regional Health
sity of Michigan Medical Center use an assessment Center, and other hospitals and state agencies across
tool based on the Modeling and Role-Modeling The- the United States have also adopted the Modeling
ory. The tool is used to gather information to identify and Role-Modeling Theory as the foundation for
the client’s need assets, deficits, developmental resid- their professional practice. Finally, the theory has
ual, attachment-loss and grief status, and potential provided a theoretical foundation for the implemen-
therapeutic interventions (see Appendix at the end of tation of nursing projects and care in diverse settings
this chapter) (Bowman, 1998; H. Erickson, personal (Alligood, 2011; Haylock, 2008, 2010; Raudonis &
communication, 1988). Acton, 1997; ).

Helen Erickson has lectured extensively, nationally Education
and internationally, and held one-on-one consultations The Modeling and Role-Modeling Theory is intro-
with nurses from various practice and educational duced into the curriculum in nursing programs
backgrounds. Nurses who practice in adult health; case throughout the country. Faculty members have con-
management; community health; critical and intensive tacted and continue to contact Erickson regarding the
care; infant, adolescent, and family health; gerontology; use of the theory in their curricula and for specific
mental health; emergency rooms; and hospices use this courses. Metropolitan State University in St. Paul,
theory. The beauty of the theory is that it can be applied Minnesota, selected Modeling and Role-Modeling as
within any setting and with any population. Erickson the conceptual framework for their curriculum, and
noted that what seemed to be a revolutionary idea as students are taught theory-based practice throughout
recently as 1972 (calling for the client to be the head the program. Other programs that use Modeling
of the healthcare team) has gained acceptance, as has and Role-Modeling Theory as a basis for curriculum
the notion that nurses can practice independently include but are not limited to: St. Catherine’s Univer-
(H. Erickson, personal communication, November sity in St. Paul, Minnesota; the Alternate Entry Master’s
1984). According to Erickson, negative responses to nursing program at the University of Texas at Austin;
the theory came from individuals who cannot accept the University of Texas at Brownsville; Lamar Univer-
the idea of listening to the client first, or who do not sity, Joanne Gay Dishman Department of Nursing in
take the concept of holism seriously (H. Erickson, per- Beaumont, Texas; State University of New York at
sonal communication, November 1984). Buffalo; University of Tennessee at Knoxville; Capital
University in Columbus, Ohio; and Foo Yin College
Brigham and Women’s Hospital in Boston has of Nursing and Medical Technology in Taiwan.
used the Modeling and Role-Modeling Theory as a
theoretical basis for the professional practice model Research
for years. The nurses use the theory as a framework to Nurses throughout the world use Modeling and
structure care planning and case conferences. Jenny Role-Modeling as the theoretical framework for their
James, former vice president for nursing, stated that
“consistency of language, the way care is talked about
and planned” is one of the major advantages of using
this theoretical basis (J. James, personal communication,

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

research. Findings from research studies continue to major constructs and theoretical linkages of the
support and validate the self-care knowledge con- theory (Erickson, 1990a). Hertz, Baas, Curl, and
struct and the importance of support and control as Robinson (1994) conducted an integrative review
well as other theoretical linkages. Erickson’s initial of research from 1982 to 1992 using Modeling
study provided evidence that psychosocial factors are and Role-Modeling as a theoretical basis. Empirical
significantly related to physical health problems evidence has provided bases for validation, refine-
(1976). A follow-up study in 1988 conducted by ment, and revision of the theory. Research will
Erickson, Lock, and Swain (H. Erickson, curriculum continue to expand the Modeling and Role-Modeling
vitae, February 1988) supported these findings, and Theory.
subsequent research has provided for the expansion
and enrichment of major theoretical concepts. As Further Development
described earlier in the chapter, perceived support,
perceived control, hope for the future, satisfaction As this theory is practiced, explored, examined, and
with daily life, need satisfaction, perceived auton- researched, much potential exists for further develop-
omy, AI, self-care knowledge, self-care actions, and ment. The theory continues to gain national and in-
self-care resources are some of the key concepts that ternational attention. One reason for this increased
have been supported and validated through research attention was the founding of the Society for the
studies. Several master’s and doctoral students at the Advancement of Modeling and Role-Modeling. The
University of Michigan School of Nursing, the Uni- society was formed to develop a network of col-
versity of Texas at Austin, and other universities have leagues who could advance the development and
pursed various research questions based on this the- application of the Modeling and Role-Modeling
ory. Campbell, Finch, Allport, Erickson, and Swain Theory. One of the society’s goals is to promote
(1985) conducted a research study at the University continued research related to the theory. The society
of Michigan Medical Center and hypothesized that held its first national symposium in 1986 and has met
the length of hospital stay correlated with the stages biennially thereafter. At the 1988 conference, held at
of development. They used a nursing assessment tool Hilton Head, South Carolina, the membership chair
adapted from the assessment model to measure announced that society members came from 12 states
a patient’s psychosocial development and to relate (H. Erickson, personal communication, 1988). By the
developmental status to the length of hospitalization 1990 conference in Austin, Texas, members repre-
and the number of health problems identified during sented more than 33 states (H. Erickson, personal
hospitalization. Results indicated that the balance of communication, July 1, 1992). These conferences
trust-mistrust accounts for a large percentage of the continue to provide a forum for researchers, educa-
variance in the length of hospitalization. No signifi- tors, and practitioners to disseminate knowledge
cant relationship was evident between psychosocial pertaining to the Modeling and Role-Modeling
coping skills and the number of health problems Theory and paradigm (H. Erickson, personal com-
identified. munication, 1988).

Erickson was the principal investigator of a research The Fourth National Conference on Modeling and
project, Modeling and Role-Modeling with Alzheimer’s Role-Modeling Theory and Paradigm, held in Boston
Patients, funded by the National Institutes of Health, in October 1992, demonstrated the breadth and depth
National Center for Nursing Research. This research of the use and research for the Modeling and Role-
project included 10 other investigators. Results sup- Modeling Theory. Presentations included studies
ported the constructs of self-care knowledge, adaptive based in critical care units and community-based
potential, and AI (H. Erickson, personal communica- practice, in multiple types of educational settings, and
tion, July 1, 1992). across the age span. In 2010, nurses from all over the
United States as well as Egypt, Canada, South Africa,
Numerous graduate students have used the Mod- China, and Great Britain attended the conference
eling and Role-Modeling Theory as a basis for held in San Antonio, Texas. The international biennial
theses and dissertations. In addition, extensive work conferences continue to provide an opportunity for
has been published that substantiates many of the

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

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

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

510 UNIT IV  Nursing Theories outcome based on the proposed nursing plan of
care. Predict the client outcome if the care is not
CRITICAL THINKING ACTIVITIES given.
4 . Assess the client from primary, secondary, and
1 . Interview a client, and use the theory to interpret tertiary sources. Compare for congruency among
the data. Identify nursing diagnoses based on the the three types of sources.
interpretations. n Erickson, H. C., Tomlin, E. M., & Swain, M. A.
(2002). Modeling and role-modeling: A theory and
2 . Propose a nursing plan of care based on the paradigm for nursing. Cedar Park, (TX): EST Co.
interview and interpretation in question one. (Original work published 1983, Englewood Cliffs,
(NJ): Prentice-Hall.)
3. Assuming the goal is to promote the client’s
health and development, predict the client

POINTS FOR FURTHER STUDY

n http://www.mrmnursingtheory.org/
n Research and conceptual references are available

on the website on mid-range theories, major
constructs, and philosophical assumptions of
the Modeling and Role-Modeling Theory.
n Erickson, H. (Ed.) (2006). Modeling and Role-
Modeling: A View from the Client’s World.
Cedar Park, (TX): Unicorns Unlimited.

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Erickson, H. C., Tomlin, E. M., & Swain, M. A. (2002).
Modeling and role-modeling: A theory and paradigm for Journal Articles
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lished in 1983, Englewood Cliffs, (NJ): Prentice-Hall.)
Erickson, H., & Kinney, C. (Eds.). (1990). Modeling and role- Construct validity of an aspect of the coping process:
modeling: Theory, practice and research(Vol. 1). Austin, Potential adaptation to stress. Issues in Mental Health
(TX): Society for the Advancement of Modeling and Nursing, 10, 23–40.
Role-Modeling. Barnfather, J., Swain, M. A., & Erickson, H. (1989). Evaluation
of two assessment techniques. Nursing Science Quarterly, 4,
Book Chapters 172–182.
Baas, L.S., Conway, G.A.(2004). Psychosocial aspects of Campbell, J., Finch, D., Allport, C., Erickson, H., & Swain, M.
(1985). A theoretical approach to nursing assessment.
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D. Thompson (Eds.),Caring for the heart failure patient: Erickson, H. (1983). Coping with new systems. Journal of
A textbook for the healthcare professional(pp. 197–209). Nursing Education, 22(3), 132–135.
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Erickson, H. (1977). Communication in nursing. In physiological problemas. Rapport: Hipnosis de Milton
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Library, University of Michigan. Erickson, H., & Swain, M. A. (1982). A model for assess-
Erickson, H. (1985). Modeling and role-modeling: ing potential adaptation to stress. Research in Nursing
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lems. In J. Zeig & S. Langton (Eds.), Ericksonian Erickson, H., & Swain, M. A. (1990). Mobilizing self-care
psychotherapy: The state of the art.New York: resources: A nursing intervention for hypertension.
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chophysiological problems. In J. K. Zeig & S. Gilligan fant dyad relationships and infant well-being. Issues in
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516 UNIT IV  Nursing Theories Kleinbeck, S. (1977). Coping states of stress. Unpublished
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Engel, G. (1968). A life setting conducive to illness: The affiliated-individuation, burden, and well-being in caregiv-
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of women caring for family members with Alzheimer’s congregate housing, experience managing their health:
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17, 201–216. tion, University of LaVerne, LaVerne, CA.
Chen, Y. (1996). Relationships among health control orien-
Landis, B. J. (1996). Uncertainty, spiritual well-being, and tation, self-efficacy, self-care, and subjective well-being
psychosocial adjustment to chronic illness. Issues in in the elderly with hypertension. Unpublished doctoral
Mental Health Nursing, 17, 217–231. dissertation, University of Texas, Austin.
Curl, E. D. (1992). Hope in the elderly: Exploring the
Leidy, N. (1994). Operationalizing Maslow’s theory: Devel- relationship between psychosocial developmental
opment and testing of the Basic Needs Satisfaction In- residual and hope. Dissertation Abstracts Interna-
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Daniels, R. (1994). Exploring the self-care variables that ex-
Leidy, N. K., & Traver, G. A. (1995). Psychophysiological plain a wellness lifestyle in spinal cord injured wheelchair
factors contributing to functional performance in peo- basketball athletes. Unpublished doctoral dissertation,
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in Nursing and Health, 18(6), 535–546. Darling-Fisher, C. S. (1987). The relationship between
mothers’ and fathers’ Eriksonian psychosocial attri-
Mahler, M. S. (1967). On human symbiosis and the vicissi- butes, perceptions of family support, and adaptation
tudes of individuation. Journal of the American Psycho- to parenthood. Dissertation Abstracts International,
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Erickson, M. (1996). Relationships among support, needs
Maslow, A. H. (1936). The need to know and the fear of satisfaction, and maternal attachment in the adolescent
knowing. Journal of General Psychology, 68, 111–125. mother. Unpublished doctoral dissertation, University
of Texas, Austin.
Miller, E. W. (1995). Encouraging Alzheimer’s caregivers. Hertz, J. E. G. (1991). The perceived enactment of auton-
Journal of Christian Nursing, 12(4), 7–12. omy scale: Measuring the potential for self-care action
in the elderly. Dissertation Abstracts International, 52,
Robinson, K. R. (1994). Developing a scale to measure de- 1953B.
nial levels of clients with actual or potential myocardial Hopkins, B. (1994). Assessment of adaptive potential.
infarctions. Heart and Lung, 23, 36–44. Unpublished doctoral dissertation, University of
Texas, Austin.
Rogers, S. (1996). Facilitative affiliation: Nurse-client inter-
actions that enhance healing. Issues in Mental Health
Nursing, 17, 171–184.

Sappington, J., & Kelley, J. H. (1996). Modeling and role-
modeling theory: A case study of holistic care. Journal
of Holistic Nursing, 14(2), 130–141.

Walsh, K. K., Vanden Bosch, T. M., & Boehm, S. (1989).
Modeling and role-modeling: Integrating nursing theory
into practice. Journal of Advanced Nursing, 14, 755–761.

Theses
Kirk, L. (1996). A descriptive study of level of hope in cancer

patients. Unpublished master’s thesis, University of
Texas, San Antonio.

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Irvin, B. L. (1993). Social support, self-worth and hope Nash, K. (2003). Evaluation of a holistic peer support and ed-
as self-care resources for coping with caregiver stress. ucation program aimed at facilitating self-care resources in
Dissertation Abstracts International, 54(06), B2995. adolescents (Unpublished doctoral dissertation). Univer-
sity of Texas, Galveston.
Jensen, B. (1995). Caregiver responses to a theoretically
based intervention program: Case study analysis. Raudonis, B. (1991). A nursing study of empathy from the
Unpublished doctoral dissertation, University of hospice patient’s perspective. Unpublished doctoral dis-
Texas, Austin. sertation, University of Texas, Austin.

Kline, N. W. (1988). Psychophysiological processes of stress Raudonis, B., & Acton, G. (1997). Theory based nursing
in people with a chronic physical illness. Dissertation practice. Journal of Advanced Nursing, 26(1), 138–145.
Abstracts International, 49, 2129B.
Robinson, K. R. (1992). Developing a scale to measure
Landis, B. J. (1991). Uncertainty, spiritual well-being, and responses of client with actual or potential myocardial
psychosocial adjustment to chronic illness. Dissertation infarctions. Dissertation Abstracts International, 53, 6226B.
Abstracts International, 52, 4124B.
Sofhauser, C. (1996). The relations among hostility, self-
MacLean, T. T. (1987). Erikson’s development and stressors esteem, self-concept, psychosocial residual in persons
as factors in healthy lifestyle. Dissertation Abstracts with coronary heart disease. Dissertation Abstracts
International, 48, 1710A. International 5B/01-B.

Miller, E. W. (1994). The meaning of encouragement and its Weber, G. (1995). Employed mothers with pre-schoolaged
connection to the inner-spirit as perceived by caregivers children: An exploration of their lived experiences and
of the cognitively impaired. Unpublished doctoral dis- the nature of their well-being. Dissertation Abstracts
sertation, University of Texas, Austin. International 56/06-B3/31.

518 UNIT IV  Nursing Theories

Appendix

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

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

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

Appendix—cont’d

Planning Tool Based on Modeling B. Facilitate a self-projection that is futuristic and
and Role-Modeling§ positive.

I. Aims of interventions C. Promote AI with the minimal degree of ambivalence
A. Build trust possible.
B. Promote positive orientation
C. Promote client control D. Promote a dynamic, adaptive, and holistic state of
D. Promote strengths health.
E. Set health-directed goals
E. Promote and nurture a coping mechanism that
II. Intervention goals satisfies basic needs and permits growth-need
A. Develop a trusting and functional relationship satisfaction.
between yourself and your client.
F. Facilitate congruent actual and chronological
developmental stages.

§Critical thinking guidelines for planning are suggested in Erickson, H. C., Tomlin, E. M., & Swain, M. A. (1983). Modeling and role-modeling:
A theory and paradigm for nursing (pp. 169–220). Englewood Cliffs, NJ: Prentice-Hall; and Erickson, H. C. (1990). Theory-based nursing. In
H. C. Erickson & C. Kinney (Eds.), Modeling and role-modeling: Theory, practice and research (Vol. 1). Austin, TX: Society for the Advancement
of Modeling and Role-Modeling.

26C H A P T E R

Gladys L. Husted James H. Husted

1941 to present 1931 to present

Symphonological Bioethical Theory

Carrie Scotto

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

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

520

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

Veterans Affairs. G. Husted served as curriculum con- professionals and patients. The name of the theory is
sultant for several schools of nursing. In addition, she derived from the Greek word symphonia, which means
has presented at many national-level conferences. “agreement.”

James Husted was born in Kingston, Pennsylvania, Ethics is “a system of standards to motivate, deter-
and has had a lifelong interest in philosophy. While in mine, and justify actions directed to the pursuit of
the army in Germany, he became interested in ethics vital and fundamental goals” (Husted & Husted, 2008,
through conversations with a former ethics professor, p. 8). Ethics examines what ought to be done, within
particularly the work of Benedict Spinoza. the realm of what can be done, to preserve and en-
hance human life. The Husteds, therefore, described
J. Husted’s post-Army career focused on sales and ethics as the science of living well.
on hiring and training agents for health insurance
companies. However, he continued to read and de- Bioethics is concerned with the ethics of interac-
velop his philosophical and ethical ideas. During the tions between a patient and a health care professional,
1980s, he joined the high-IQ societies, Mensa and what ought to be done to preserve and enhance hu-
Intertel, serving as a philosophy expert for Mensa and man life within the health care arena. Within the past
a regional director for Intertel. century, the expanding knowledge base and growth of
technology altered existing health care practice and
The theorists met and were married in 1974, estab- created threatening and confusing circumstances not
lishing and cultivating a dialogue that brought about previously encountered. Increasing numbers and
the theory of Symphonology. They are coauthors of types of treatment options allowed patients to survive
several editions of Ethical Decision Making in Nursing. conditions they would not have in the past. However,
Their book was selected as one of Nursing and Health the morbidity of the survivors brought new questions:
Care’s Notable Books of 1991, 1995, and 2001. It also Who should receive treatment? What is the appropri-
won the Nursing Society Award in 2001. Their regular ateness of treatments under particular circumstances?
column, “A Practice Based Bioethic,” appeared in Ad- Who should decide what treatments are appropriate?
vanced Practice Nursing Quarterly from 1997 to 1998. In this way, bioethics became a central issue in what
In addition to publishing books, book chapters, and previously had been a prescriptive environment. It
journal articles, they have presented their ethical the- became essential to consider ethical concerns, as well
ory at conferences and workshops. as scientific solutions, to questions of health (Jecker,
Jonsen, & Pearlman, 1997). Through personal experi-
The Husteds reside in Pittsburgh and continue to ence and observation of nurses, the Husteds recog-
develop and disseminate their work through teaching, nized the increasingly complex nature of bioethical
writing, presenting at conferences and workshops, and dilemmas and the failure of the health care system to
serving as consultants for ethics committees. adequately address the problem.

Theoretical Sources To clarify the reasons for the deficiency of the
health care system in addressing the issue of deliver-
The authors define Symphonology as “the study of ing ethical care, the Husteds examined traditional
agreements and the elements necessary to forming ideas and concepts used to guide ethical behavior.
agreements,” (Husted & Husted, 2008, p. xv). In These ideas include deontology, utilitarianism, emo-
health care, it is the study of agreements between tivism, and social relativism. Deontology is a duty-
health care professionals and patients. An agreement based ethic in which the consequences of one’s
is based on the nature of the relationship between the actions are irrelevant. One acts in accordance with
parties involved. In its ethical dimensions, it outlines preset standards regardless of the outcome. The inap-
the commitments and obligations of each. Although propriateness of this type of guideline is obvious in
the theory developed from the observation of nurses relation to health care professionals, because they are
and nursing practice, it later expanded to include all responsible for foreseeing the effects of their actions
health care professionals. The development of this and acting only in ways that benefit a patient. Utilitar-
theory has led to the construction of a practice-based ian thought would have health care professionals act-
decision-making model that assists in determining ing to bring about the greatest good for the greatest
when and what actions are appropriate for health care

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

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

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

MAJOR CONCEPTS & DEFINITIONS—cont’d

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

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

524 UNIT IV  Nursing Theories Health
The authors do not address or define health directly.
awkward and anonymous terms distract readers from The entire theory is driven by the concept of health in
thinking in terms of real people within the context of the broadest, most holistic sense. Health is a concept
a particular situation. Therefore, they chose to refer to applicable to every potential of a person’s life. Health
individuals as he, in the case of patients, and she, in involves not only thriving of the physical body, but
the case of health care professionals in particular situ- also happiness. Happiness is realized as individuals
ations and examples. This chapter will continue with pursue and progress toward the goals of their chosen
this practice. life plan (Husted & Husted, 2001). Health is evident
when individuals experience, express, and engage in
Major Assumptions the fundamental bioethical standards.

The assumptions from this theory arise from the Environment or Agreement
practical reasoning. The model is meant to provide The environment established by Symphonology is
nurses and other health care professionals with a formed by agreement. “Agreement is a shared state of
logical method of determining appropriate ethical ac- awareness on the basis of which interaction occurs”
tions. Although many of the terms are familiar to (Husted & Husted, 2001, p. 61). Agreement creates
nurses and health care professionals, some have been the realm in which nursing and all other human in-
redefined to support the reality of human interaction teractions occur. Every agreement is aimed toward a
and ethical delivery of health care. final value to be attained through interactions made
Nursing possible by understanding.
Symphonology holds that a nurse or any other health
care professional acts as the agent of the patient. Using The health care professional–patient agreement
her education and experience, a nurse does for her is formed by a meeting of the professional’s and the
patient what he would do for himself if he were able. patient’s needs. Their agreement is one in which the
Nursing cannot occur without both nurse and patient. needs and desires of the patient are central. The pro-
“A nurse takes no actions that are not interactions” fessional’s commitment is defined in terms of the
(Husted & Husted, 2001, p. 37). The nurse’s ethical patient’s needs. Without this agreement, there would
responsibility is to encourage and strengthen those qual- be no context for interaction between the two. The
ities in the patient that serve life, health, and well-being relationship would be unintelligible to both (Husted
through their interaction (Fedorka & Husted, 2004). & Husted, 1999).

Agency is the capacity of an agent to take action Symphonology Theory is not a compilation of tra-
toward a chosen goal. A nurse as agent takes action ditional cultural platitudes. It is a method of deter-
for a patient, one who cannot act on his own behalf. mining what is practical and justifiable in the ethical
The shared goal of a nurse and a patient is to restore dimensions of professional practice. Symphonology
the patient’s agency. The nurse acts with and for the recognizes that what is possible and desirable in the
patient toward this end. agreement is dependent on the context.
Person or Patient
The Husteds define a person as an individual with a The context is the interweaving of the relevant facts
unique character structure possessing the right to pur- of a situation—the facts that are necessary to act upon
sue vital goals as he chooses (Husted & Husted, 2001). to bring about a desired result (Husted & Husted,
Vital goals are concerned with survival and the en- 2001). There are three interrelated elements of context:
hancement of life. A person takes on the role of patient the context of the situation, the context of knowledge,
when he has lost or experienced a decrease in agency and the context of awareness. The context of the situa-
resulting in his inability to take the actions required for tion includes all facts relevant to the situation that
survival or happiness. The inability to take action may provide understanding of the situation and promote
result from physical or mental problems, or from a lack the ability to act effectively within it. The context of
of knowledge or experience (Husted & Husted, 1998). knowledge is an agent’s preexisting knowledge of the
relevant facts of the situation. The context of awareness

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

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

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

acter structure. Each person has the right to
choose and pursue, without interference, a course
of action in accordance with his needs and
desires.
• Agreements between individuals are demonstrated
by a shared state of awareness directed toward a goal.

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

Context of Awareness
Healthcare professional/

patient agreement
AUTONOMY

Context of knowledge Objectivity Freedom Context of the situation

Beneficence Self-assertion

FIDELITY

Decision

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

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

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

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

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

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

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

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

of Symphonology and the relationships among the Accessibility
concepts. The book may be difficult for beginning nurses Symphonology is a theory grounded in ethical principles
to read because deeper concepts meant for advanced and based in reality. Evidence has demonstrated support
practitioners are included along with basic ideas. The of the theory in nursing practice decision research, and
third edition, Ethical Decision Making in Nursing and the reality of the usefulness of the theory in practice is
Healthcare: The Symphonological Approach, begins with evident. Nurses and other health care professionals can
the basic concepts for understanding and using the easily understand the concepts and apply them in all situ-
theory and then moves to more advanced concepts in ations. The result of using the Symphonological model is
later sections (Husted & Husted, 2001). Along with this a patient-centered, ethically justifiable decision.
improved organization, the third edition shows the Importance
emergence of increasing clarity for all concepts, the Being able to identify ethical actions in health care is
bioethical standards in particular. The fourth edition of vital importance to patients, health care profession-
provides yet further clarity using tables and figures and als, and the health care industry itself. Understanding
includes a user-friendly teacher manual. the ethical dilemmas of nursing practice is an impor-
tant issue for nursing education, research, and prac-
This work challenges traditional methods of thought tice. Before a nurse or any health care professional
and requires the reader to develop a new understand- takes action (regardless of how effective the action has
ing of familiar concepts. Storytelling and examples been in the past), the action must be justified as ethical
provide the opportunity to recognize and understand with regard to the particular patient at hand. Reliance
the importance of alternative and extended meanings on concrete directives to guide action serves the direc-
for familiar terms. The conversational tone of the writ- tives, but only by chance serves the patient. Therefore,
ing is appealing and creates a comfortable atmosphere the pursuit of a practice-based ethical theory is essen-
for a complex subject. tial for nursing practice and health care.

Simplicity Summary
The authors first challenge the truth and efficacy of
traditional ideas about ethical behavior and decision The Husteds recognized that the traditional methods
making. This is a simple matter if the reader is open- of decision making were insufficient to address the
minded to a different view of nursing events. As the bioethical problems emerging in the evolving health
reader accepts the challenge, the simplicity of the care system. They developed a theory of ethics and a
theory is evident. There are few concepts, and the re- decision-making model based on rational thought
lational statements flow logically from the definitions. combined with ethical principles, insight, and under-
The model clearly demonstrates the elements of the standing. Their theory is founded on the singular
process of ethical reasoning and the manner in which concept of human rights, the essential agreement of
these elements interact. nonaggression among rational people that forms the
foundation of all human interaction. Upon this foun-
Generality dation, health care professionals and patients enter
Symphonology is applicable at all levels of nursing into an agreement to act to achieve the patient’s goals.
practice and in all areas of health care. The princi- Preconditional to this agreement are recognition
ples can be applied between nurse and patient, re- and respect for each person’s unique character struc-
searcher and subject, manager and employee, and ture and the attendant properties of that structure:
educator and student. Health care professionals of freedom, objectivity, beneficence, self-assertion, and
all types can use this method to determine appropri- fidelity. Ethical decisions are established within the
ate ethical behaviors in practice. This theory can also context of a particular situation, using knowledge
be applied to the process of establishing health care pertaining to the situation. Symphonological theory
policy that is ethical in nature. Indeed, these princi- and the model for practice ensure ethically justifiable,
ples can be applied in all walks of life, depending individualized decisions.
on the nature of the agreement between the parties
involved.